Ron Dobson (former LFB Commissioner) continues evidence about correspondence with government on fire safety concerns. Admits government 'had no intention of accepting' his recommendations on external fire spread, that he failed to communicate risks to operational crews, and that he was 'unsuccessful in bridging the cultural gap between fire safety and operations'.
# Transcribed with OpenAI Whisper (medium model)
# Source: Local audio transcription (no YouTube captions available)
00:00:30 Good morning everyone. Welcome to today's hearing. We're going to continue hearing evidence today
00:00:39 from Mr. Ron Dobson, formerly the Commissioner of the London Fire Brigade. So I'm going to ask
00:00:45 Mr. Dobson to come back in please. Good morning Mr. Dobson. Good morning sir. We're ready to
00:01:02 carry on. I am, thank you. Now I'm going to say this now but please try to remember that the
00:01:08 transcriber has a difficult job in taking down everything everyone's saying. So if it's possible
00:01:14 to speak a little more slowly that I think she would be grateful. And it's also quite important
00:01:19 in this case for you and Mr. Kinnear not to be too keen to ask the next question or answer the
00:01:26 question until the previous one has been finished because speaking over each other causes difficulty
00:01:32 of a similar order. I know it's hard not to do it because you're keen to give an answer but if
00:01:40 you can that would be very much appreciated. Anyway with that preliminary, yes good morning Mr. Kinnear.
00:01:44 Thanks sir. Now last Thursday before we broke we were discussing the correspondence that you
00:01:49 were having with the Minister of State Mr. Brandon Lewis and I'd like to return to that next stage
00:01:55 and in that chain of correspondence. Now two months later on the 6th of February 2013 a reply
00:02:01 to your letter was sent by Louise Upton, an official at DCLG. Now you kindly exhibit this
00:02:07 letter at RJD 5 which we can find at LFB trouble 0 32153. Now her letter did not contain a response
00:02:18 to recommendation 7 which we were discussing last Thursday on fire risk assessors and competency but
00:02:24 her response to recommendation 1 is on the third paragraph of this page and what she says is this
00:02:30 in terms of recommendations 1 and 2 we've considered previously the extent to which the regulatory
00:02:36 reform fire safety order 2005 which gives effect to a number of European Council directives designed
00:02:43 to improve safety and health of workers at work was intended to apply to premises or parts of
00:02:49 premises other than those which could be viewed as workplaces or places to which the public have
00:02:54 access. As you know the order specifically does not apply to domestic premises except to the extent
00:03:01 in article 31 10. Now if we could skip to page 3 in this letter and Ms Upton's response to
00:03:08 recommendation 5 and she said this on recommendation 5 requirement B4 of the building regulations and
00:03:16 its supporting guidance explicitly state that external walls should adequately resist the spread
00:03:22 of fire over the walls and from one building to another. Further guidance is given in the BRE
00:03:28 publication, BRE 135, fire performance of external thermal insulation for walls of multi-story
00:03:34 buildings which explains the objectives for controlling fire spread on the external envelope
00:03:41 of tall buildings in detail. Now Risa Dexter's evidence was that that letter did not feel quotes
00:03:49 very satisfactory close quotes and that it wasn't a sufficient response to the concerns that you had
00:03:55 raised in your letter. Did you share that view at the time? I did. Given that you'd written to
00:04:03 Brandon Lewis in the terms that you had done presumably you did not agree that requirement
00:04:08 B4 and the supporting guidance explicitly stated that external walls should adequately resist the
00:04:14 spread of fire in their own right i.e. not just from building to building. Now given the letters
00:04:19 that Mr Jack had also written to the government department how view was that still need to be
00:04:24 clarified and the letter from Ms Upton just really restated the problem in many respects.
00:04:29 And does that answer apply equally to the citation of BRE 135? Did you feel that BRE 135 was sufficiently
00:04:38 clear given the problems that you had identified to the minister in your correspondence? No.
00:04:43 Now put bluntly it appears that the government had no intention of accepting your invitation to
00:04:52 intervene on the issues you'd identified in your correspondence namely external fire spread and
00:04:58 non-compliant external panels. Would you agree however that those risks nonetheless remained
00:05:04 for the LFB to address on the ground when confronted with fires involving external fire spread? Yes,
00:05:11 I would. Can you help us to why those risks which had prompted you to write to officials and ministers
00:05:18 at DCLG, why they didn't prompt you to communicate those problems at this stage given the government's
00:05:26 obvious disinclination to take any positive steps, why you didn't communicate those risks
00:05:32 out to LFB operational personnel? I think the risks that we identified that you brought me to
00:05:37 in this letter Mr Keneer were largely in relation to the enforcement of fire safety regulations on
00:05:44 buildings by our fire safety regulation department. I think our feeling was still that there was
00:05:50 nothing in what we'd seen at Lackinall House and what prompted us to write these letters to consider
00:05:56 the risk was such that was realised at Grenfell Tower and therefore I think our view was that
00:06:03 whilst these risks exist they were still at risk that were able to be covered by operational
00:06:09 firefighters in a normal course of their duties. But having regard to that answer doesn't your
00:06:16 approach to DCLG, the proactive response you took there and the absence of communication to your own
00:06:22 operational crews illustrate something about the LFB and I'll put two points to you to see your
00:06:27 response. They illustrate two disconnections here or absence of connections. First that whilst you
00:06:34 felt that the nature and extent of non-compliance was sufficiently serious for you to write to both
00:06:39 officials and DCLG, you didn't communicate with your own personnel as to the risk they presented
00:06:48 on the ground these non-compliances and how best those crews could deal with those non-compliances
00:06:54 when manifested in the fire. Would you agree with that? I would agree that we didn't put it to our
00:06:58 operational crews in the same terms as we express these things to DCLG but my contention would be
00:07:03 that the the risks arising from these these things were identified in the letters was addressed
00:07:08 through things like the Lack of My House training case study. Now bearing in mind that answer though,
00:07:14 would you agree that at least there was a disconnection between Fire Safety Department
00:07:19 within the LFB and operations characterised by the fact that the knowledge that Fire Safety held
00:07:25 about the risks posed by non-compliant facades if I can put it broadly had not informed operational
00:07:33 practice policy and procedure? Yes. And following on from the answer you gave earlier on in your
00:07:38 evidence on Thursday, would you agree that this particular episode shows that no effective steps
00:07:43 have been taken to bridge the cultural gap between fire safety and operations at the LFB? Well I would
00:07:49 argue that steps had been taken to try to do that but they obviously haven't been as successful as
00:07:53 we would like them to be. I think the key word in my question was effective. Okay no they haven't been
00:07:58 as effective as I'd like them to be. And that by this stage we're dealing with early 2013, you'd been
00:08:04 imposed nearly four years by this stage? Yes. And so we can take it from that that nearly halfway
00:08:09 through your term you'd been unsuccessful in bridging the cultural gap between fire safety and
00:08:13 operations? Yes. Can we now turn to your evidence of the Lacknell House inquest? Excuse me the
00:08:20 letter that we've just looked at was dated February which was effectively midway through the Lacknell
00:08:26 House inquest. Am I right in understanding that you gave not only witness statement to the inquest
00:08:31 but you also gave oral evidence to the coroner? Yes I did. Now we can turn to the written statement
00:08:37 that you provided to the coroner and that's at LFB quadruple zero zero seven one seven.
00:08:44 And if we can turn to page four in this document and in particular paragraph eight. Now this is
00:08:59 provided in the context of residential high-rise fires and at paragraph eight you said this. The
00:09:05 brigade's approach is necessarily predicated on certain assumptions about the construction of blocks
00:09:10 of flats and compliance with relevant legislation. These assumptions are reflected in fire safety in
00:09:15 purpose-built blocks of flats document produced by the local government group in 2011 the LGG
00:09:22 guidance. The LGG guidance identifies certain assumptions which are made for the purposes of
00:09:29 the design of communal means of escape. These are equally applicable assumptions which are made when
00:09:35 planning firefighting and rescue. The LGG guidance states paragraph 16.9 page 24 design of communal
00:09:43 means of escape and purpose-built blocks of flats is based on certain assumptions. These include first
00:09:49 the most likely place of origin of a fire will be in a flat itself. Secondly that there is a high degree
00:09:55 of fire separation between flats and the common parts and therefore the likelihood of fire and
00:10:00 smoke spread beyond the flat of origin is low. The materials used in the construction of the
00:10:05 building or the protection afforded to them are such that a fire is unlikely to spread through the
00:10:10 fabric of the building and turn over the page. That the use of the common parts and the nature
00:10:15 of any combustible items present is such that any fire originating in the common parts is unlikely
00:10:22 to spread beyond the immediate vicinity. There will be no external rescue and residents should
00:10:27 be able to escape by themselves. Now if we can turn to your live evidence on this point and we
00:10:33 can find the transcript which is at CWJ quadruple zero double zero one zero forward slash one one
00:10:42 five. We can see at line one at top of the page you are asked the following question on residential
00:10:52 high rise fires by council to the inquest and he asked you this. In the remainder we see from paragraph
00:10:59 five which is paragraph five of your witness statement to the inquest five percent were resolved
00:11:04 by four pumps maximum and three percent by six pumps or more. The reason I take you back to that
00:11:10 is I want to ask you in the context of the way in which high rise fires and the dealing with them
00:11:15 and the fighting them is planned bearing in mind the assumptions of building design,
00:11:21 compartmentation and so on which we have all talked about. Is it your view one way or the other that
00:11:28 it is very much still appropriate to plan for firefighting and rescues according to the building
00:11:34 design and legislation as it stands today? Your answer can be found starting at line 12 and you
00:11:41 said this. It is and I'd like to go slightly further and say I can't. I can't imagine any other way of
00:11:48 doing so because if we start to plan if we're required to plan for instance in a way in which
00:11:54 we expect the regulation and the requirements to not be present then there is no basis on which to
00:12:01 start pre-planning our operations. Now taking a step back from all of that despite confirming that
00:12:09 it was appropriate to plan for high rise fires based on assumptions of compartmentation etc.
00:12:14 You knew that a significant number of buildings at least in London were not acting in accordance
00:12:22 with those assumptions. That's right isn't it? Well I know that a number were I wouldn't call it
00:12:26 a significant number. You knew a number of the buildings and the problem was you were
00:12:33 unable to quantify the number of buildings that were acting in that way weren't you?
00:12:37 Other than the numbers that were given in my statement to the coroner.
00:12:41 And you had difficulties in identifying the number of buildings that were non-compliant?
00:12:47 Yes.
00:12:48 So it's potentially a significant problem would you accept that?
00:12:52 Yes.
00:12:53 And indeed as several of your former colleagues have confirmed to the inquiry in evidence the
00:13:04 problem was that buildings may not act in accordance with the assumptions was indeed
00:13:08 well known to the LFB because of their experience at Lacknall would you agree with that?
00:13:11 Yes.
00:13:12 That being the case would you accept from me that it was based on the evidence available to you at
00:13:19 the time dangerous to plan on the assumption that building regulations would be met and that
00:13:24 compartmentation would always subsist? I think we still had no other way to plan because the
00:13:29 majority of buildings had still been built with that as a requirement and therefore the
00:13:34 fiber gaze expectation. We knew that some buildings would not perform in the way they were designed
00:13:40 because they'd been refurbished or maintained not poorly and therefore that sort of information was
00:13:46 brought to the attention of crews through particularly through the Lacknall house case study
00:13:50 and others and also crews were aware through their attendance at incidents and through
00:13:56 72 DVDs and others that some of the buildings were not being maintained as well as they should have been.
00:14:01 There are two other means though aren't there of mitigating the problem. First of all that you
00:14:08 could ensure the proper contingency planning is made by your crews in the event that a building
00:14:14 does not behave as intended. That's one practical route isn't it? It is yes. And the second
00:14:19 reasonably practical route is to train your operational crews on the fact that the assumptions
00:14:27 that planning has currently labored under i.e. the buildings will perform in accordance with the
00:14:32 regulations may not hold true in all circumstances. That is something you could have done as well
00:14:37 isn't it? Yes. Could we now turn to post-inquest correspondence with DCLG? Now following the
00:14:46 conclusion of the inquests on the 28th of March 2013 the coroner sent what were then known as
00:14:52 rule 43 letters containing recommendations that she considered would reduce the risk of future
00:14:58 deaths. A letter was sent to the LFB, a letter was also sent to the Secretary of State at CLG. Now
00:15:07 could we turn we'll come on to the substance of all this in due course but could we first of all
00:15:11 look at the letter that was sent to the Secretary of State and that can be found at CLG quadruple
00:15:17 0 0401 so that's quadruple 0 0401. Thank you. Now if we can turn to page three of this letter
00:15:27 and really look at the heading building regulations and approve document B.
00:15:37 Now the letter states this during these inquests we examined approved document B 2000 edition
00:15:55 incorporating 2000 and 2002 amendments ADB. I'm aware that ADB has subsequently been amended
00:16:02 and believe that a further amendment is due to be published soon. The introduction to ADB states
00:16:08 that it is intended to provide guidance for some of the more common building situations.
00:16:13 However ADB is the most difficult document to use. Further it is necessary to refer to additional
00:16:19 documents in order to find an answer to relatively straightforward questions concerning the fire
00:16:24 protection properties, fire protection properties and materials to be incorporated into the fabric
00:16:29 of a building. It is recommended that your department review ADB to ensure that it provides
00:16:36 clear guidance in relation to regulations B4 of the building regulations with particular regard
00:16:42 to the spread of fire over the external envelope of the building and the circumstances in which
00:16:47 attention should be paid to whether proposed work might reduce existing fire protection.
00:16:53 It is expressed in words and adopts a format which are intelligible to the wide range of people and
00:16:58 bodies engaged in construction, maintenance and refurbishment of buildings and not just to
00:17:04 professionals who may already have a depth of knowledge of building regulations and building
00:17:09 control matters. Now first question did you see a copy of the letter to the Secretary of State
00:17:15 at the time? I think so yes. Now Eric Pickles who was then the Secretary of State responded
00:17:22 in May 2013. Can you remember did you see that response soon after it was sent? I don't recall
00:17:27 seeing that. Do you remember seeing a draft was anything sent to you before it was finalised? No.
00:17:34 Now we can find the Secretary of State's response at HOM 000 4743
00:17:46 and if we could turn to page two we can find the Secretary of State's response to the recommendation
00:17:53 that additional guidance be given on functional requirement B4 and it's really in the penultimate
00:17:58 paragraph of this page and there the Secretary of State says this. Finally in relation to building
00:18:06 regulations I've noticed your concerns about the difficulties that some of those involved in the
00:18:11 inquest had with the interpretation of approved document B. I can assure you that my department
00:18:16 is committed to a program of simplification however the design of fire protection in buildings is a
00:18:22 complex subject and should remain to some extent in the realm of professionals. We have commissioned
00:18:28 research which will feed into a future review of this part of the building regulations.
00:18:33 We expect this work to form the basis of a formal review leading to the publication of a new edition
00:18:39 of the approved document in 2016-17. Now when you became aware that the release of new guidance on
00:18:47 B4 was at least three or four years away did you consider how that affected LFB's operational
00:18:54 tactics and in particular whether you ought to be taking steps in the meantime to ensure that
00:19:00 crews were aware of the risks being presented by non-compliance? No the view we took was that this
00:19:07 was more an issue for specialist fire safety officers rather than operational crews and as
00:19:12 I said we believe we've already communicated to staff some of the risks associated with non-compliance.
00:19:19 Now four months later we're dealing on the 18th September 2013 Rita Dexter emailed you a draft
00:19:25 to send to DCLG and if we could go to that email exchange LFB 001 00509.
00:19:43 That could be amplified. Thank you.
00:19:49 Can you see that Mr Dobson? Yeah. I'll read it out so it may well help. Ron you know that the
00:19:58 Lacknell House Working Group agreed that the chairman should be provided with a draft letter
00:20:02 to send to Brandon Lewis to follow your letter of December 2012. I have struggled to put the
00:20:08 right letter together mostly because I'm not sure that I understand the extent to which
00:20:13 Louise Upton's reply in February could be deemed to have dealt with some of the points you raised.
00:20:19 I asked for advice about what a reply meant in February but was told that it was a holding reply.
00:20:24 I can't tell. I find it a bit impenetrable and no one here seems keen to carefully dissect it
00:20:32 and reach a considered view about which of your points were dealt with adequately and which not.
00:20:37 Perhaps I should have asserted myself and made someone do that. I now wish I had but I didn't
00:20:43 and now have a task that has been gently chased. What do you think about this draft?
00:20:48 Now Mrs Dexter explained in her evidence that the Lacknell House Working Group members were
00:20:53 quote dissatisfied with the quality of the exchange close quote marks between you and
00:20:59 CLG. First of all is that your recollection of the Working Group's views? I wasn't at the
00:21:05 meeting where this was agreed but yes it certainly was those views were expressed to me outside of
00:21:10 that meeting. Can you remember now what the principal causes were of their dissatisfaction
00:21:16 with the quality of the exchange? Well the letter at the exchange that we had as I recall was
00:21:24 presented to the Lacknell House Working Group and I believe that Mr Turek from the Fire Safety
00:21:29 Department was in attendance at the meeting and was unable to clarify the letter any further than
00:21:35 we'd been able to previously so I think it was expressed to members that the letter didn't answer
00:21:40 our questions. Now we can go to your reply to Mrs Dexter which was the following day so the 19th
00:21:46 of September 2013. We can find that at LFB 0010 0440.
00:21:54 A brief email which says as follows a few amendments and one comment from me in the
00:22:05 attached but otherwise I think the letter fits the bill well. I'm not going to take you to your
00:22:10 amendments they were minor okay but I'd like to instead take you to a copy of a letter that you
00:22:16 due course sent to Brandon Lewis and that letter was sent on the 26th of September at 2013 so a
00:22:23 week later and we find that at LFB 000 32149. Now we can see from the first page that your letter
00:22:33 was prefaced by a covering letter from the El FIPA chairman James Cleverley. Your letter
00:22:41 appears on page two of this exchange
00:22:46 and we can see that its first two paragraphs provide context. Now if we go halfway down the
00:22:52 second paragraph and really the fourth line down in that paragraph you said the following
00:23:00 whilst my first letter received a reply from one of your officials Ms Louise Upton in February
00:23:06 members have reviewed that exchange in light of the outcome of the inquest and the rule 43 letters
00:23:11 issued by the coroner. They feel that there remain issues to be addressed.
00:23:16 The issues covered by my letter and Ms Upton's response were and then you set out various bullet
00:23:22 points in the body of the text. Let's look at the first bullet point which set out the LFB's request
00:23:28 for guidance on the operation of the RRO in relation to common parts and how the RRO was
00:23:35 intended to operate where the responsible person does not have control over features
00:23:41 affecting the common parts. Now what you say is this underneath the italicized text. In her reply
00:23:47 Ms Upton explained the department had no evidence to suggest that the order was intended to apply
00:23:53 generally to the structure of a block of flats as it would be artificial to delineate domestic
00:23:59 premises in such a way that exclude the structure such as external walls around a flat. She added
00:24:06 that the department believed this to be the case regardless of whether the structure is in property
00:24:11 law terms comprised within the lease or tenancy of a flat because considering the variety of
00:24:18 possible arrangements and extent to which various combinations might apply in any one building
00:24:22 the results are anomalous. She further added that she therefore did not consider that the order
00:24:28 could have been intended to apply in this way. Members of the authority have studied this response.
00:24:34 They think that it is reasonable to expect the DCLG should be authoritative on the policy intention
00:24:40 but leaving that to one side with the best will in the world it is hard to penetrate what this means
00:24:46 and the evidence of the Lacknall fire and of our wider fire safety work in London is that it is an
00:24:52 issue that is significant and that deserves further attention. It is accepted that the
00:24:58 department has over the years funded work which was intended to provide clarity but it remains
00:25:03 a confused landscape which is too important to not resolve. Now was your reference to the evidence
00:25:12 of the Lacknall fire and of our wider fire safety work in London a reference to the growing number
00:25:17 of non-compliant buildings resulting in unusual and significant fire and smoke? No it was more a
00:25:24 reflection of our inability where we sought to bring prosecutions under the fire safety order in
00:25:31 relation to premises multiple, the premises of multiple, applications like high-rise flats.
00:25:36 It was extremely difficult to actually identify firstly who the responsible person was in every
00:25:41 case which is very difficult to do and then once we'd managed to do that even it was very difficult
00:25:46 to actually bring a prosecution where we felt the act was being not complied with as a result of the
00:25:52 difficulties in terms of interpretation that's laid about what's covered by the acts and what wasn't.
00:25:57 Can we turn over to the foot of page three? Excuse me and this deals with the brigade
00:26:04 recommendation relating to functional requirement B4 and we see the recommendation set out in
00:26:11 italicised text namely that government provide further guidance in relation to requirement B4
00:26:17 of the building regulations particularly with regards to the spread of fire over the external
00:26:22 envelope of the building. Immediately below that you said this. Mr Upton provided comments in
00:26:29 response to this recommendation with reference to the existing guidance given in the BRE publication
00:26:35 BR134 fire performance of external thermal insulation for walls of multi-storey building.
00:26:42 However you'll be aware that this is a subject that the coroner addressed very fully during
00:26:47 the inquest and was one of the specific issues detailed in the rule 43 recommendation issued to
00:26:52 DCLG. In DCLG's response to the coroner's recommendations there is confirmation that
00:26:58 research work had been commissioned which would feed into a future review of this part of the
00:27:03 building regulations. It would therefore be helpful to understand the process of this research
00:27:08 and the timescales for reviewing this aspect of the building regulations. Now having read
00:27:14 DCLG's response to the coroner which indicated that a new approved document B would be forthcoming
00:27:20 in 2016 or 2017 what did the LFB or more particularly the Alfipa working group members
00:27:27 hope or intend would come of this renewed request? Further information about exactly
00:27:33 what might be included in that revision to the document. And if for the sake of completeness we
00:27:40 go to the second bullet point on page four we see that there was a renewed call for guidance on
00:27:50 fire risk assessor competency the letter noting that no response had been received on that point.
00:27:56 Yes now you get a reply on the 16th of October so slightly more than two weeks later from Brandon
00:28:04 Lewis and it's in a letter which was addressed to James Cleverley. We find that letter LFB 0058
00:28:13 treble nine. Thank you. Now if we can just look at his response to the points we've just been
00:28:22 discussing. First of all on the operation of the 2005 order if we turn to the third paragraph
00:28:31 Mr Lewis said this in respect of revised guidance for sleeping accommodation we consider that
00:28:37 LACORS and LGA fire safety guidance documents that tailored to the specific needs of housing
00:28:46 providers are appropriate to assist those responsible for ensuring the safety of residents
00:28:51 and others in multi-occupied buildings to compliance with the provisions of the fire safety
00:28:56 order and the housing act. We make both documents available on the fire safety pages of the
00:29:02 government's website. Pausing there the thrust of that third paragraph appears to be that nothing
00:29:11 more was needed or at least nothing more from the government. Was that how you read that particular
00:29:17 paragraph at the time? It was. Would it be helpful if it be possible to give a little bit of context?
00:29:22 Yes please do. I think we've said before Mrs Dexter and I have both said in evidence
00:29:27 that we were not surprised by the government's response to our letters. I think this needs to
00:29:32 be put therefore in the context of the government's stated objective at this time was to reduce the
00:29:39 regulation on buildings on an industry particularly in order to actually free up industry to
00:29:46 you know to be more effective. So and that there was a government, I understand a government
00:29:52 directive that no more legislation one in one out so if a new regulation came in another one
00:29:57 had to go out somewhere else. So we were very much of the view that this was affected by the
00:30:03 government policy in terms of not increasing the regulation on industry generally and the building
00:30:08 industry in particular. So we wasn't surprised that there was going to be no more guidance or
00:30:13 governance forthcoming for that reason. Could we look at the final paragraph on this page which
00:30:18 relates to the LFB's recommendation regarding functional requirement B4. It said this,
00:30:26 we've also commissioned a range of research to inform a future review of the building regulations
00:30:31 part B. The chief fire officers association and others are involved in the research program to
00:30:36 support the next iteration and individual fire and rescue authorities will have the opportunity
00:30:42 to feed in comments at the consultation stage. We plan to publish a new edition of approved document
00:30:48 2016-2017. Again that did no more than reiterate the response to the rule 43 recommendation.
00:30:56 Was that how you read that letter at the time? Yes. And finally for the sake of completeness
00:31:02 could we turn over the page and look at the second paragraph and this was again the VEX
00:31:07 matter of fire risk assessor competency and the response there was set out thus. Finally your
00:31:15 letter notes that London Fire Brigade did not receive a response in respect to the recommendation
00:31:20 that the government provide guidance to the responsible person on how they might assess
00:31:25 that the risk assessor is competent to carry out a suitable assessment of risk in complex and high
00:31:30 rise premises. Fire Sector Federation published in February 2013 the competency criteria for
00:31:37 fire risk assessors that had been developed and agreed by the fire safety sector. Now did anyone
00:31:44 at the LFB examine the FSF competency criteria to see whether it satisfactorily answered the
00:31:51 issue raised by the LFB? Yeah I believe that our office in our fire safety department had looked
00:31:56 at this document. Our view was that it didn't actually hold any regulatory weight or force
00:32:09 because it came from the Fire Safety Sector Federation which was effectively a voluntary
00:32:15 body of people that were interested in the fire and rescue service and in some respects therefore
00:32:21 had a vested interest in the actual recommendations that it was actually putting forward. So what we
00:32:26 were looking for was something from the government with the weight of government in terms of
00:32:31 recommendations about the qualifications that fire risk assessors should hold for carrying out
00:32:37 various inspections at various different types of buildings. What you're faced with now is the
00:32:44 prospect of no government action pending a new approved document B. Did it, was it a subject of
00:32:53 discussion at the LFB that in light of the non-compliances you had found and experienced
00:33:00 that this was going to be a problem that would only increase over time in the absence of effective
00:33:05 regulatory intervention by the government? Yes it was. Given that and given the absence of
00:33:13 effective action from the government what steps did you take first of all to ensure that operational
00:33:18 crews were fully aware of the risks that you had identified and indeed has been the subject of
00:33:23 correspondence with DCLG? Well the risk that we'd identified many of which would relate to this
00:33:29 particular issue were our own fire safety officers carrying out their duties in relation to fire
00:33:37 safety order and examining risk assessments and finding risk assessments that weren't necessarily
00:33:43 competent in their view in relation to the building that was being inspected. So I'm not sure that
00:33:48 that particularly was a matter which was of relevance to operational crews. However we did
00:33:53 raise this and I raised this personally with the chief fire officers association at the time and I
00:33:59 remember discussing it at the chief fire association and the chief fire association was part of work
00:34:07 that was done by the industry generally to develop guidance around risk assessments and the competence
00:34:12 of risk assessors. One thing that the LFB could have done was to proactively write to housing
00:34:19 providers inviting them to check the compliance of if they had them cladding another façade
00:34:27 i.e. doing what you encouraged Sir Ken Knight proactively to do back in November 2009. That was
00:34:34 a reasonably practical course wasn't it? Yes. Can you help us to why it wasn't done? Well it wasn't
00:34:40 raised with me but the reason I think why we didn't do that was because we'd already asked for the
00:34:47 guidance to be clarified to make it clearer. So what we're likely to get if we wrote to local
00:34:52 authorities in that way would be a tranche of letters coming back asking us for further guidance
00:34:57 that would all be asked for from the government so I'm not sure it would have been served any
00:35:00 great purpose. Mindful of that answer you said that no one raised it with you. Was it a thought
00:35:06 that crossed your mind given that you were at least the stated author of the letter to Sir Ken
00:35:12 back in I think it was December, apologies, 2009? Yeah no it didn't. For the reasons you just given. Yes.
00:35:22 Could we turn on to a separate topic now which is the LFB's highly insulated buildings training
00:35:33 package. Now a number of LFB witnesses have explained their role in the knowledge of the
00:35:39 LFB's development of a highly insulated buildings training package in 2015. Now Gary Reason explained
00:35:47 it was based in part on an analysis of the 2007 Atherton on Stour incident which we discussed at
00:35:54 the very beginning of your evidence. The first question is the straightforward one were you
00:35:59 familiar with this training package? I was familiar with its existence but not familiar with the
00:36:04 absolute detail of it. Mindful of that can we look at the originating t cap for this particular element
00:36:11 of training. It can be found at LFB 0010 2213. Now if we can turn to page four
00:36:23 I'll read the bottom of the page in the box entitled background context. It says this.
00:36:29 The key thrust of the Ops News 30 article package is that firefighters should be aware of the
00:36:36 implication on their firefighting tactics of the increasing use of highly insulated
00:36:41 sealed compartments, fire development in these compartments and the hazards associated with
00:36:47 modern methods of construction. The article and package should highlight a number of key concerns
00:36:52 and developments relating to modern methods of construction and signpost the new improved
00:36:57 modern methods of construction CBT package that's computer-based training. The emphasis in the CBT
00:37:05 package should be on the implications of modern methods of construction for firefighting tactics.
00:37:11 This should be in greater depth than currently exist in training package. It is not sufficient
00:37:16 to talk about rapid fire spread and or unusual fire spread through voids cavities etc. Now in
00:37:22 terms of what they were seeking to achieve by this package we can go to page seven and box 4.1
00:37:29 And we can see there the entry reads thus CBT package should reference the following and it sets
00:37:34 out a number of bullet points that it needs to look at and I'll go through those. First of all
00:37:41 background for the development of increasingly well sealed compartments. Secondly the technologies
00:37:47 that are used to make this happen. Celltex, Kingspan etc. Third bullet point this sort of
00:37:55 point this sort of technology has been retrofitted in old buildings under development so not just
00:38:01 found in new builds. Next this sort of technology is highly interdependent if one aspect fails it
00:38:09 can undermine the entire design solution. Next signpost the BRE research and the NOG that's
00:38:16 the national operational guidance guidance as a resource both for operational staff but also
00:38:21 writers of training policy. Next specific firefighting strategies to address the hazards
00:38:28 associated with high compartment fuel loading and temperature associated with modern building
00:38:34 contents. We get less compartment fires but when they happen they are hotter and more vigorous
00:38:39 and they can be different to an old Victorian semi that might traditionally have been our
00:38:43 bread and butter. What a perfect response should look like consideration of ventilation path,
00:38:50 weight of attack, pro jet covering jets, crews, external safety officer monitoring and communicating
00:38:57 window compartment failure and effects crews can anticipate on the compartment fire conditions.
00:39:05 Having looked at all of that it appears certainly to the lay eye that this training not only sought
00:39:12 to implement some of the lessons learned at Afton on Stour but also the direct links with the LFB's
00:39:19 findings following LACNOR. Would you agree with that? I'm not sure this training package
00:39:25 particularly had LACNOR in mind although obviously parts of it would obviously be relevant to LACNOR.
00:39:30 Which parts do you think are relevant to LACNOR?
00:39:39 Potentially the penultimate bullet point,
00:39:46 potentially the final bullet point,
00:39:49 which is really that final bullet point that distills it down isn't it? It's changes to existing
00:39:56 operational practice that crews need to think about. I think the point with this T-cap was I
00:40:01 think the author had in mind this, fires that were contained for longer in compartments perhaps and
00:40:07 they would otherwise have been because of the nature of the way the compartments are now
00:40:13 insulated and sealed for all the reasons laid out in the T-cap. So I think they particularly had in
00:40:18 mind internal firefighting and internal compartment firefighting and the effect that would have on the
00:40:24 conditions and the way in which firefighters gained entry to the compartment and the conditions
00:40:30 they would meet when they actually gained access to that compartment which was different. Now
00:40:35 whatever may have been set out in this T-cap we know that like many other CBT based packages
00:40:43 this was not rolled out due to technical difficulties. Now first of all were you
00:40:48 aware of those technical difficulties? I was aware there were technical difficulties yes.
00:40:53 Would you accept that those IT difficulties which prevented the rollout of training programmes
00:41:02 represented an organisational failure on the part of the LFB to use modern technology to improve
00:41:09 training? Yes. Would you accept that it was a major failing? Yes.
00:41:18 Linked to that can we look at the LFB's knowledge of international fires and how they were treated
00:41:24 internally at the LFB? Now during AC Daly's evidence we heard details of a number of international
00:41:30 fires with which we're now all familiar which involved cladding an external fire spread
00:41:35 and the particular fires that were picked up on in AC Daly's evidence were the Torch Fire,
00:41:40 Torch Tower Fire in Dubai, La Crosse Fire in Melbourne and the Address Tower Fire also in
00:41:46 Dubai all of which were in 2015. Now AC Daly accepted that these fires were known to the LFB
00:41:54 but that he was not aware of any work at the LFB to investigate the details and in particular
00:42:00 whether there were any lessons to be learned. The LFB's failure to consider these fires
00:42:05 resulted in this didn't it that opportunities were lost to better understand cladding fires? Yes.
00:42:13 Can you help us as to what the problem was which effectively prevented the LFB from
00:42:20 learning from international fires? I think that the problem was there was an expectation that
00:42:27 as these fires were international and therefore had a an impact potentially on the whole fire
00:42:31 rescue service in England, I say England because it's covered by the department, an impact on the
00:42:37 whole of the fire rescue service in England that I think we were expecting there to be more
00:42:43 contribution from national bodies in relation to the investigation of these fires and their
00:42:48 implications for the fire rescue service rather than individual fire rescue services. Now with
00:42:54 hindsight I wish we had taken a more proactive stance to actually doing this for ourselves who
00:42:58 were at the end of the day the largest and probably best resource fire rescue service in
00:43:03 the country and therefore perhaps we could have taken on a broader role but the fact was we didn't.
00:43:08 And there's nothing stopping you taking on first of all investigating the root causes of these
00:43:14 international cladding fires was there and seeing whether any lessons could be applied to the London
00:43:18 context? No there wasn't. Is one of the particular features of the London built environment is the
00:43:25 constantly evolving nature of construction techniques and there's much to be said for
00:43:30 the LFB learning from experiences with other high rise towers elsewhere when they involve a fire?
00:43:35 Yes there was but in terms of context for that I think we were certainly reliant or we believe
00:43:43 we could be reliant on the building regulations and other rules and regulations regarding the
00:43:47 built environment in place in this country and also whilst we might not have been as proactive
00:43:53 as we might have been in relation to actually investigating these fires and learn the lessons
00:43:58 we were the first brigade in the country to have a group of officers that were trained to degree
00:44:02 level in fire engineering and their knowledge of new building techniques etc was deployed
00:44:10 in consultations in the design and delivery on buildings like the Shard, the Cheese Grater and
00:44:17 other major buildings in London so we did believe that we were as far as we could be at the
00:44:23 forefront of new types of building techniques, new types of building requirements and perhaps
00:44:31 there was a disconnect between what that group of staff knew and how that was transferred to the
00:44:37 operational workforce. But it would appear given that there was no work done on seeing what could
00:44:44 be learned from those international fires that the LFB's if I can put it perspective was very
00:44:50 much limited to England. Yes. Now international cladding fires appeared in a July 2016 presentation
00:44:58 entitled Tall Building Facades which has been reviewed on a number of occasions, a number of
00:45:03 witnesses. Now could we go to that presentation which is LFB trouble zero three two eight nine four
00:45:10 forward slash nine six. Thank you. First of all have you seen this presentation before? Yes. When
00:45:19 did you first see it? I'm not sure if this, I can't quite recall if this was the presentation I did to the
00:45:28 to the firefighters, the Worshield Company of Firefighters and there's another presentation
00:45:33 I actually did. That's not something that any other witnesses said but it might well be as we
00:45:40 go through the substance you'll see that it isn't we think but as we go through it it may well
00:45:48 trigger a different memory. I think I suspect obviously we'll go through but I suspect
00:45:53 the presentation I gave was derived upon this anyway. Okay now could we first of all look at page 98.
00:46:01 Here we can see images of three fires, Grozny the address Dubai and the Tamwheel town Dubai.
00:46:08 Can we go to the next page, page 99? We have further fires in Shanghai and Baku. If we go to page 100
00:46:18 we see photographs of fire damaged building, one in Basingstoke and the other in Garmert Court
00:46:23 which you indicated in evidence on Thursday that you hadn't previously heard of. Now if we go to
00:46:29 page 101 this is entitled external fire spread and if we look at the large text on the right hand side
00:46:39 the page reads thus fires allowed to develop may flash over and break out through windows,
00:46:45 flames spread up over or through the cladding, flames can extend over two meters above window
00:46:51 opening regardless of cladding. If fire re-enters the building second to the building,
00:46:57 the fire re-enters the building, secondary fires may then develop and if we look at the left hand
00:47:03 that side of the page we see a diagram which shows fire spread
00:47:08 up a building and that's supported by some supplemental text and smaller
00:47:14 writing explaining how a cladding system can contribute to external flames, flames spread to all levels.
00:47:21 Um
00:47:25 Were you aware that that particular diagram had come from BR 135 which we discussed
00:47:32 in the previous context? Now I'm aware of that diagram but I didn't know it had come from BR 135.
00:47:37 Can we go over to page 102 again a slide on mechanisms of external fire spread. If we go to page 104
00:47:46 there's a summary of the requirements of ADB. Now in evidence Mr. Daley said that this presentation
00:47:55 and I quote was taken as reassurance about what we were seeing internationally and a reassurance
00:48:01 of the conditions and the regulations in this country. Now do you accept that the comfort
00:48:08 that Mr. Daley took from this presentation was fundamentally at odds with what you have seen
00:48:13 and fundamentally at odds with what you had learned about the compliance with building regs
00:48:19 in the wake of Lacknell House? Just to say first of all this is not the presentation that I gave
00:48:23 to the Westfield Company first of all and yes I do agree. Yeah and in light of that knowledge
00:48:29 would you accept that it was complacent at best of the LFB to continue to assume that buildings
00:48:35 would indeed comply with the building regulations? Yes. Can you explain that complacency?
00:48:44 I think complacency was because we expected the building regulations to still be effective.
00:48:52 The fires that we had seen largely had been small relatively small breaches of the building
00:48:58 regulations and at that point they had not resulted in large loss of life. Another aspect
00:49:06 of this discussion is that when he gave evidence Mr. Daley said that upon assuming his role as
00:49:12 head of fire safety in March 2016 he was not made aware of the LFB's communications to
00:49:18 correspondence with DCRG about the widespread misunderstanding of and non-compliance with
00:49:24 functional requirement B4. Given that the incoming head of fire safety was not made aware
00:49:32 of that vital correspondence would you accept that that evidence is at the very least a failure to
00:49:38 embed important fire safety knowledge in the senior responsible levels of the LFB? Yes.
00:49:46 Again given the seniority of level at which this absence of information is seen what's the
00:49:53 explanation for it? I can't account for that I would expect that to be something that was
00:49:57 either handed over or of which Mr. Daley would already have been aware.
00:50:01 Now this presentation was prepared specifically for LFB fire safety staff
00:50:08 and Mr. Daley told us that no thought was given at the time to cascading the substance of these
00:50:14 slides to operational crews. Again isn't that failure to communicate this information to
00:50:24 communicate knowledge of these risks an example of the disconnect that existed between fire safety
00:50:30 on the one side of the LFB and ops on the other? Yes. And again this is 2015 you are I think eight
00:50:40 years now into your tenure. Again there are no grounds to believe that whatever you were doing
00:50:48 to bridge that cultural gap the measures were effective. This would indicate that although I
00:50:54 would just it's not it's not a justification by any means but I would just say that during the
00:50:59 period in which this was going on we were going for a period of 49 strikes by the fire brigade union
00:51:05 resulted in significant workload on everybody and I think we're going for a period of very
00:51:10 difficult industrial relationship and then and to some extent you know I'm not trying to justify
00:51:15 it but we were distracted in some way during this period particularly. Now we heard from Peter Groves,
00:51:21 Dan Daley and the others that until the release of a fire safety power point delivered to
00:51:28 operational crews and this was done over an 18-month period starting in or about April 2017
00:51:35 there had been no comprehensive training focused exclusively on fire safety matters as opposed to
00:51:42 the mention of fire safety in the context of other thematic training. Were you aware of that absence
00:51:47 of fire safety specific training? Not particularly no.
00:51:53 Now AC Daley upon assuming the role of AC fire safety in March 2016 had what he described and I
00:52:00 quote as a fairly limited close quote training in fire safety. Do you accept that again that
00:52:07 whatever attempts were made to bring fire safety more closely into the fold failed during your
00:52:13 tenure as commissioner and that failure ultimately was a failure of strategic direction on your part?
00:52:19 Not completely no because we did not have a career structure in place at the moment at that time and
00:52:26 I don't think believe is in place now actually where in order to be a strategic leader within the
00:52:30 fire safety department you had to have particular experience of background in the fire safety
00:52:34 department. Now some people might argue that that would be appropriate but it would have undermined
00:52:41 the whole development process for officers within the service at the time. Maybe we should have
00:52:46 reviewed that and made it a requirement but actually we hadn't and that was a historic thing
00:52:50 that whilst I perpetuated it I wasn't responsible for it for the cause of it. Can we now look at
00:52:57 the Sheppard's Court file which was in August 2016? Yes. Now I think I'm right in understanding
00:53:03 that you attended as monitoring officer is that right? I did. And just to assist people who may
00:53:10 be watching Sheppard's Court is a residential high-rise block and in August 2016 the fire started
00:53:16 on the seventh floor before spreading up the exterior of the building to the 11th floor.
00:53:22 Is that a broadly correct summary? Yes. And although Sheppard's Court is primarily constructed of brick
00:53:28 the block contained strips of panelling around the windows is that right? Yes.
00:53:32 And it was that panelling that was found to contain combustible polystyrene insulation
00:53:37 which had contributed to the external spread of fire is that right? Yes. Now Mr Daley told the
00:53:43 inquiry that the fire spread at Sheppard's Court wasn't a one-off. Does that accord with your
00:53:48 knowledge? Yes. Would you accept that that fire was yet another example of the risk of significant
00:53:56 external fire spread presented by combustible materials on the external wall?
00:54:02 Yes, but the use of the combustible material in this particular building was much more limited
00:54:09 than we've seen elsewhere. So whilst I agree yes it was, I think it was always unlikely,
00:54:16 in fact impossible, to actually have the same degree of fire spread as we saw at Grenfell Tower.
00:54:22 But nonetheless the same phenomenon? Yes. Now Mr Daley gave evidence that there was nothing in the
00:54:28 the later IMP report for Sheppard's Court about external fire spread resulting from combustible
00:54:34 panels because the incident response was considered to be a success or in his term past the tests.
00:54:41 The lessons of the fire were not disseminated in the LFB. Now would you accept not passing on
00:54:49 learning from successes, not perceived successes, is also a failure in the arrangements for the
00:54:56 dissemination of knowledge of particular risks and here combustible materials assisting rapid
00:55:04 external fire spread? No, not entirely because there is a degree to which we had to be careful
00:55:12 about just how much information we were passing on to fire crews when they had an awful lot coming
00:55:18 at them from other directions as well. So yes it was normal practice to share good practice.
00:55:24 Certainly the PRC process which I know the inquiries heard about before was designed to
00:55:30 share both good and learning points from incident command and also the IMP database was required to,
00:55:40 well it was able there to record good practice as well as learning points. This particular fire,
00:55:47 and I think Mr Daley said this in his evidence as well, was that his view was that the way the fire
00:55:53 was dealt with had demonstrated to some extent the success of the Lackinall House case study
00:56:00 and my view was of the same actually so having attended the incident and taken note of the fire
00:56:07 spread and the way the crews dealt with the fire, I was of the view that the Lackinall House training
00:56:13 package had had some success in helping crews to deal with this fire. Looking at it somewhat
00:56:19 differently, Mr Daley gave evidence and he said this, excuse me, with hindsight one of the things
00:56:26 that the LFB possibly could have done was remind crews of the learning from Lackinall House because
00:56:32 he explained the Lackinall fire had very much more in common with the circumstances of Shepard's
00:56:37 Court than anything else. You're nodding presumably except that that was a reasonably practical step
00:56:45 that could have been taken at the time. Yeah I agree. And there's nothing to be lost even if you
00:56:50 think the lessons have been learned by reaffirming and emphasizing those lessons is there? No there
00:56:54 isn't but that had to be taken in the context of everything else was going on as well and other
00:56:58 things we were communicating to operational staff at the time so things like you know information
00:57:03 around the terrorist threat, how that was changing, the risk was going up and down
00:57:07 and we were introducing new procedures for terrorism, for water rescue, all sorts of things
00:57:14 around climate change. There was lots and lots of stuff we were imparting to fire crews at the time
00:57:19 so there had to be a balance between what we gave them and what we didn't and this one we just didn't
00:57:24 didn't see the necessities to actually communicate this particular incident or the others were.
00:57:30 The point I would like to put to you though following from that is that looked at in the
00:57:37 broad wasn't Shepard's Court confirmation or further evidence that supported the fears that
00:57:46 you had held now for some time seven years or so that serious fires could result from non-compliances
00:57:53 with a misunderstanding of the requirements of the building regulations? Yes it was but it was also
00:58:00 my perspective confirmation that the training intervention that we've taken following Lacknell
00:58:05 House had had some success and I think the our ability to actually deal with the compliance that
00:58:11 we've been speaking about was not entirely in our own hands but that which we enabled our operational
00:58:18 crews to deal with this sort of non-compliance I think Shepard's Court demonstrated we'd had some
00:58:23 success in that. Can we look at what Mr Jack just flowing from that answer what Andy Jack said about
00:58:31 Shepard's Court and he was head of fire safety enforcement and obviously had a background at
00:58:35 CLG as well and he said this an email he sent on the 26th of September 2016 which we can find
00:58:43 LFB trouble zero five two one three five forward slash four and really looking at the middle of the page
00:58:53 he says this I believe
00:58:55 this is I believe this incident is an archetypal example of the issue faced across the residential
00:59:00 built environment due to lack of adequate guidance and consequent historic misinterpretation by
00:59:06 building control bodies of functional requirement B41 to the building regulations. Now did you agree
00:59:15 first of all were you aware of that opinion at the time and if you did did you agree with it?
00:59:20 First of all were you aware of that opinion at the time and if you did did you agree with it?
00:59:24 I didn't see this email but yes I would have agreed with it.
00:59:31 Now if we can stay in Mr Jack's email and go to the panultimate paragraph which starts with the
00:59:36 word overall. Overall although a new version of the ADB guidance is apparently due this year or
00:59:43 next there is an ongoing issue for built environment for the construction and or refurbishment of
00:59:49 blocks that has taken place of the last over the last 30 years or more in relation to materials used
00:59:57 and the approvals potentially given including for window replacement involving spandrel panel
01:00:02 replacement using competent person schemes. Now given the nature of the ongoing issue and
01:00:09 the affected blocks constructed within the last 30 years or so do you accept that the LFB knew that
01:00:15 this was likely to be a widespread problem in the built environment in London? Yes.
01:00:21 And there were many blocks in London that had been built within the last 30 years self-evidently?
01:00:26 Yes. And that the LFB did not have a precise list of nor a number for those buildings? No we didn't.
01:00:36 Now AC Daily said that the delamination of building materials with an internal flammable core
01:00:42 has a has quotes huge implications for firefighting tactics and one of those implications indeed a
01:00:48 significant one was the need for instant commanders to consider the reversal of stay put at a
01:00:54 particular instant depending upon its circumstances. Now that being so can you help us as to why there
01:01:01 was no attempt to forewarn crews and to train them on that and particularly incident commanders
01:01:07 if not after Lacknall then certainly after Shepherds Court?
01:01:12 I don't think Shepherds Court would have been a reason to change that.
01:01:18 I believe it well I think our position was certainly my position was that whilst there was
01:01:24 significant evidence that some of the buildings were non-compliant with some of the regulations
01:01:29 the step to actually inform people about changing the stay put guidance
01:01:36 would have resulted in evacuations from buildings in lots of inappropriate times
01:01:43 and what we had already seen following the Lacknall House fire was people self-evacuating
01:01:48 from buildings when actually they should have stayed put and their self-evacuation
01:01:54 made life much more difficult for attending fire crews because they couldn't gain access to the
01:01:57 building so there was a judgment to be made in terms of how well we spoke to crews about the
01:02:07 need to consider reversal of the stay put policy because there was a danger that it was actually
01:02:13 doing that as well. Now following Shepherds Court the tall buildings facade presentation was updated
01:02:21 to reflect what had been found now again that presentation the circulation was confined to the
01:02:28 fire safety department when Mr. Daley gave evidence about this he said that although there
01:02:33 was no conscious decision not to share the presentation with operational crews it wasn't
01:02:39 necessary because it was not and I'm quoting an emerging trend in the built environment
01:02:45 and it was not something that the LFB had evidence of in this country now would you accept that
01:02:53 that observation is flawed for this reason that high rise facade fires were an obviously foreseeable
01:03:00 trend given what the LFB had encountered over the past decade or so? I think what I would accept
01:03:06 is that given this information was the subject of a presentation within the fire safety department
01:03:11 it's further evidence of the disconnect that existed between fire safety and operational crews
01:03:16 and that shouldn't have been the case. And with the consequence that crews didn't receive up to
01:03:21 date knowledge of the risks that they may be encountering on the fire ground and the way
01:03:25 fires were performing with non-compliant buildings? Yes. Can we turn to an email at LFB
01:03:33 0024232?
01:03:42 Now this is an email from your staff officer Keely Foster
01:03:47 and she emailed you in respect of what was described as a fire summit presentation
01:03:52 and first of all what was the fire summit? To be honest there were a number of things called
01:03:59 fire summits over the years so I must admit I can't remember exactly which one this was.
01:04:03 Can you remember what had prompted the request for or the willingness of the LFB to provide
01:04:10 a presentation on firefighting in high-rise buildings? Can I just read the email? Please do.
01:04:29 Okay it doesn't help I'm afraid in terms of which fire summit this was but I do remember
01:04:44 the issue. Thank you. Just so it's read into the record Keely Foster's email said there's
01:04:51 boss I've asked Richard Mills to look over a previous presentation on high-rise
01:04:56 in preparation for the fire summit on 17th of October and an early draft is attached
01:05:00 for your review. They've asked for a presentation of about 30 minutes on LFB's view and role in fire
01:05:06 strategies in tall buildings including the planning, engineering, enforcement and the
01:05:11 firefighting strategies should the systems fail and a fire develop in these structures.
01:05:16 She goes on to say this in addition to this and not mentioned in this presentation currently
01:05:21 do you think it should also include growing concerns over the cladding of buildings?
01:05:25 This article is quite interesting and details external spread through cladding and insulation
01:05:31 products. Now having read that in in the second line of the email Miss Foster said they have
01:05:38 asked for a presentation do you know who they would have been? I don't I'm afraid. Who usually
01:05:43 organised fire summits then you say there were a number of them? Yeah it could be the fire
01:05:47 sector federation, it could be the chief fire association, it could be the local government
01:05:51 association, it could be any number of private sector bodies, individual companies that are
01:05:58 involved in the fire sector so it could be a range of range of organisations. So fire summit was a
01:06:03 sort of bland catch-all term that was used for meetings at which fire and its various aspects
01:06:09 were discussed? I don't wish to be too unkind but I think people used it when they wanted their
01:06:13 meeting to sound important. Understood. Before we go on to the article that Miss Foster refers to here
01:06:19 would it be fair to say that the LFB did at this stage, so we're talking September 2016,
01:06:26 have quotes growing concerns over the cladding of buildings close quotes?
01:06:32 I think we certainly had knowledge of fire spread in covered voids most particularly
01:06:41 in relation to cladding. I'm not sure that the actual combustibility of the cladding was
01:06:47 the concern she was raising here. Certainly when I read this email my view would have been the
01:06:52 ability of fire to travel through concealed voids caused by cladding rather than its own combustibility.
01:06:58 Now mindful of its date Mr Daley thought that this email had been sent in the wake of investigations
01:07:06 following Shepard's court, does that sound right to you? Not unless the article that she references
01:07:13 here is about Shepard's court and I don't know what the article actually references.
01:07:17 Well we'll go to that article now maybe easier. INQ trouble zero 14891.
01:07:30 Now we see here various photographs of the Carlton tower block in Leeds in 2006,
01:07:35 Shirley Towers, Hampshire 2011 and the Altair in the UAE in 2011.
01:07:42 If we look at the third paragraph below those images the text says this,
01:07:48 also becoming more of an issue is external spread through cladding and insulation products.
01:07:54 A common practice in the UK when refurbishing high-rise buildings is to clad the outside of
01:08:00 the blocks of polystyrene insulation sheets which are at least four inches thick. Then they are
01:08:05 covered with mesh and rendered. This gives them compliance with class one surface spread of flame
01:08:11 and a low fire propagation to BS 476 part 6 1989. Unfortunately once this thin render coat fails
01:08:19 or is disrupted it exposes vast quantities of polystyrene. Installation of these insulation
01:08:25 systems is a highly skilled process that required fire breaks through the wall surface. The guidance
01:08:31 UK ADB and BS 8414 generalises that the insulation material should be of limited combustion
01:08:39 and that the cladding system will not permit excessive fire spread outside the building.
01:08:44 Unfortunately there are already instances in the UK where fire has travelled up the outside of a
01:08:49 high-rise building via a clad insulation system. In one instance Glasgow 2009 it travelled nine
01:08:57 stories. Then if we go over the page there's a diagram of a fire followed by three more photographs
01:09:03 that's showing frame and various glazing failures and in the middle photograph
01:09:10 see that thank you it says fire spread through external cladding in Roubaix 2012.
01:09:17 Now first of all did you read the article that Miss Foster repented to her email?
01:09:22 I can't recall to this I think I probably would have done.
01:09:26 Can you remember what your reaction was to the comment regarding
01:09:29 not only rapid fire spread but the observations on combustibility?
01:09:35 I think my reaction was looking at the photographs as well. Some of the photographs are obviously
01:09:40 much more extensive than others in terms of the fire spread. Some of the photographs I would say
01:09:46 particularly the one on screen at the moment on the left the glazing failure that would be something
01:09:51 that would be completely a normal occurrence for firefighters to have experienced that. Similarly
01:09:59 the picture on the right hand side of the frame currently showing that is what firefighters I
01:10:05 think would expect over the years to experience a normal type of fire spread in any building let
01:10:10 alone a high-rise building. That said that I would have been concerned by particularly the photographs
01:10:16 on the previous page and also the middle photograph in terms of the spread up the building.
01:10:24 One thing that is striking about this article I admit I've only taken you to certain extracts
01:10:29 from it is that it provides yet further confirmation of an apparently widespread
01:10:34 misunderstanding of functional requirement B4 and that those frankly the concerns the LFB had
01:10:41 communicated previously appear to be well founded. Yes. Would you accept that? I do yeah.
01:10:47 Can you remember whether the proposed fire summit presentation was amended to reflect the substance of this article?
01:10:55 No I can't I'm afraid. If it had been amended who would have been responsible for making those amendments?
01:11:04 Probably the person that was going to perform or provide the presentation at the fire summit.
01:11:10 Do you remember whether you did? I can't remember. Is it more likely that someone from fire safety
01:11:15 would have made that type of presentation? To be honest well had it been me to give the presentation
01:11:20 then it probably would have been someone from the fire safety department do it on my behalf
01:11:24 just because of the role that I had but I think it's more likely although not necessarily because
01:11:32 Keighley Foster refers to Richard Mills in her email I believe I saw. Well Richard Mills was
01:11:37 the assistant commissioner for operations so it may well be that we saw this particular fire summit
01:11:42 as more operationally focused than fire safety focused in which case it might be Mr Mills that
01:11:46 made any amendments. Now on the 6th of April 2017 so after you'd retired Mr Daley wrote to all
01:11:54 London local authorities and housing providers and we can find that letter at RBK
01:11:59 00268.
01:12:23 We've seen this letter a number of times now it's entitled tall buildings external fire spread and
01:12:28 if we could look at the third and fourth paragraphs in particular
01:12:35 they say we have seen a number of cases where it appears on the basis of the information available
01:12:39 to us that the level of fire protection to the external face of the building did not comply with
01:12:44 the requirements of part b of the building regulations in so far as they seek to limit
01:12:49 the speed with which a fire can travel and spread over the external face of a building or may
01:12:54 contribute to a fire testing of panels has found that the combustibility of the panels
01:12:59 at shepherd's court did not meet the levels expected for conformity with the building regulations
01:13:04 on testing it was found the panels may deform or delaminate exposing any combustible core or
01:13:10 constituent material resulting in the panel becoming involved in the fire and allowing the
01:13:15 fire to spread and enter flats other than the flat of origin of the fire if we go to the final
01:13:21 paragraph on this page it starts with the phrase in the light of in the light of fires that have
01:13:28 occurred i would urge you to consider carefully your arrangements for specifying monitoring and
01:13:33 approving all aspects of future replacement and improvement to building facades and construction
01:13:38 of new buildings for which you are responsible contracts for the provision and installation of
01:13:43 replacement elements of building facades including installation replacement double glazing associated
01:13:49 spandrel and infill panels must ensure compliance with all parts of part b if they are to secure
01:13:56 public safety and minimize fire losses now my question is a straightforward one would you
01:14:03 accept that this message is one that could and should have been sent by the lfb following the
01:14:08 lateral house fire when sir ken knight declined to do so i'll say it could it could i think the
01:14:16 difficulty with this letter of course is that the the issues around part b are still in existence
01:14:24 and therefore it may well be that the panels that were used at shepard's court actually did comply
01:14:31 originally with with part b because of the the difference interpretation about what the requirement
01:14:36 was so whilst i you know fully support the the the the core of the concept of this letter and the
01:14:42 reason for sending it it wouldn't necessarily have the impact that it was desired to have because
01:14:50 the the issues around part b still existed hadn't been hadn't been resolved by government
01:14:55 so that is a convenient spot it is it is right well uh i think mr dobson that's a good point to
01:15:02 have the break for the morning we'll stop now we'll resume please at half past 11 and as before
01:15:08 please don't discuss your evidence or anything to do with it with anyone else
01:15:12 all right thank you very much you could go to the usher then please
01:15:22 thank you very much how fast to live thanks
01:15:38 you
01:16:08 you
01:16:38 you
01:17:08 you
01:17:38 you
01:18:08 you
01:18:38 you
01:19:08 you
01:19:38 you
01:20:08 you
01:20:38 you
01:21:08 you
01:21:38 you
01:22:08 you
01:22:38 you
01:23:08 you
01:23:38 you
01:24:08 you
01:24:38 you
01:25:08 you
01:25:38 you
01:26:08 you
01:26:38 you
01:27:08 you
01:27:38 you
01:28:08 you
01:28:38 you
01:29:08 you
01:29:38 you
01:30:08 you
01:30:38 you
01:30:55 would you ask mr dobson to come back in please
01:31:08 you
01:31:10 right mr dobson thank you we're ready to keep going thank you thank you very much yes mr can you
01:31:14 thanks sir um the next topic i'd like to discuss with you mr dobson is the lfb's consideration of
01:31:19 the fire safety legislative background and the context um the first subtopic is the lfb elfipa
01:31:27 review of the ro now we've seen earlier in your evidence that you wrote to dclg twice
01:31:34 um seeking clarification on a number of fire safety matters first of all the meaning of common
01:31:40 parts under the order and its application to the common parts now we heard from rita dexter
01:31:47 that elfipa's strategy committee requested the lfb to provide a report on the fire safety
01:31:53 legislative landscape and any issues arising from it and that she was working on preparing that report
01:32:00 now that is the overall context for an email which mrs dexter sent to you
01:32:05 and which we can find lfb trouble zero 861 47 forward slash three
01:32:13 now this is an email chain this one's dated 19th of october 2013 it's a month or so after your
01:32:20 second letter to mr louis and it's entitled nog national operational guidance and the rro mrs
01:32:27 dexter wrote this i'm working on a piece of work for the next strategy committee about the rro
01:32:34 when i look back over the last three to four years i feel disappointed with myself that we
01:32:40 haven't effectively enough marshalled our arguments about the effectiveness of the regulatory fire
01:32:45 safety environment government have approached it in in piecemeal way and responded on the grounds
01:32:51 that they have said but when you stand back and think about whether it all works not just the rro
01:32:57 but the way it works alongside housing act duties and responsibilities and the separate
01:33:02 structural fire safety regimes including building control you have to question whether we should go
01:33:08 back to the drawing board one of my own tentative conclusions was that a simple regime for lots of
01:33:13 very different classes of premises might be wrong in principle and having concluded that i was then
01:33:19 a bit dismayed and a bit amused to find that brian robinson has written something similar in that
01:33:25 futures stuff i asked for a copy of a report which dealt with this idea and when it arrived
01:33:30 yesterday brian was given as the author with a contribution from nick collins dclg published an
01:33:36 evaluation of the rro in march 2009 but in truth this was much too soon which report itself
01:33:43 acknowledges and is quite quiet i think she means on issues that since then have emerged as key
01:33:49 issues and problems sue button was whispering in my ear about nog money at cmb this week
01:33:56 much to seb's annoyance who's seb surgeon edison bunce i think but has caused me to wonder whether
01:34:03 our grants were taking a lump of that up to 50 to 100k to commission a new national question mark
01:34:09 study of what works and what needs to change we ourselves spend over 15 million a year on fsr so
01:34:16 our safety yes and it's difficult to know if that's all good value and effectively targeted
01:34:23 what do you think now we'll look at your response in just a moment but can you help us to what your
01:34:29 understanding was of what mrs dexter was referring to when she stated our arguments about the
01:34:35 effectiveness of the regulatory fire safety environment i think what she was referring to
01:34:43 was that we had some discussions about the regulatory fire safety environment and one of
01:34:49 the real benefits of mrs dexter take on the role of deputy commissioner with responsibility for
01:34:53 fire safety regulation was that she was very forensic in her assessment of things and while
01:35:00 i was really pleased i was keen actually this was one of the things that she would take on in terms
01:35:04 of assessing whether or not we had an appropriate regulatory regime we were working within and if
01:35:10 we didn't what could we do about it now we find your response the next email up to the chain on
01:35:17 page two and it's dated the 25th of october at 2013 you said this i've been thinking quite a bit
01:35:26 about this since your email i think my conclusion is that i agree that we do have a hot potch of
01:35:32 legislation that has been developed over many years and probably does not best serve all of
01:35:36 those involved in dealing with safety in the built environment i also agree that a wholesale
01:35:42 review of this would be a good thing to do however i'm not convinced that it is for us to do alone
01:35:49 and it is certainly not for us to do alone on a national basis however i would be supportive of
01:35:54 a collaborative approach between us and possibly london councils the mayor's office and maybe
01:36:00 others involved in the area the funding for this is something that i have some ideas about but i'd
01:36:05 prefer to discuss these rather than commit them to email excuse me i do however think a consideration
01:36:12 before we take this any further is where it might end up particularly in an environment where
01:36:17 government is only interested in reducing the legislative burden and certainly not on increasing
01:36:23 it want to discuss next week before it goes any further i think in what ways did quotes a hot
01:36:30 potch of legislation not best serve all of those involved in dealing with safety in the built
01:36:35 environment well i think the the responsibilities for fire safety in the built environment were
01:36:41 unclear were in some cases responsibilities were duplicated and others where there was potentially
01:36:48 gaps in responsibility certainly our experience of taking prosecutions under the fire safety order
01:36:56 demonstrated that it was not easy to identify the responsible person if we could identify them it
01:37:02 was not easy to contact them for them or for them to take responsibility their willingness to take
01:37:07 responsibility for what they were responsible for was sometimes dubious and i think because of the
01:37:14 amount of legislation there was and different types there was very few people that actually
01:37:20 had a complete grip on the legislation or understanding it in a practical sense because
01:37:26 i'm sure there were people within the government department particularly who understood it
01:37:31 technically but i was really interested in how we could apply it and understand it in a practical
01:37:37 sense as a fire and rescue authority and i think we were undermined in doing that by the amount of
01:37:42 legislation and by the complexities and the duplications etc within it and is the reference
01:37:48 in your email to reduction of the legislative burden a reference to the government's one in
01:37:55 two out it is but my point there was that i was worried that if we were to
01:38:00 go into this without having thought through exactly what we wanted at the end of it
01:38:04 we might end up in a slightly worse situation than what we were because if the government were to
01:38:09 have taken as an opportunity to reduce the legislation in the area it may well be that
01:38:13 the gaps and our problems in terms of enforcing and ensuring safety might be made more difficult
01:38:19 now you received a reply from mrs dexter a few hours later and that reply starts on page one of
01:38:25 this chain um just below the point which is it starts at the bottom of page one and starts
01:38:35 substantially the top page two when she says okay we should discuss further this is the draft report
01:38:41 that has been issued for the pre-meet with councillor hayward on tuesday it doesn't mention
01:38:46 study but it does refer to questions about whether the current regime is fit for purpose
01:38:51 towards the end it says she quotes also appearing on the agenda for the meeting of the committee
01:38:57 is a draft public affairs strategy that paper reflects the analysis in this report
01:39:02 so there are problems with the current regulatory regime which may well need changing it notes that
01:39:08 this would not be an easy objective to achieve would likely take some years possibly four and
01:39:14 any campaign to achieve it would need to be based on some detailed legal and policy work to develop
01:39:20 a model for a revised ro that we would consider satisfactory it would also need to consider the
01:39:26 interaction of the ro with other relevant legislation including approved document b
01:39:33 and other building regulations and the housing acts 1985 and 2004 i produced the attached report
01:39:40 only last saturday ian and i discussed it during the week who's ian there i think that would have
01:39:45 been i can't be certain i'm he was someone that works in public relations department um at the
01:39:51 lfp at the lfp yes as a result we thought that if well put together we might be able to sell a change
01:39:57 to the regulatory structure under the general deregulation framework if we get rid of old ones
01:40:04 and introduce a new clearer and more functional new one one in two out rule a bit of a stretch
01:40:11 but not impossible so we've also added a further sentence to the public affairs report to that effect
01:40:20 can you help us in your view what were the principal problems with the ro
01:40:25 lack of definition i think was the the main one so we've already heard in evidence about the
01:40:32 lack lack of definition around the responsibilities of the responsible person
01:40:36 that was a real problem i think that the fact that it it removed fire and rescue services
01:40:44 ability or it reduced my primary service ability to enforce in my view when compared to the fire
01:40:51 precaution legislation existed before under which pharmacy services issued fire certificates for
01:40:57 certain classes of premises and in widening the scope it gave pharmacy services a much more in
01:41:03 my view difficult job to do now mrs dexter told the inquiry that she felt that the deficiencies
01:41:11 in the order amounted effectively to a risk to life was that a view she expressed at the time
01:41:19 i can't say for definite but she she might have done but i don't actually recall it for definite
01:41:24 was that a view that you yourself held at the time i think i think my view was that potentially
01:41:31 yes if if the if buildings were being risk assessed on an inappropriate basis
01:41:36 because of the difficulties around the responsible person and the clarity around what
01:41:42 qualifications risk assessor should have that could result in inappropriate or incorrect risk
01:41:47 assessments taking place which could then potentially that endangered life now your response
01:41:54 we can find in the next email up in the chain which is on page one
01:42:00 you say this this is quite a significant report and i can't do it justice reading it on my phone
01:42:06 however i must admit that i'm surprised probably more disappointed really that it could be dispatched
01:42:12 to members without any discussion at cmb or at least informally with me if we go to the final
01:42:17 paragraph of your email you say this there are bits of the report that i don't think are accurate
01:42:23 and others with which i simply disagree but as it has now gone to members already i don't suppose
01:42:29 it's worth commenting now now we'll look at the detail of the report in just a moment but can you
01:42:36 help us what was the essence or the gist of your disagreement with mrs dexter just that this was a
01:42:41 quite a significant recommendation to make in terms of reviewing the legislation this way
01:42:48 it would require significant resources from london fire brigade we also worked in a very political
01:42:54 and politicized environment this is making a recommendation to elected members to take on
01:43:01 the piece of work that hadn't been discussed with me and been therefore there's been no funding
01:43:07 either and my concern would have been that london fire brigade or even elfiba taken on this action
01:43:14 on its own would result in quite significant cost potentially and actually potentially wouldn't get
01:43:22 its due deserves in terms of consideration because it was done by one fire rescue service
01:43:28 and one fire authority it would at least in my view have needed support from the greater
01:43:33 and also the mayor's office thank you now we can see at the very head of this email chain that you
01:43:40 received a response from mrs dexter on the 28th of october 2013 and she said this as i said i would
01:43:48 i've looked at this report again to see where it could be refined in line with your comments
01:43:54 now that sentence tends to suggest that you had had an offline discussion with mrs dexter
01:44:01 about the report um is that right first of all possibly probably i would say
01:44:07 and but i don't know whether or not the amendment she's might referring to there is the ones that
01:44:11 you mentioned earlier that were you said were insignificant or not very important it may have
01:44:16 been those ones right what instruction did you give her can you remember now
01:44:22 uh well there would have been a discussion i'm sure there would be discussion but i can't remember
01:44:25 the detail of that now did you make your views known to her that you were um not happy that this
01:44:33 report had been circulated without discussing with you beforehand well i think i did that in the email
01:44:38 that you read out earlier but re-emphasizing that point now we have the version of the report that
01:44:44 mrs dexter amended in line with your comments and observations that can be found at lfb 0086148
01:44:52 now we can see from the top that the title has changed from fire safety legislation does it work
01:44:59 to the more neutral relatively speaking fire safety legislation review of current legislation
01:45:07 first of all why did you request that particular change just i just felt that it it um the the
01:45:15 the original um drafting might have given a view that we already decided what the review was going
01:45:20 to actually find and i think it's made it more neutral one and made it more of a impartial review
01:45:27 mrs dexter suggested that the change may have been prompted by a view on your part that the
01:45:33 reservations or the conclusions in this report have been overstated or overdone in some way
01:45:38 and that you preferred not to be in a rush on this matter is that a what would you what would
01:45:44 your response to that i think i think i probably made that recommendation that that changed there
01:45:49 if that one was in fact for me for me um i think i made that probably when i was on the first that
01:45:54 was the first thing i read of the paper and that was my first comment comment i wouldn't have read
01:45:57 the whole paper and then gone back and made that that change as i said she observed that
01:46:03 you were quote not in a rush on this topic um what would you say to that
01:46:08 um
01:46:10 i'm not sure that i have you really in terms of how quickly it was going to go i think we were
01:46:14 already required to take a paper this paper to the strategy committee um and i was happy with us
01:46:20 taking it at that place now where it was going to go after that was a different issue because i
01:46:25 don't know that the strategy committee was a strategy committee i don't think would have had
01:46:29 the authority to take this forward on their own anyway we probably would need to go to the
01:46:33 full authority to spend money this way could it have been a reflection of your concern
01:46:38 that the necessary groundwork had not been laid before putting forward a paper such as this
01:46:45 potentially yes now if we can go over the page page two and the first paragraph
01:46:52 you see that under the heading introduction background the paper says this the committee
01:46:58 has decided that it wishes to undertake a review of the effectiveness of fire safety legislation
01:47:04 officers do not see this as being only the fire safety regulatory reform order 2005 the rro
01:47:11 the work will need to concern itself with legislation and regimes that are not under
01:47:16 control or direction of the fire service there is arguably as much potentially effective fire safety
01:47:22 legislation under the control and delivery responsibility of other local authorities
01:47:28 and others as fire authority as fire authorities how well responsibilities are a understood and b
01:47:35 exercise will need to be a feature of this work now if we go to page nine rather than paragraph 34
01:47:45 now we see that under the heading do the necessary tools and competencies for the task exist the text
01:47:52 said this the lacnal house experience provides some insight into the kinds of failure that can
01:48:00 occur illustrating some tasks not undertaken and others undertaken without sufficient regard
01:48:07 others undertaken without sufficient regard to relevant fire safety considerations
01:48:13 now we can see on the screen that mrs dexter deleted the text at the start of that passage
01:48:20 which previously read based on the experience of the brigade there is room for doubt and that she
01:48:27 added the following however although it is difficult to quantify it seems highly likely to be the case
01:48:34 that many london local authorities and other public bodies have since sharpened their focus
01:48:40 and increased their investment in respect of their fire safety management responsibilities
01:48:45 the newly established high-rise forum has demonstrated a great deal of enthusiasm
01:48:50 for better competence and better action were those changes affected as a result of your
01:48:57 comments and observations i really can't remember i'm afraid can you help us now
01:49:04 refreshing your memory why the line based on the experience of the brigade there is room for doubt
01:49:09 was removed once again i think this is mark this was just a drafting issue i might have commented
01:49:16 on that my view on that on that sentence would have been that's unnecessary to put that in the
01:49:20 report i think the report is actually we wouldn't be doing the report at all if there wasn't any
01:49:24 any doubt around it i don't think any needs of restating in that paragraph
01:49:29 to what extent had the brigade experienced a sharpening of focus to use mrs dexter's phrase
01:49:36 post lacnoe sorry could you repeat the question yes of course you see the text that's added here
01:49:42 yes local london local authorities and public bodies had sharpened their focus since lacnoe
01:49:48 was that the brigades experience yes and what the brigade was encountering was more examples
01:49:56 of misunderstanding of relevant fire safety legislation including the building regs and
01:50:02 prove document b is that right yes
01:50:07 do you think that phenomenon suggests that london local authorities had not in fact sharpened their
01:50:13 focus or at least not done so effectively i think they had sharpened their focus
01:50:21 perhaps not as effectively as they could have done can you help us why do you think they had
01:50:25 sharpened their focus it's a bit unclear given the continuing concerns to which you know the
01:50:30 contemporaneous correspondence speaks to i think they were i think the whole issue of the lacnoe
01:50:36 house fire and the the causes and the issues of related for lacnoe house so they were starting
01:50:43 to emerge were causing local authorities to review their own policies and procedures
01:50:48 in relation to the management and maintenance of their social housing their high rise in particular
01:50:55 and also in relation to the way they contracted with external bodies to carry out refurbishments
01:51:01 and changes to the building and in relation to the latter did you find that their requirements
01:51:06 regarding assurances that materials complied with relevant legislation were more onerous
01:51:13 or more demanding i've got no evidence either way actually now if we can go to page 11 in this
01:51:18 document and really the conclusion section you'll see paragraph 43 says this also appearing on the
01:51:27 agenda for the meeting of the committee is a draft public affairs strategy that paper reflects the
01:51:33 analysis in this report that there are problems with the current regulatory regime which may well
01:51:38 need changing it notes that this would not be an easy objective to achieve would likely take some
01:51:45 years possibly four and any campaign to achieve it would need to be based on some detailed legal
01:51:50 and policy work to develop a model for a revised ro that we would consider satisfactory it would
01:51:57 also need to consider the interaction of the ro with other relevant legislation including approved
01:52:04 document b and other building regulations and the housing acts 1985 and 2004 now we have the public
01:52:12 affairs strategy report it can be found at lfb trouble zero three two three four two and if we
01:52:21 turn to page two it begins by explaining that the paper's purpose is to set out a strategic approach
01:52:31 to public affairs campaigns and policy work on key prevention and protection issues and then we see
01:52:39 over pages two and three starting halfway down page two it sets out campaign criteria now if we
01:52:47 can go to the foot of page three the text deals with what are called campaign candidates and if
01:52:59 we could look at paragraphs eight and nine in particular they say this eight the regulatory
01:53:05 reform fire safety order 2005 ro approved document b and related legislation the ro has known flaws
01:53:15 as a regulatory framework for fire services the recent exchange of correspondence between the
01:53:20 commissioner and dclg officials shows that there is vagueness in the existing regulations for
01:53:26 example in relation to inspection of common parts in blocks of flats and that seeking clarification
01:53:32 from government is not likely to be successful the brigade also experiences repeated problems
01:53:38 in progressing investigations because fire officers do not have powers to compel witness
01:53:44 statements or seize relevant documents it is possible that progress might be made through
01:53:50 formal guidance but it is more likely that a revised ro or replacement secondary legislation
01:53:56 would be needed nine this is not an easy objective to achieve would likely take some years possibly
01:54:04 four and any campaign to achieve it would need to be based on some detailed legal and policy work
01:54:10 and effectively reflects the paragraph we just discussed from the substantive paper did you
01:54:16 agree at the time that the fire safety legislative landscape was a good candidate for an lfe pa
01:54:24 campaign of lobbying um i wasn't convinced completely no if i can stop you there what
01:54:30 were your reservations well my reservations were that whilst i completely agreed that it was good
01:54:37 a good candidate for a public affairs campaign or for action to try to get
01:54:41 out encourage a review to improve it i wasn't sure i wasn't convinced that that was something
01:54:47 for lfe pa to do alone now in evidence mrs dexter considered that her fire safety legislation report
01:54:57 would provide the background or the foundation for some external research now we know that an
01:55:03 independent study was ultimately conducted by the bre and let's turn to the bre's report
01:55:11 lfb trouble zero 46812
01:55:16 it's dated the 9th of september 2015 and i think you'll remember this is a long and
01:55:22 somewhat technical document but nonetheless there are some discrete matters that we should
01:55:28 explore together now there we go we've got the front page there if we could turn to page three
01:55:39 we see the
01:55:42 next steps if we turn over page four
01:55:49 roughly half halfway down the page we've got sorry the subheading next steps and we see five
01:55:55 bullet pointed recommendations in broad terms they focus on community collaboration between
01:56:01 regular regulators review of guidance and competency of fire risk assessors now below that first list
01:56:10 there is a second list of bullet points which is preceded by the text which says this the other
01:56:18 most widespread concerns identified are and the bullet points read thus enforcement of other
01:56:26 related legislation such as housing act and building regulations the fso is seen as a tool
01:56:33 to pick up the pieces secondly the competency of fire safety managers risk assessors both in-house
01:56:41 contract and their understanding of quotes risk close quotes the competency of enforcement
01:56:48 officers the understanding of open speech marks risk close speech marks and consistency of
01:56:55 approach both within and between fire and rescue services fourthly the significant rise of independent
01:57:04 living premises that are care homes in all but name and regulation fifthly dealing with the common
01:57:12 areas and blocks of flats and similar finally the inspection of individual flats in blocks of flats
01:57:19 in particular their front doors now when you read those recommendations and concerns was it your view
01:57:26 that the list had fully captured the concerns that the lfb had held regarding the inadequacies of the
01:57:33 ro yes i would say yes there's nothing missing in your view not not that i can think of now
01:57:42 now the bre report was never published do you know why it was never published um no
01:57:51 i believe was it not published with the authority report the report on this that went back to the
01:57:55 strategy committee our understanding is that it wasn't published okay but you're unable to
01:58:00 i can't account for that now can we now turn to a separate topic which is the fire safety
01:58:06 department's concerns about the order now if we can start with the evidence of mr daily
01:58:13 he explained that the fire safety department's concerns centered on poor compartmentation in
01:58:18 buildings and the application of ro to compartmentation itself now we took mr daily to the report
01:58:27 which we can find at lfb trouble zero two five six five four
01:58:39 as you can see this is an lfb internal report it's headed to entitled compartmentation issues
01:58:45 within the built environment and it's dated the 26th of november 2015 so two months after the bre
01:58:54 report we've just looked at now if we look at the summary on this page it says this
01:59:01 compartmentation is the subdivision of a building by fire resisting walls or floors for the purpose
01:59:07 of limiting fire spread within the building for a given period of time the success of many building
01:59:14 evacuation strategies are heavily reliant upon adequate compartmentation especially in buildings
01:59:20 where the majority of occupants other than those directly affected by fire
01:59:24 stay in the building in the event of fire fire safety officers are increasingly aware of fire
01:59:31 stopping issues in new and refurbished buildings this awareness has been raised as a result of
01:59:37 post-fire reviews of buildings where there has been unusual fire and smoke spread through
01:59:44 partnership work and through investigative work by other fire and rescue services
01:59:50 the general conclusion is that compartmentation issues within the built environment are
01:59:54 widespread due to either poor workmanship or a lack of oversight of building quality
02:00:00 by building control bodies and main contractors an overall strategy to address fire stopping
02:00:06 issues and london's building stock is needed the london strategy will benefit from coordination
02:00:11 with other stakeholders to integrate our work with any proposed national strategy
02:00:17 now perhaps one of the most striking features of that summary is the extent to which it reflects
02:00:24 the substance of the concerns that you communicated to officials and ministers at dclg were you aware
02:00:31 of and did you inform the substance of this particular paper um i've certainly saw the paper
02:00:39 i can't remember being involved in a discussion about it beforehand but i may well have been
02:00:43 so i really can't remember if i actually had involved in the draft i didn't have
02:00:47 involved in drafting but certainly in terms of the content probably looking at what set out in the
02:00:54 summary it would appear that you'd agree with the substance of what's set out i would can we look
02:01:02 at the foot of this page and the recommendation we find there
02:01:09 what it says is that the lfb should develop a and i quote a strategy to reverse the trend of
02:01:16 compartmentation failures and fire stopping issues as part of fire safety regulations lsp that's
02:01:22 london safety plan yes yes six proposals now presumably those particular proposals were put
02:01:30 before you for your consideration um it mentions lsp 6 um i think london safety plan 5 was the last
02:01:38 one that i was responsible for so if that's correct and it doesn't mean lsp 5 then i probably wouldn't
02:01:43 have seen them okay now this report appears to have fed into a yet further later report
02:01:50 dated august 2016 and if we could turn to that please um lfb 00120301
02:02:00 thank you um as you can see this report entitled fire resisting compartmentation flats was written
02:02:14 by the head of regulatory enforcement and fire safety andy jack now mr daly could not recall
02:02:21 whether this report was put before the cnb are you able to help us on that point i don't recall it
02:02:30 and the fact that the date says tbc would indicate to me that perhaps it wasn't now if we can look at
02:02:35 the first paragraph of the summary it reads thus the application of the regulatory reform fire
02:02:44 safety order 2005 rrfso to the walls floors and ceilings separating the flats from one another
02:02:53 the compartmentation in residential blocks is as yet untested in law application to common services
02:03:01 such as soil pipe rises that pass through multiple flats is also untested to increase public safety
02:03:09 particularly in specialized housing and conversions it is necessary to clarify the position through
02:03:15 enforcement and where necessary rulings in the courts now as we go through this document
02:03:22 the draft explains the importance of compartmentation at page two
02:03:28 if you could look at the bottom paragraph in particular and it says this the compartmentation
02:03:34 between flats is of vital importance to prevent the spread of fire through a building containing
02:03:40 multiple dwellings and is essential if an evacuation strategy based on defending place
02:03:47 is to be utilised in the building in the absence of adequate fire resisting compartmentation
02:03:54 fire and or products of combustion are liable to spread into other dwellings in the block
02:03:59 and all the means of escape in the absence of an early warning of fire persons in those premises
02:04:06 may be overcome or prevented from making a safe escape if we turn over the page and look at the
02:04:11 first paragraph on page three it says this the ongoing experience of the authorities inspectors
02:04:19 is that fire risk assessments rarely consider compartmentation in areas of the building away
02:04:26 from the means of escape and rarely consider services that run through flats e.g. soil pipes
02:04:33 and ventilation consequently scant factual basis is available to justify or validate use
02:04:41 of a state put emergency plan now those compartmentation concerns combined with the
02:04:48 lfb's knowledge of widespread misunderstanding of or non-compliance with the building regulations
02:04:56 evidenced a very real risk of serious rapid fire spread and a number of high rising high rise
02:05:02 buildings would you agree with that proposition i would my only comment i would make though is that
02:05:08 as mr jack quite rightly mentions in in this report that the the evidence of these failures
02:05:15 actually in flats was scant and that's because we had no there was no ability for the fire rescue
02:05:22 service to inspect inside people's flats the ro was confined to the common areas of the building so
02:05:28 the evidence for this would have been confined to fire investigation reports where fires have
02:05:32 actually occurred or through inspections of common areas of buildings what that amounts to though is
02:05:39 that the lfb was aware of the existence of the risk would you agree yes where there was doubt and
02:05:45 concern was that you didn't know its full extent is that a fair summary agreed now if we can look
02:05:52 stay on this page of the of the draft we see various examples there of fire safety breaches
02:05:59 that had violent or breach compartmentation at various incidents the first of which was at
02:06:07 lacna which we can see in the first bullet point there now if we can go to page eight and the
02:06:15 conclusion section what is said there is this and it's at the top of the page there are significant
02:06:26 examples sets the word significant again examples of compartmentation issues posing high levels of
02:06:32 risk to the public more examples are very likely to be discovered and so rectified as a result of
02:06:39 fire risk assessments before fires occur pushing the boundaries of the rrfso to ensure that this
02:06:46 happens is in the interests of public safety
02:06:53 put more bluntly was the lfb strategy in effect to hope that is identified buildings with poor
02:07:01 compartmentation before a fire broke out well we were always focused on that yes
02:07:09 and that is why if we turn to the first page of this report under recommendations
02:07:14 we look at recommendation b b for bravo it said that the decision be taken on implementing the
02:07:23 lf epa stance on the rro and i quote on the basis of either promoting application with view to
02:07:31 housing providers updating fire risk assessment over an agreed period of time for example via
02:07:37 via their own inspection regime or i emphasize this awaiting a further significant
02:07:44 instant or audit result and using that as a catalyst for immediate action across the sector
02:07:53 if i can put this again bluntly that appears to amount to the lfb knowing
02:08:00 it's got a ticking time bomb would you agree with that
02:08:05 agree with this lfb recognize and we've got a problem yes
02:08:12 now mr daly told the inquiry that keep the key points in this report were that that stay put
02:08:19 as an evacuation strategy that should only be relied upon where it can be established
02:08:24 that a building's compartmentation is effective also that the lfb held concerns
02:08:30 excuse me that fire risk assessors were not able to assess the compartmentation
02:08:36 building as a whole and drawing that together he also told us that a lot of the lfb's rro enforcement
02:08:43 activity was and i quote predicated on compartmentation because it is a significant risk
02:08:50 where we find it's being breached now mindful of that mindful of the evidence that we've been
02:08:56 reviewing both on thursday and again this morning do you accept that there's a failure of the brigade
02:09:03 during your tenure as commissioner to take effective steps to ensure that the risks
02:09:09 flown from misunderstanding of a non-compliance with the building regulations were clearly
02:09:15 communicated to operational staff i don't accept that completely no because i believe
02:09:24 the operational staff were made aware of the risk of failure of complementation they would have got
02:09:28 that through their their own operational experience and also through training they've been given in
02:09:34 relation to compartment compartmentation issues generally however i do recognize that this was a
02:09:42 significant issue within the fire safety department that wasn't made as clear to
02:09:47 operational staff as it might have been however i'm not sure what difference that would have made to
02:09:54 operational staff in terms of the way they went about their day-to-day job because their role is
02:09:58 to deal with the circumstances with which they're faced with and they had procedures that would
02:10:03 enable them to deal with the files that they they came across and actually the evidence suggests
02:10:08 that most of if not all the high-rise building fires and other fires the london fire brigade
02:10:14 dealt with during the period were successfully dealt with now mr daily gave evidence that not
02:10:19 withstanding the concerns about compartmentation the lfb would assume that a building was properly
02:10:25 maintained and that compartmentation was intact unless the particular conditions and dynamics of
02:10:31 an incident suggested otherwise now based on what the lfb knew would you agree that that assumption
02:10:39 was fundamentally unsound for the reasons we've been discussing this morning
02:10:45 i wouldn't say it was completely unsound no because once again i go back to the fact
02:10:49 firefighters are used to dealing with incidents where things have gone wrong
02:10:54 and most of the failures that we is the jackie's talking about here are certainly failures that
02:11:00 would endanger life but they're not failures that would fundamentally undermine the whole
02:11:04 safety of the building the other side to that of course is that if we were to
02:11:10 work on that basis the option we have the only options we have is to seek the people responsible
02:11:18 for the buildings to actually correct the buildings or to repair them or actually to adopt a
02:11:24 strategy whereby we don't accept the compartmentation in any building and therefore we have a general
02:11:31 escape evacuation of all high-rise buildings which i don't think would have been
02:11:35 effective justified or safe i'm now going to move on to another topic and that is the actions taken
02:11:43 by the lfb after the laknow fire but before the inquest started in january 2013 now the first
02:11:52 start of the or the starting point for the discussion i'd like to take you to is the 34
02:11:57 pre-actions that the lfb identified before the inquests started and we've gone to this document
02:12:04 now a number of times but if we can go to the action plan which was append or concluded within
02:12:09 the minutes of the laknow house board meeting for the 15th of september 22 and that can be found
02:12:15 lfb trouble zero eight four zero three one four slash seven
02:12:20 so
02:12:42 thank you
02:12:42 now could we look first of all at action one at the top of the table which concerns analysis of
02:12:51 high-rise policy and if you look towards the bottom of the page action six which is to review high-rise
02:12:58 policy now the policy we're concerned with is pn 633 is that right yes now all those these
02:13:06 although these actions were identified and crystallized in september 2010
02:13:11 we heard from peter caup when he gave evidence that on the 14th of july 2009 so
02:13:18 11 days after the fire at laknow the national gra 3.2 and high-rise firefighting was prioritized
02:13:25 for a review and in light of laknow and that the lfb led that review and mr caup also explained
02:13:33 that the work informed and was heavily intertwined with the review of 633 yes does that reflect your
02:13:39 own memory yes it does now shortly after latin alfas ken night prepared a report for the secretary
02:13:45 of state on the issues that have been identified at that preliminary stage and we can find that
02:13:50 report at h o m quadruple zero one zero nine two
02:14:03 we can see that the the bottom right hand corner of the report the date is the 30th of july 2009
02:14:12 do you remember seeing that report at the time no
02:14:14 no
02:14:19 can we take it therefore that this was an internal document to clg yes have you ever seen it
02:14:28 up before today or at least before preparation for your witness statements
02:14:33 i don't recall seeing it previously could we go to page 33
02:14:38 thank you
02:14:41 now we see in the bottom half of that page sir ken set out what he described as operational
02:14:48 guidance emerging issues he said this the chief fire and rescue advisor's team has conducted a
02:14:54 preliminary review of the national operational guidance relating to high-rise buildings the
02:15:00 incident command system and breathing apparatus procedures from this preliminary desktop review
02:15:07 no urgent or immediate requirements for current national operational guidance to be significantly
02:15:12 changed however there are some concerns that this guidance will need further clarification
02:15:20 and additional information particularly in the areas of simultaneous multi-level fires
02:15:26 fire behavior within high-rise buildings safe systems of work and systematic search procedures
02:15:32 so when the lfb later acquired responsibility for the revision of gra 3.2 did you understand
02:15:39 that these particular areas set out here would be addressed even if you hadn't seen sir ken's report
02:15:46 yes and those matters would be addressed together with any more detailed findings arising out of the
02:15:54 are rising out of the lacnole inquest's investigation yes
02:16:00 was it also your expectation that these matters would be addressed in the review and revision
02:16:06 of pn 633 yes
02:16:11 now peter cowt told us that in the immediate aftermath of lacnole the lfb had identified
02:16:17 the principal characteristics of the lacnole fire and they included the following compartmentation
02:16:23 had not subsisted fire had spread unexpectedly and rapidly and that external fire spread had
02:16:29 been facilitated by the presence of non-compliant facades given your correspondence with sir ken
02:16:36 and dclg presumably you agree with that essential summary i do now to implement pre-action one which
02:16:45 we looked at at the start of this session analysis of high-rise policy a gap analysis was carried out
02:16:51 by dac kevin hughes and we can find that at lfb trouble zero five nine five seven nine double eight
02:16:59 so that's lfb trouble zero five seven nine double eight
02:17:10 and if we go to page two
02:17:11 we can see from the heading of the columns that the 2008 version 2 of gra 3.2 was compared and
02:17:24 contrasted to the brigades then pn 633 yes now and we see various the gap analysis and recommendations
02:17:33 flowing first of all were you aware of this gap analysis when it was prepared yes did you review
02:17:40 its contents i did were you satisfied that the gap analysis had captured all relevant points
02:17:48 i believe so if there's anything that i wasn't unhappy with i would have gone back to um not
02:17:55 directly to mr hughes probably and i would have raised him at the lacon or bald no as mr calp
02:18:02 confirmed the gap analysis captured a number of points for inclusion and adoption in pn 633
02:18:10 first one was that pn 633 like gra 3.2 provided and i quote limited information on rapid fire
02:18:18 spread and subsequent failure of compartmentation on the fire floors and secondly that pn 633 and
02:18:25 i quote could be enhanced with the inclusion of further information on building evacuation strategies
02:18:31 and by inclusion of further information on the challenges of the competing demands
02:18:36 of assisting residents evacuate from a place of relative safety and deploying to attack the fire
02:18:41 additionally how to control large numbers of residents that could evacuate from a residential
02:18:46 high rise now do you remember those specific points i don't you do i think so yes did you also
02:18:55 consider them to be important yes were you satisfied having reviewed and considered the
02:19:01 gap analysis that the relevant lessons from from lacno had indeed been captured yes not only in the
02:19:09 gap analysis but also in any recommendations that flowed from them yes now the document itself
02:19:15 suggests that its purpose was to make recommendations for the next iteration of pn at 633 and mr calp
02:19:22 confirmed that was the case and that extensive reference was made to the gap analysis in the
02:19:27 next iteration were you aware of that yes now we can find that particular policy at lfb double zero
02:19:35 one zero two three zero six and we can see from its date of the head that it was reviewed as current
02:19:51 the 18th of november 2011 now did you assure yourself that this policy effectively and fully
02:19:58 addressed the lessons of lacno not only has identified in the gap analysis but also the
02:20:03 lessons that you yourself had identified from that instant this was sort of been discussed at the
02:20:09 lacuna house board and i would have asked officers there exactly that question yes and so the answer
02:20:15 to my question is that you did satisfy yourself by the means you just identified yes
02:20:19 yes now can we go to page 15 and appendix one
02:20:28 now as you can see this instructs crews to consider a number of matters which are set out
02:20:35 a paragraph form and if we can look at the 10th bullet point which starts with the words the
02:20:42 likelihood
02:20:45 you see that bullet point says this the likelihood and impact of any fire spread
02:20:50 beyond the compartment of origin and the potential for multiple rescues
02:20:57 now whilst crews are directed to be familiar with the matters set out here and the impact on
02:21:04 firefighting and search and rescue do you accept that that single bullet point provides no guidance
02:21:10 to crews as to what to do in the event that fire spread beyond the compartment of origin
02:21:19 uh well this this paragraph is in respect to 72d visits isn't it so this is about the
02:21:24 identification of issues rather than the operational dealing with them which i believe will come
02:21:28 elsewhere in the document so this particular bullet point in my view is asking crews to
02:21:36 look at the building in relation to mainly the occupancy actually because the crews would not
02:21:41 be able to carry out any invasive or intrusive examination of the building itself so they will
02:21:49 be looking particularly here about things like the housekeeping of the building itself so during
02:21:54 their visit were fire doors wedged open were fire doors ineffective was there inappropriate
02:22:01 storage taking place on landings or in corridors that's the sort of thing i think which is picked
02:22:06 up particularly by that and rather than an intrusive survey of the structure of the building
02:22:11 where would you expect crews to derive guidance on how best to respond what to do in the event of
02:22:19 compartmentation failure which necessitated multiple rescues where would they find the
02:22:24 guidance on that elsewhere in this document it should be it should be it okay well come on to
02:22:28 that okay can we go to bullet points further down here which said which instructs crews who
02:22:34 are conducting some 2d visits to and i quote ensure that they are familiar with it says their
02:22:43 floor layouts and any building construction features which may promote rapid or abnormal
02:22:48 fire spread such as sandwich panels timber frame construction atria or voids now you can take it
02:22:55 from me that that language has been adopted from gra at 3.2 version 2 and it has removed the reference
02:23:03 to cladding systems now first of all were you aware that that reference to cladding systems had been
02:23:09 removed no given the content of your correspondence with dclg officials and ministers
02:23:22 is reference to cladding systems something that you would have expected to see dealt with here
02:23:28 in the list of facts and matters to which crew should have regard when carrying out section 72d
02:23:33 visits if cladding was specifically mentioned in the gra then yes and you can see no good reason
02:23:39 why it was not included not on the face of this not
02:23:43 now following the adoption of the revised pn 633 in november 2011 you'll be aware that the lfb
02:23:52 continued to work on version 3 of gra 3.2 that version was ultimately published in february 2014
02:24:00 and thereafter a further revision to pn 633 was brought into effect in june 2015 now
02:24:10 we've discussed the substantive drafting of both those documents with mr cap and mr utting so i
02:24:15 don't want to go over that ground with you there are however a few matters that i'd be grateful to
02:24:20 explore with you and to see what your views are on particular subjects okay could we stay with the
02:24:26 subject of cladding now the 2008 edition of gra 3.2 identified cladding systems as potentially
02:24:34 promoting abnormal or rapid fire spread now by contrast the 2014 version of gra 3.2
02:24:41 retained the reference to cladding systems as a building construction feature but removed the
02:24:47 text that these and other building features may have promoted rapid abnormal fire spread
02:24:55 mr cap described that and i'm quoting as an oversight
02:24:58 and he added that his department and i'm again quoting did not understand the hazard of cladding
02:25:04 now given that evidence from mr carol do you accept that a failure to transfer the fire safety
02:25:09 department's knowledge post-lacknol knowledge i emphasize of the risks posed by external walls
02:25:16 and external panels as well as your own concerns you'd expressed in correspondence contributed to
02:25:22 wall and external panels as well as your own concerns you'd expressed in correspondence
02:25:27 contributed to mr cow's lack of understanding yes
02:25:35 mr cow also said that he would and again i quote very much close quotes have expected the regulatory
02:25:42 fire safety department to have brought materials concerning combustible cladding for example the
02:25:47 2012 lga guide on fire safety and purpose built blocks of flats to his attention and they didn't
02:25:53 do so would you accept that incident of itself was a failure of internal communication within the lfb
02:26:02 yes can you assist the panel as to why there was such an important set of communication
02:26:10 on a matter that had been occupying the lfb at the most senior levels for some time i can't
02:26:17 account for that i'm afraid can we return to the statement that you provided to the
02:26:25 macklehouse inquest and that can be found lfb at quadruple zero zero seven one seven
02:26:38 if we could turn to page 16 and paragraph 53
02:26:42 as you can see this paragraph is under the heading state policy and fire survival guidance and you said this
02:26:54 the established state put principle both in london and nationally is predicated on the expectation
02:27:00 that residential high-rise premises are constructed and maintained in accordance with statutory
02:27:06 requirements it follows that if a fire takes hold in a flat it should be safe for persons
02:27:12 elsewhere within the building not affected by fire and or smoke to stay where they are 54 indeed
02:27:21 there's no safe basis upon which to fight fires and carried out rescues in high-rise residential
02:27:27 buildings excuse me because they are not designed or managed in a way which permits mass evac
02:27:35 mass evacuation a sufficiently wide single staircase and or multiple escape routes appropriate
02:27:42 fire alarms and evacuation policy including an up-to-date record of people within the building
02:27:48 and awareness by residents of this policy would all be necessary to allow a mass evacuation approach
02:27:54 this equally applies to a partial evacuation in the case of lakon are not similar to most other
02:28:00 residential high-rise blocks there is no communal alarm system and the single staircase is not
02:28:07 wide enough for all residents to leave simultaneously now bearing in mind what you've set out there
02:28:15 would you agree that by march 2013 the brigades collective knowledge was that the assumption or
02:28:22 expectation that residential high-rise premises are constructed and maintained in accordance with
02:28:27 statutory requirements was neither a safe nor reliable one in all circumstances no i wouldn't
02:28:34 agree with that why wouldn't you agree with that because i think the evidence was that in many
02:28:38 many premises where where fires actually did occur the staple policy despite the breach of some
02:28:44 types of compartmentation was still an effective strategy to allow fire fighters to get into the
02:28:48 building and actually deal with the fire and had we taken the assumption that no building was
02:28:53 any longer compliant then that would have mean evacuation of all buildings immediately there was
02:28:59 a fire that would have undermined the ability of firefighters to deal with the fire and in my view
02:29:04 endangered some of the residents unnecessarily but i think the question was slightly more nuanced than
02:29:10 that was that the assumption or expectation that residential high-rises would be constructed in
02:29:18 accordance with requirements was not safe or reliable in all circumstances and at that stage
02:29:23 march 2013 you're aware of a significant instance of buildings which didn't comply with the
02:29:32 regulations and so the question is you knew by march 2013 when you wrote the statement that it
02:29:38 wasn't an expectation or assumption that held good in all circumstances and i'd underline
02:29:43 that. No, not in all circumstances but still maintain the point that actually had we tried
02:29:51 to move away from that given that most of the fires which land and fire get attended where
02:29:58 breach of compartmentation was experienced the general strategy of stay put still worked
02:30:04 and those people that were in flats where smoke got into despite them not actually having a fire
02:30:12 those residents would leave that flat so that would be the expectation in line with the policy.
02:30:16 Now the key word in that answer i suggest to you is the word general. What is missing in this
02:30:22 witness statement is the acknowledgement that it is a general provision that there are circumstances
02:30:29 in which the generality does not hold good. Would you accept that that necessary qualification is
02:30:34 missing here? Yes. And that is a qualification which the coroner ought to have been informed of
02:30:39 Would you accept that? Yes. Now during his evidence Mr Carrot, I took Mr Carrot to a series of emails
02:30:48 which illustrated and set out CLG's concerns about the drafting of GRA 3.2 and in particular
02:30:56 the point that they didn't adequately address the coroner's recommendations which have been
02:31:00 directed towards the Secretary of State. Now if we can go to HOM quadruple zero double zero one eight forward slash two
02:31:15 And we see in the second paragraph
02:31:28 their concern was that to really deal with the recommendation that GRA 3.2 be reviewed to provide
02:31:36 consolidated national guidance on from second bullet point down awareness that fire can spread
02:31:42 downwards and laterally in a building awareness of the risk of spread of fire above and adjacent to
02:31:48 a fire flat awareness that insecure compartmentation can permit transfer of smoke and fire between a
02:31:54 flat or masonet and common parts of high-rise residential buildings which has the potential
02:32:00 to put at risk the lives of residents or others with those concerns that the lfb draft did not
02:32:06 encompass those four matters with those concerns directly communicated by dclg to you not to me no
02:32:19 You told us that you were aware at the time of the rule 43 letters
02:32:26 that a response had been sent by Lord Pickles I think who was then Secretary of State. Were you aware of
02:32:31 the assertion in the second page of the CLG response and I'll take you to it so you can see what I'm
02:32:35 talking about HOM 000 4743 forward slash two
02:32:49 And if we look at the third paragraph were you aware of the assertion that set out here
02:32:54 I quote on your other recommendations I can confirm that my department's generic risk
02:33:00 assessment guidance on high-rise firefighting is under review at present and will be informed by
02:33:05 all the recommendations you have made in your rule 43 recommendations it will also include advice
02:33:12 to incident commanders to inform decisions on evacuation should it become clear during an incident
02:33:17 that the state put principle is no longer tenable were you aware of that
02:33:24 Not from this document no but it would be my expectation that this would be inclusions in the
02:33:28 GRA now Mr. Cout told us that he believed he did not see the response that the Secretary of State's
02:33:34 response the corona at the time did you send it to him given his responsibility for GRA 3.2
02:33:41 and 3 3 6 3 3 I don't remember seeing this document person anyway now as for the rule 43
02:33:47 letters the LFB we can find that at LFB trouble zero three two one five eight
02:33:52 I didn't send this to Mr. Pickout because I don't recall seeing it but these are the GRA review
02:34:00 was being conducted by London Fire Brigade on behalf of CLG and therefore this would be my
02:34:07 expectation that they would share this document with him certainly those issues there would be
02:34:11 clearly shared with Mr. Cowup in his work on the GRA and indeed the GRA is covered with it's
02:34:19 makes it clear that it's a CLG document yes
02:34:24 can we go to the rule 43 letter the LFB which is at LFB trouble zero three two one five eight
02:34:36 now we'll review some of the substance in more detail later but for present purposes can we go
02:34:40 to page three
02:34:42 and there we can see that the recommend the coroner recommends that incident commanders be
02:34:47 trained to enhance their performance in a number of areas and we see the third bullet point down
02:34:54 it requires them my quote to anticipate that the fire might behave in a manner inconsistent with
02:35:01 the compartmentation principle now my immediate question is a narrow one and I think that's
02:35:09 that's a narrow one and did it occur to you at the time that this recommendation was relevant to an
02:35:17 instant commander's firefighting strategy for high-rise residential buildings where the
02:35:22 compartmentation principle is critical yes that being the case did you raise this matter with
02:35:29 Mr. Cowup or any other senior officer in the context of the review of pn 633 or any consequential
02:35:36 training needs required by the revision to 633 not in in the actual review of 633 but I believe
02:35:43 I did in relation to the training consequent training required by the revision of 633
02:35:48 now we heard earlier in this model particularly from Mr. Cowup that discussions between the LFB
02:35:55 and the CLG reached a place where the LFB said it was doing no further work on the document
02:36:02 we understand that you discussed that particular point with the then chief fire and rescue advisor
02:36:10 Mr. Peter Holland first of all is it right that you discussed that particular AMPAS with Mr. Holland
02:36:16 yes can you help us now if you can remember when that discussion took place was it in late the
02:36:22 last quarter of 2013 I think so I can't be absolutely sure I can't remember the chronology
02:36:30 of when Mr. Sir Ken Knight left CLG and Peter Holland took over but it would have been shortly
02:36:35 around around that time yes can you help us now and forgive me I recognise this is the latter
02:36:40 half of 2013 yeah are you able to give the panel the gist of the discussions you had with Mr.
02:36:46 Holland on the AMPAS that had been reached between the LFB and CLG over the drafting of GRA 3.2
02:36:52 well I think it would have been in the context of the discussions between London Fire Brigade,
02:36:57 Mr. Cout and Mr. Cout's team in particular with officials from CLG it would have also
02:37:02 have been in the context of the work we were doing by then on national operational guidance
02:37:07 which is in fact funded by London Fire Brigade and so it would be in those contexts because Mr. Holland
02:37:12 was very clear that well we all knew that there were two GRAs that were going to be continued by
02:37:19 CLG after CFAW and the LGA and London Fire Brigade took their responsibility for national operational
02:37:25 guidance and they one of which was high rise firefighting and the other one was breathing
02:37:30 apparatus and it's fair to say that the resources within Mr. Holland's department were not really
02:37:38 sufficient to enable either of those documents to be carried out or that they were used to be
02:37:45 carried out in a timely way or with the detail that I know Mr. Holland would have wanted them
02:37:49 to be done so the discussion Mr. Holland and I had was in the context of London Fire Brigade
02:37:56 continuing to do this whilst also working on the national operational guidance and the resource
02:38:02 implications of that and also that there were to put it kindly some poor relations between some of
02:38:10 the officers involved both CLG and London Fire Brigade and that I would do what I needed to do
02:38:16 to ensure London Fire Brigade came with this from a positive position and I would like and I asked
02:38:23 Mr. Holland to do the same to his officers. When you talk about poor relations did you feel
02:38:29 if the breakdown in communications probably putting it too harshly between Mr Cowop and his
02:38:36 counterparts at CLG? I think they're very close to breakdown in fact you know we wouldn't have said
02:38:40 we wouldn't going to continue if it if there wasn't at that point so yes I would say it was
02:38:45 very close to that. And were you content with the decision to say that the LFB would do no
02:38:51 further work on 3.2 at this stage given what given the subject of the discussions that had been
02:38:56 going on between the two parties? Yes and particularly in the context that London Fire Brigade
02:39:00 was already committing significant resource to national operational guidance anyway which was
02:39:05 a range of other documents that previously the government department had responsibility for.
02:39:10 Can we go to the the final version of GR3.2 which is a LFB quadruple 01255.
02:39:24 As we discussed earlier top left Department for Communities and Local Government top right
02:39:29 the Chief Fire and Rescue Advisors logos. Can we go to page 19?
02:39:33 And can we look at the first substantive paragraph at the top of that page which says this,
02:39:38 Contingency plans for particular premises should cover and the first bullet point says this,
02:39:44 Fire spread beyond the compartment of origin and the potential for multiple rescues.
02:39:49 And then if we go to the second bullet point which was added by the department I should emphasize,
02:39:55 an operational evacuation plan being required in the event of the stay put policy because
02:40:01 in the event of the stay put policy becomes untenable. Now were you aware of that particular
02:40:08 addition made by DCLG? I knew this was in the document but I wasn't aware at the time it might
02:40:15 be made specifically by DCLG. Were you aware of the reasoning which had prompted DCLG to include
02:40:22 that second bullet point? Yes. And what was the gist of the explanation that presumably Mr Kaup
02:40:29 gave you? This was the CLG being absolutely keen that all the coroner's recommendations were covered.
02:40:42 I don't know if I'm going to frame your next question Mr Keneer but the reason perhaps it
02:40:47 wasn't there in the first place was whilst this is a reasonable thing to put in the plan,
02:40:53 we were also keen that these plans are practical and achievable and I think Mr Kaup's position or
02:41:00 concerns would have been his department was that yes we knew that stay put might not always be
02:41:06 appropriate but we didn't have alternatives to give people in terms of the way in which to carry
02:41:11 out the evacuation. Given what you've said there, presumably you read 3.2 in its final version.
02:41:18 I did. The one thing that's striking about that document from the lay perspective
02:41:24 is that it's neither fish nor fowl. It's not a risk assessment. It strays into operational matters
02:41:32 but then stops short of certain other operational matters that you'd expect to find in there such as
02:41:40 the detail of an operational evacuation plan and the rest of it. First of all would you accept
02:41:44 that as a characterisation of the document? Absolutely. Given that tension that lies within
02:41:52 it, what were the problems in providing for example brief advice and guidance on the substance of an
02:42:02 operational evacuation plan? I think to answer that question I need to provide just a little bit more
02:42:09 context once again if I may. The GRAs were very often neither fish nor fowl and the reason for
02:42:21 that was they were supposed to be a risk assessment to enable fire and rescue services to implement
02:42:27 appropriate and safe procedures based upon the risk the GRA was covering. The government department
02:42:34 in my view were always very concerned about placing additional financial burdens on fire
02:42:40 and rescue services as a result of GRAs. So therefore if they were to implement or recommend
02:42:46 actual procedures that would inevitably have an impact in terms of the numbers of firefighters,
02:42:51 numbers of fire engines, numbers of fire stations, fire and rescue services maintained to complete
02:42:57 their statutory duties. So the GRAs were always in my view an overarching document that provided the
02:43:04 risks which tried to stay away from giving specific guidance on how to overcome those risks
02:43:11 for the reason that it might imply resource implications for fire rescue services and the
02:43:17 government and CLG didn't want the Gage to then make a claim against them for those additional
02:43:21 resources as a result of their GRA. That was always an issue that was suffering the fire and
02:43:27 rescue service in lots of areas in terms of working with the government department was that they were
02:43:32 always reluctant to bring forward recommendations or requirements that would enable Gage to make
02:43:38 additional financial claims in order to actually implement those requirements. So that's why,
02:43:43 but this document starts out on that basis and then has some very specific points mentioned in
02:43:50 it such as this one in order to comply with the coroner's recommendations and despite the fact
02:43:56 that potentially some of those things are included here need further in terms of guidance on how to
02:44:02 do them. Now that as you said is context it's a generic explanation is that right? Yes. Are you
02:44:09 aware that that consideration informed the limited nature of the addition that CLG included at the
02:44:17 second bullet point in particular? I can't state, I can't confirm completely because I didn't have
02:44:22 that conversation with anyone but I strongly suspect that it did. You can't confirm specifically,
02:44:27 can I put it, you can't confirm at all can you because you weren't involved with the detail?
02:44:31 Yeah and I can't confirm because I'll be. Looking at the second bullet point can you help us?
02:44:38 A requirement of an operational evacuation plan in the event that stay put no longer being tenable
02:44:47 it's not obvious that that would bring in an onerous resource consequence. As a general
02:44:54 observation would you accept that or not? Not really no.
02:45:00 So given that there is no reason. I'd quite like to know why you say that.
02:45:07 Because to carry out an evacuation in this nature would need additional resources.
02:45:14 I think you'd need more firefighters to carry out this investigation safely than you probably
02:45:20 need to extinguish the fire if people stay in their place of residence. Now potentially for
02:45:25 London and maybe some of the other metropolitan brigades that might be doable just by asking for
02:45:31 additional resources but in the context of incidents like Lacknell House, Grenfell Tower,
02:45:36 Shepherd's Court, happening in smaller fire and rescue services it wouldn't be practical
02:45:42 and therefore probably those fire and rescue services would see this as a means to go back
02:45:48 to seal duty to ask for additional money, additional grant, fire grant.
02:45:54 The question I was going to ask you is given the answer you gave earlier on there doesn't appear
02:46:00 to be a reason in principle why at least briefer guidance couldn't be given in this document to
02:46:07 fire and rescue services as to what an operational evacuation plan would look like or at least the
02:46:12 factors that would inform such a plan. Would you agree with that?
02:46:17 Superficially yes. The difficulty of course is that in answering that question is that I know
02:46:23 that the Chief Fire of National Fire Service Councils is now and other bodies are still
02:46:27 struggling with this point to this day in terms of what an operational plan for evacuation of
02:46:34 high-rise premises should look like and they still haven't to my knowledge issued very effective
02:46:40 guidance on that and it's still something that's being discussed in terms of how do you inform
02:46:44 people, how do you get people to come out, how do you protect the stairwells, how do you get
02:46:48 people to actually come out safely so I agree but superficially but not in practice. I suppose it
02:46:56 an alternative could have been for the draftsman to include prompts to consider those particular
02:47:00 considerations that will need to be weighed in the balance when formulating the plan. I agree.
02:47:04 Okay could I look at a second edition with you and that can be found at page 21 in the document
02:47:13 and there's a section which starts on training
02:47:17 and it says training which will cover high-rise incidents must include and then we go to page 22.
02:47:35 Thank you. The eighth bullet point which is I think fourth up from the bottom of memory serves
02:47:48 says this evacuation and casualty removal tactics and then incident commanders should
02:47:55 understand when a partial or full evacuation strategy might become necessary in a residential
02:48:01 building where a stay put policy is normally in place. Were you aware of that edition? Yes.
02:48:10 Again was your understanding of the reasoning which prompted the edition
02:48:14 the same as the answer you gave in relation to the first? Yes.
02:48:20 Now to the lay eye at least those two editions address two points. First the concept of stay put
02:48:28 not being adhered to and secondly the notion that advanced planning and training is required
02:48:33 for the reversal of stay put should circumstances demand that. Did you at the time of the exchanges
02:48:39 between the LFB and DCLG understand the significance of DCLG's editions?
02:48:47 Yes. And you understood in particular the nature of the consequential amendments that first of all
02:48:59 have to be made to PN 633? Yes. And if so the consequential training requirements on any revised
02:49:06 updated version of 633? Yes. Was it a matter of concern to you at the time that senior officers
02:49:15 had not included these two matters in the original draft of GRA 3.2?
02:49:23 So the subject matter of these two editions we've been discussing? Yes. Yes. It was a concern? Well
02:49:30 to be you know completely accurate I assumed they were but perhaps that's my area in terms of not
02:49:36 actually completely checking PN 633 against this document. I didn't do that in detail personally.
02:49:43 And so those two matters for the avoidance of doubt are matters which you expected your officers
02:49:50 to have appreciated and included because of their importance? Because they were in 3.2.
02:49:56 Now I'm talking about why they're included in 3.2. They weren't included in 3.2 by your officers.
02:50:02 Yeah. Oh sorry. Would you have, sorry I think you're assuming I'm talking about 3.2. I wasn't.
02:50:08 I'm not. Looking at 3.2 were you concerned that your officers had not picked up the subject matter
02:50:16 covered by these two editions included by DCLG? No. Can you help us as to why you weren't concerned?
02:50:24 For the reasons I gave earlier in terms of you know the practicality and the resource requirements
02:50:29 and also because this was CLG's document.
02:50:33 Sure. But these editions are ones which you expected to find in 633? Yes. And the reason
02:50:41 being if they were in 3.2 they needed to be in 633? Yes. Thank you.
02:50:51 Now if I can turn to a related but separate topic and that's training following the revision to 633.
02:50:59 Now we've got no completed TCAP form for the consequential training arising from the revised
02:51:07 633 that came in in June 2015. We've identified no new training following the publication of that
02:51:16 policy in June 2015 and Mr. Groves who you will call as the former head of your training department
02:51:23 could not recall any amendments to the training as a result of the revisions to 633
02:51:29 despite Mr. Utting characterising the training implications of the revisions as
02:51:33 in quotes massive. Now do you accept that the lack of any new or amended training to
02:51:41 supplement and inform staff about the revisions to 633 which had been revised reflect LACNL and
02:51:48 the recommendations rising thereafter was a significant failing on the part of the LFB?
02:51:53 Yes. Do you accept responsibility given your role as commissioner for failing to ensure
02:52:00 that the training consequences of the learning post LACNL were not included in training programmes
02:52:06 after June 2015? Yes. Now the present commissioner Andy Rowe in his witness statement provided to
02:52:14 this inquiry has confirmed that at the time of the Grenfell fire the LFB provided no guidance
02:52:20 or direction in either its policies or training as to when and how a state put strategy should be
02:52:27 reversed. That admission occurred during your tenure as commissioner do you accept that? Yes.
02:52:37 Do you accept that following LACNL there was a clear need to train firefighters on rapid fire
02:52:43 spread and in particular the need in certain circumstances to withdraw state put and how best
02:52:49 to make that decision? Yes. Can you help us as to why therefore crews were denied the training they
02:52:58 required in order to do that? Well whilst whilst I accept responsibility I was the commissioner
02:53:04 and that's why I accept responsibility but in terms of the state put I think there was still
02:53:12 a debate going on within the brigade in terms of when and how state put would be revoked or
02:53:18 when it would be continued with. In terms of the general high rise policy whilst there were my
02:53:26 completely accept there was no T cap in 2015 high rise policy was something which was a
02:53:32 significant training burden on London fire brigade at station level you know all the time
02:53:37 even when I was a firefighter it was a significant policy that we were trained on
02:53:40 regularly in terms of lectures and high rise premises and fire drills at high rise premises
02:53:46 so whilst that is absolutely the case my belief is still that firefighters were aware of the policy
02:53:53 the changes were apart from the state put issue were such that the communication of the policy
02:54:00 itself and the publication of the policy would have prompted them to train on that at local level
02:54:05 but I fully accept that it should have it should have had a T cap and it should have been a training
02:54:10 a brigade wide training policy. And those training needs had not been identified following Lacknell
02:54:16 they hadn't been identified following the inquests after Lacknell they'd not been identified
02:54:21 following the publication of 3.2 would you accept that those are major organisational failings on
02:54:28 the part of the LFD? I'm not I'm not completely sure that I agree completely that all of those
02:54:32 things were missing actually because there was significant training take that took place after
02:54:37 the Lacknell house fire and the inquiry I think has seen some of the T caps relating to that
02:54:42 the Lacknell house case review was a very significant piece of training and awareness
02:54:46 that was provided to firefighters as well that's not to say that it was complete or that we
02:54:51 shouldn't have done much better so I do accept there was some failings there yeah but I don't
02:54:54 accept that it was complete failure to do any training on those issues
02:54:57 looking at this a slightly different way
02:55:07 the LFB's other learning mechanisms and I'm thinking of DIOT and ODCB they seem to have
02:55:14 been dependent on a significant incident or a series of incidents amounting to a trend
02:55:20 to identify an organisational weakness or a training weakness. Doesn't that system
02:55:27 raise the very real risk that the LFB didn't learn the right lessons i.e. didn't learn the
02:55:33 right lessons from Lacknell? I don't agree that with your description of the diet process
02:55:39 the diet process is very clear that any incident can be a learning incident I know
02:55:46 the inquiry has been through in quite some detail the number of entries on the diet and the fact
02:55:51 and the low number of entries I would suppose it's best to describe it but those entries on
02:55:56 the diet process are supposed to come from any incident LFB that it ends but 3.3 of the
02:56:01 paragraph 3.3 of diet is very clear that it should be exceptionally reporting of good or
02:56:08 less than good practice so no I don't agree that was the only thing that the ODCB was reliant
02:56:15 was a major incident they were reliant on other information coming from there as well but also
02:56:20 from a range of other sources as well I think the inquiry's seen some of the agendas from ODCB
02:56:25 and there were many other things on that agenda which they considered in terms of training
02:56:29 interventions other than the IMD the IMD database. Do you think there were any deficiencies
02:56:36 in the procedural arrangements for identifying training needs at the LFB during your tenure as
02:56:41 commissioner? Oh yes. Can you identify them please for the panel? I think
02:56:48 the diet process with in all its I think there's lots of good things about diet process but perhaps
02:56:53 it wasn't as well communicated and well used as we'd like it to have been it certainly think I
02:56:57 think was a good practice and a good policy but not necessarily followed through and used by
02:57:03 station-based staff as well as we would like it to have been. I think we've already identified
02:57:10 fires from high-rise fires from other countries it's probably an area where we could have identified
02:57:16 additional training and I think things the rule 43 recommendations from other fires other than
02:57:23 Lacknall which while they were standing agenda item on the ODCB board perhaps we might have been
02:57:31 able we should have taken more learning opportunities from those as well. And the cultural disconnect
02:57:38 between fire and safety and operational has been a general contextual problem? Yes absolutely yes I
02:57:43 agree with that. So we are just before one o'clock the next set of questions will take
02:57:49 a bit longer so this may be the best point. Yes of course well if that's a sensible point let's
02:57:54 take a break now. Right Mr Dobson well it's obviously a good point at which to break for
02:57:59 lunch we'll stop now we'll resume please at two o'clock and as before please don't talk to anyone
02:58:05 about your evidence while you're out of the room. Okay thank you sir. Thank you very much.
02:58:13 Thank you Mr Kinnair. Two o'clock. Thank you.