Evidence session examining the London Fire Brigade's response to the Grenfell Tower fire, including operational decisions, command structure, and lessons learned.
# Transcribed with OpenAI Whisper (medium model)
# Source: Local audio transcription (no YouTube captions available)
00:00:00 Thank you.
00:00:29 Could you ask Mr. Dobson to come back in please?
00:00:31 Thank you.
00:00:42 Mr. Dobson, ready to carry on?
00:00:44 Thank you very much.
00:00:45 Yes, Mr. Kaneo.
00:00:46 Good afternoon, Mr. Dobson.
00:00:48 Could I go back to one point we were discussing before the lunch break.
00:00:52 Excuse me.
00:00:53 In evidence, you said that there had been or you thought there had been significant
00:00:57 debate within the LFB about when and how to reverse statehood.
00:01:02 Yes.
00:01:03 Now, we have seen no evidence in the contemporaneous documents or in the witness statements or
00:01:10 in the oral evidence about such a debate.
00:01:13 Can you help us?
00:01:14 Who were the parties to that debate?
00:01:16 When was it continuing?
00:01:18 And in what forum or fora did that debate take place?
00:01:21 My recollection is that it was a more informal debate, actually, as a result of operational
00:01:28 officers' concerns around the practicalities of changing the advice to a full evacuation
00:01:33 rather than stay put.
00:01:35 There were varying operational views around that, its practicality and what the implications
00:01:41 of actually advising staff on that should be a consideration would be.
00:01:47 The people that would have been involved in that debate would have been Mr. Cutbill,
00:01:51 I'm sure Mr. Cowart was part of that, the directors.
00:01:56 But I couldn't say it was any particular forum or any particular day.
00:02:00 It was just a general debate that we had in relation to the various views that existed
00:02:03 around the state put policy and changing from it.
00:02:06 Can you remember when that debate took place?
00:02:09 I think it was ongoing, to be perfectly honest.
00:02:12 So I think it started shortly after the Lacknall fire when state put advice started to be discussed
00:02:18 and it went on right away really until near when I retired.
00:02:23 Now, a number of LFB officers have now given evidence that evacuations of high rise residential
00:02:30 buildings with state put strategy in place did in fact take place.
00:02:34 And can I explore five particular examples of evacuation that we've heard from?
00:02:40 First of all, Gary Reason told us that evacuating high rise buildings, quotes,
00:02:45 wasn't something that was unusual.
00:02:47 I think the inquiry has seen evidence of other fires in London and around the country
00:02:51 where partial or full evacuation has been conducted successfully.
00:02:56 Do you agree with the general proposition that evacuation wasn't unusual?
00:03:02 Yes.
00:03:03 Gary Reason also gave evidence that a failing building with rapid external fire spread
00:03:08 would be an obvious risk and hazard and one which would, quotes,
00:03:13 obviously inform the decisions that officers have to take, close quotes.
00:03:17 Would you agree with that observation?
00:03:19 I would, but it depends on the degree of the rapid fire spread.
00:03:23 So rapid in one officer's mind might be different in somebody else's.
00:03:27 I think something where the fire was developing that quickly and that rapidly
00:03:31 on the external face of the building that the whole building was likely to be engulfed
00:03:34 would be one extreme where I think actually I agree completely.
00:03:38 But there are also examples of buildings where there was external fire spread
00:03:41 only on one face of the building.
00:03:43 And there are potentially people on the other side of the building,
00:03:46 depending on the internal fire separation and how successful that was,
00:03:50 the size of the staircases would mean that potentially you might have rapid fire spread,
00:03:56 but you don't need to evacuate.
00:03:58 Mr Cowop said evacuation was something that we carried out
00:04:02 and in many respects it's fairly intuitive,
00:04:05 but that the LFB did not understand, quotes,
00:04:08 the need to provide firefighters with specific guidance to deal with it.
00:04:13 Would you agree with Mr Cowop's view on that?
00:04:16 In the context of high-rise residential buildings, yes,
00:04:21 because actually firefighters are well acquainted with evacuation
00:04:26 of all sorts of buildings, including high-rise,
00:04:28 where there are commercial buildings, where there are fire registers
00:04:32 and fire alarms and all that sort of stuff.
00:04:34 Firefighters are well aware of those sorts of things.
00:04:37 Would you agree though, just to allow you the opportunity to respond,
00:04:41 that the LFB did not understand the need to provide firefighters
00:04:45 with specific guidance to deal with the need to evacuate?
00:04:49 Yes.
00:04:51 Charlie Hanks' witness statement, we don't need to go to it
00:04:54 unless you'd like me to take you to it,
00:04:56 he describes his decision as the second incident commander
00:05:00 at the Sheppard Court fire to ensure the flats were empty
00:05:03 in the direct line of travel immediately above the fire
00:05:07 and any occupants removed to safety when it was possible to do so.
00:05:11 First of all, as you were monitoring officer at Sheppard's Court,
00:05:14 presumably you were aware of and the reasons for Mr Hanks' decision.
00:05:18 Yes.
00:05:20 Whilst Sheppard's Court was seen as a successful operation,
00:05:25 it was not translated to the broader base of LFB fighters as an exemplar
00:05:30 or an instigation for training to ensure similar success stories.
00:05:34 Again, can you help us as to why that wasn't done?
00:05:38 Well, I'll go back to my answer I gave earlier, Mr Kinnearie,
00:05:41 which is that firstly, it was a well-managed incident
00:05:45 in terms of incident command.
00:05:47 The firefighting was effective, the evacuation that did take place was effective.
00:05:52 I wouldn't actually have expected there to be more evacuation
00:05:55 in that purpose, having actually experienced a staircase
00:05:58 and the amount of congestion there was in there with hose lines
00:06:01 and other things and the size of it.
00:06:03 But once again, the communication of success or otherwise incidents
00:06:07 is dependent on a whole range of other factors of things
00:06:10 that we're trying to communicate at that time.
00:06:12 I can't remember exactly what was going on at the same time,
00:06:15 but there would have been a whole range of other things
00:06:18 that communication about that incident would have been competing with.
00:06:21 Finally, Tony Biles, that's B-I-L-E-S,
00:06:24 who is a senior officer in the CBRN department,
00:06:27 he gave a witness statement to the MPS,
00:06:30 which we can find at MET, trouble 080605.
00:06:36 Excuse me.
00:06:38 If we could turn to page 7 and look at the final paragraph on that page,
00:06:44 he discussed the LFB's response to the fire at Adair Tower,
00:06:50 which he attended as the incident commander.
00:06:52 And what he says there is this,
00:06:54 the first thing I considered was why is the building causing
00:06:58 the residents problems and how am I going to get them out?
00:07:01 My thought process was I'm getting them out irrespective of what policies
00:07:06 and procedures are in place for a high-rise fire.
00:07:09 And if we go over the page and really the fourth paragraph down from the top,
00:07:16 he says this,
00:07:18 I didn't revoke the stay-put policy verbally or inform the control room of this.
00:07:24 I did revoke the policy as part of my plan.
00:07:27 Firefighters were briefed to clear the building,
00:07:30 but not verbally told.
00:07:32 The stay-put policy was revoked.
00:07:35 Did you expect incident commanders to consider evacuating
00:07:38 high-rise residential buildings in the way that Mr Biles describes?
00:07:43 I'm not sure there's enough detail there to actually enable me
00:07:46 to make a real sort of judgement on what Mr Biles has done here.
00:07:49 Because I can't quite work out in my own mind how this would have worked
00:07:53 if he'd not told people to actually do it, not even verbally.
00:07:57 And also, if there's no single means of informing everybody in terms of a fire alarm,
00:08:04 the only way that you can let residents know to evacuate really is fire
00:08:08 when they call control or firefighters knocking on doors in this circumstance.
00:08:12 I can't quite understand exactly what was in his mind here.
00:08:15 Or how that was communicated to operational firefighters.
00:08:18 Yeah.
00:08:19 Could we consider the question of targeted evacuation?
00:08:24 And that was something you asked about during the Lacknell inquests.
00:08:28 And we've got the transcript of the exchange.
00:08:31 And if we could go to CWJ quadruple zero, double zero, one zero, forward slash eight five.
00:08:39 And if we go to line 13.
00:08:45 Thank you.
00:08:50 The question you were asked was this.
00:08:52 You were asked about evacuation and you explained the difficulties.
00:08:56 And certainly other witnesses have as well.
00:08:58 That there would be in evacuating a building such as Lacknell House entirely.
00:09:03 Is any guidance given to firefighters about targeted evacuation?
00:09:07 So the flat's immediately above a fire, flat's diagonally above a fire,
00:09:11 or the flat's next to a fire?
00:09:14 Answer.
00:09:15 As Mr. Holland said yesterday, in the case where evacuation is needed,
00:09:19 then firefighters would go to the premises above the fire first of all.
00:09:23 And also the premises adjacent to the fire.
00:09:26 They would be the ones the premises closest to, but particularly above and adjacent.
00:09:31 If we go to page 286 and at line six, you then ask this.
00:09:36 Do you think there's scope for giving guidance on targeted evacuation?
00:09:41 So advising firefighters when they attend a scene,
00:09:44 look in the flat immediately above the fire and try to evacuate it.
00:09:49 Look in the flat next to a fire, evacuate it.
00:09:52 Look in the flat's diagonally above a fire, try to evacuate them.
00:09:56 And you replied thus.
00:09:58 I think that already exists in terms of firefighters, as I said,
00:10:02 would go to those places because they understand that's the place where the fire is most likely to spread to,
00:10:08 or where smoke is most likely to spread to.
00:10:11 They would go to the places nearest to the fire anyway.
00:10:14 Whether there's additional guidance required around that, I would need to think about.
00:10:19 But at the moment, I don't think there's any evidence that that is needed.
00:10:23 Now, pausing there, your answer suggested that you expected firefighters
00:10:28 to be able to conduct a partial or targeted evacuation without the need for additional guidance.
00:10:33 Is that a correct reading of what you were saying there?
00:10:36 Yes.
00:10:37 If we go back to the questioning, you were next to ask this.
00:10:42 Well, that didn't happen in the Lacknell House fire, certainly for the flats above and diagonally above the fire.
00:10:48 Yes.
00:10:49 Is it your understanding that guidance was in place at the time of the fire?
00:10:53 To return over the page.
00:10:55 Yes.
00:10:57 And I, you know, and clearly I, I wish we got firefighters to flat 79,
00:11:02 particularly above the fire more quickly than we did.
00:11:06 But, but whilst that was in progress and the incident commander or the bridgehead commander
00:11:11 had requested additional resources after firefighting commenced, as we know,
00:11:16 the fires broke out below the bridgehead, which then placed the incident commanders
00:11:20 and the officer in charge of the bridgehead in a very difficult position
00:11:25 and outside of something which was within, it was outside of their experience.
00:11:29 Question.
00:11:30 I understand that, but isn't there scope for training firefighters
00:11:34 or providing further guidance that says when you arrive at the scene of a fire in a high rise,
00:11:39 your number one priority is to firefight the fire,
00:11:42 but your number two is to then immediately check above the fire to see if there's anyone in danger?
00:11:48 Answer.
00:11:49 Well, I believe that is the case already.
00:11:52 What's the problem that while senior officers may have the experience to recognise a building failure
00:11:58 and to consider evacuating the building, whether totally or partially,
00:12:02 more junior incident commanders who had less operational experience amidst a decline in incidents
00:12:08 did not have that experience to draw on?
00:12:11 I think there's two issues here.
00:12:14 Firstly, I wouldn't expect junior firefighters at firefighter level
00:12:19 to have the understanding of when to evacuate the building to make those command decisions.
00:12:24 That's an issue for the officer in charge anyway, because it needs to be done in a coordinated way.
00:12:30 The other thing, and the reason why I made the comments that I made at the inquest,
00:12:35 was that the actual places to go to check for people when there's a fire
00:12:40 is basic firefighting skills that firefighters actually learn on their basic firefighting course.
00:12:44 I remember learning exactly that during my firefighter training in 1979,
00:12:49 that if you're asked to evacuate or if you're at a high rise fire,
00:12:53 the most likely place where people need to be rescued is either the flat of origin or the one immediately above it.
00:12:59 So that were things that generally firefighters have already been trained on as part of their basic course.
00:13:07 Sorry, could I just return to that? I'm not entirely certain it's an answer to the question I asked.
00:13:12 Okay, sorry.
00:13:13 Don't worry, the fault almost certainly lies with me.
00:13:17 What I was inviting you was really an answer to this question,
00:13:22 whether the problem was effectively that junior incident commanders,
00:13:26 I wasn't talking about fire, I was talking about junior incident commanders,
00:13:30 now have less experience of practical decision making,
00:13:34 whether to evacuate in part or in whole,
00:13:37 than their more senior experience officers have because of the decline in the number of fires.
00:13:42 I would agree with that, yes.
00:13:45 And as we've heard from Commissioner Roe in the extract I put to you before the lunch break,
00:13:50 there was no training to make up for the absence of practical experience.
00:13:55 Would you accept that?
00:13:56 Not entirely, no. I think the absence or the decreasing amount, not absence,
00:14:01 but decreasing level I would say of actual operational experience was a factor that I think London Fire Brigade
00:14:08 and the rest of the country actually recognise and I think that's noted in the National Operational Guidance and elsewhere.
00:14:13 So the intention had always been to increase the amount of training taking place,
00:14:18 and I'm talking about practical training really, in order to actually make up for that.
00:14:24 And that is why London Fire Brigade increased the amount of real fire training,
00:14:29 so-called real fire training that firefighters need to do in order to try and make up for that deficiency in actual operational experience.
00:14:36 Mr Cowop described evacuation and then when to evacuate and how to execute that decision
00:14:45 as a blind spot for the LFB. Indeed I think he put it more broadly, he said nationally as well.
00:14:51 In relation to the LFB first of all, would you accept or agree with Mr Cowop's evidence?
00:14:57 I'm not sure I'd describe it as a complete blind spot because as we know evacuation-
00:15:02 I think you just described it as a blind spot, the word complete wasn't there.
00:15:05 Okay, well even so I don't think I'd go quite that far.
00:15:08 Because I think as we've seen today there's evidence of where evacuation does take place,
00:15:12 so it is something that firefighters know is necessary at times.
00:15:17 That is confirmed by them every time they attend a fire in a commercial building
00:15:21 where there's lots of people standing outside on the street, evacuation points are always in the forefront of their mind.
00:15:26 The evacuation might be necessary, it's just that it's much less at the forefront of their mind
00:15:33 at residential high-rise buildings because of the problems they know in actually communicating with people
00:15:39 and then getting people out that might be in various states of consciousness because it might be at night,
00:15:45 it might be during other times, therefore they're very aware of the difficulties of carrying out evacuation,
00:15:51 therefore wouldn't be keen to do it unless absolutely necessary.
00:15:55 From the sound of it going back to something else Mr Cowop said when he described evacuation as
00:16:00 quote fairly intuitive close quotes, it sounds to me given what you said that is something with which you'd partially agree with.
00:16:08 Yes.
00:16:09 And the reason why you'd partially agree with it presumably is because the references to training
00:16:14 as part of basic firefighter training that you've referred to already.
00:16:17 Yes.
00:16:18 Can I now turn to a separate topic which is control room and the management of FSG calls after LACNL.
00:16:26 Now the starting point of our discussion today will be action five and it's action five for the pre-inquest actions
00:16:36 and if we go to the LACNL assurance review first of all which is LFB quadruple 0 4801 forward slash 12.
00:16:44 Mr Dobson the document is dated August 2018 so it post-dates your time.
00:16:57 Yes.
00:16:58 But if we could go to page 12 which is on the screen and you'll see it deals with action five in the bottom right-hand corner
00:17:06 and action five required this undertake a gap analysis of national and brigade fire survival guidance policies and
00:17:14 guidance in order to produce a report identifying where brigade control fire survival guidance policy differs from national
00:17:23 guidance.
00:17:24 Now keeping that in our mind for the moment we know that at the LACNL house board meeting on the 22nd of February 2010
00:17:33 Scott Haywood went through the gap analysis and let's look at the meeting minutes which are LFB trouble 0 84026.
00:17:44 Now as we can see you're in section three you passed on your apologies for not being able to attend.
00:18:04 Can I take it as read that you read and considered the minutes when they were circulated?
00:18:10 Absolutely.
00:18:11 Now if we can turn to page three we see at the top of the page under item 5.17 the minutes record this.
00:18:21 SH that's Scott Haywood went through the control gap analysis and identified the relevant gaps.
00:18:28 Noted that national guidance FSC 10 1993 was introduced following a fatal fire in the Midlands.
00:18:36 FSC 10 93 had been compared against brigade policy 539 and brigade training documents.
00:18:44 5.18 the gap analysis has identified that areas of both national and LFB guidance need to be updated.
00:18:52 We would be looking to write to CLG to advise them on areas that need reconsideration in national guidance.
00:18:58 Actions and if we look at the second one Scott Haywood to draft the letter to CLG and provide to RD I think Rita Dexter in this context.
00:19:08 Yes.
00:19:09 And commissioner for comments.
00:19:11 Now we know the gap analysis was finalized in April 2010.
00:19:16 Did you read that analysis?
00:19:18 Yes.
00:19:20 Did you know or were you informed that the analysis excluded a review of national guidance fire service circular 54 2004?
00:19:30 I don't recall being told that no.
00:19:32 If you had been told that would that have been a source of concern given the requirement to carry out a gap analysis of national guidance?
00:19:41 Well I would have sent it back for it to be done again and to include it.
00:19:46 And so the consequence of that was that the gap analysis did not identify that LFB's policy 539 and the training documents did not explain to the caller the need for continual reassessment of the caller's situation and an assessment of the caller particularly the age and mental and physical disability.
00:20:06 Were you aware of that?
00:20:07 Yes.
00:20:09 But you were aware that they didn't have.
00:20:10 Oh sorry.
00:20:12 That those matters had not been identified.
00:20:14 No.
00:20:19 Is the reality therefore that you delegated the conduct of the gap analysis to Scott Hayward and his team and assumed that they would carry out and discharge their task competently and thoroughly?
00:20:31 Yes.
00:20:36 Can you how certain are you that you were never informed that relevant national guidance had excluded from the gap analysis?
00:20:46 Well I certainly can't remember having been informed of it.
00:20:49 In my preparation for appearing before the inquiry I've seen a number of documents and it was a surprise to me then.
00:20:57 Thank you.
00:20:58 We now turn to action 13 which is a letter to DCLG.
00:21:02 And if for that purpose can we go back to the lack of assurance review which is LFB quadruple 0 4801 forward slash 15.
00:21:16 If we look at the left hand column and it's the bottom half of the page we find action 13 which said this.
00:21:23 Draft the letter to the Department of Faculties and Local Government DCLG to obtain clarification on the national guidance for fire survival guidance in order to ensure that a consistent approach is followed by all fire rescue services.
00:21:38 Now we saw earlier that in the meeting on the 22nd of February 2010 Scott Hayward was to draft the letter and to provide it to you and Rita Dexter for comments.
00:21:51 Do you remember commenting upon any draft prepared by Mr. Hayward for this purpose?
00:21:55 No I don't.
00:21:58 Now at the start of your evidence we looked at the or your update to the Latin or house board that was provided on the 12th of September 2010.
00:22:06 And we can go back to it again so you know what I'm talking to.
00:22:10 LFB trouble 0 84031 forward slash 2.
00:22:24 And it's paragraph 5 10 so roughly halfway down the page we looked at.
00:22:29 It said there RD and that's you in this context.
00:22:32 Okay.
00:22:33 Commented that there are potentially two or three areas to consider in relation to control.
00:22:38 Two the question of where LFB stand in relation to training slash guidance compared to national guidance.
00:22:46 It is evident that national guidance is in need of improvement.
00:22:51 What was your basis for concluding that national guidance was in need of improvement.
00:22:56 On the basis of the information provided to me at the board meeting by I think Mr. Hayward.
00:23:02 Now if we can go to the Latin or house board meeting which was held on the 12th of December 2011.
00:23:08 That or the minutes rather can be found at LFB trouble 0 84039.
00:23:27 Thank you.
00:23:28 We can see that your number one and list of attendees.
00:23:33 If we go to page two roughly halfway down that page we see item 8.1.
00:23:41 It's recorded the following the draft letters CLG has been reviewed by control and legal and is now ready to be sent to CLG.
00:23:49 The commissioner confirmed that the letter should be sent action JS SH.
00:23:55 I think that's Joanne Smith or Stibbards Scott Hayward to provide the final letter to the commissioner to be signed.
00:24:01 Do you recall confirming that the letter should be sent.
00:24:04 I do remember this year.
00:24:06 And remember from this presumably you were content with the contents.
00:24:10 I would I would have I was I was intended to review it again when it was right to me.
00:24:14 But I certainly have it OK for it to be sent.
00:24:17 Can we go to LFB quadruple 0 4728.
00:24:25 That is a letter dated the third of February 2012.
00:24:38 Is that the letter that you confirmed should be sent.
00:24:42 I'll let you familiarize yourself before answering.
00:24:46 I believe so.
00:24:54 Yes.
00:24:55 Thank you.
00:24:56 Mr. Hayward explained in his evidence that he submitted the letter the letter to the board by Tim Cuthbill and that it's sat with the deputy commissioner Rita Dexter.
00:25:07 But for signature by you.
00:25:09 Is that your recollection of the process?
00:25:11 I don't remember that bit.
00:25:13 Turning to the minutes of the Lacknell House Board of the 14th of December 2012 LFB trouble 0 4 double 0 double 3.
00:25:32 We can see that you are in the chair.
00:25:35 And if we look at the foot of page one and paragraph six point one.
00:25:41 I see the heading action plan for action 13.
00:25:46 It says draft letter to CLG on Fsg.
00:25:49 This letter will not be sent and will be reviewed after the inquest has concluded.
00:25:55 Who made the decision not to send the letter and to review it after the conclusion of the inquest.
00:26:01 I'd be very surprised if that was a decision made by anybody else made by anybody else other than me.
00:26:09 Did you discuss that decision with, for example, Rita Dexter before you made it?
00:26:13 I certainly would have discussed it with others.
00:26:16 I'll be surprised if we didn't actually discuss it at Lacknell Board.
00:26:19 Can you remember now why you did not want the letter sent but you would hold it pending conclusion of the inquest?
00:26:26 I think I was convinced by arguments that it would be better to wait until after the inquest to allow the coroner to make judgments on some of these issues and then raise our views with CLG later.
00:26:38 So to await the coroner's conclusions?
00:26:40 Yes.
00:26:46 Could we turn to the Lacknell Control Report which is LFB quadruple zero 4724?
00:26:57 Now as its title suggests this was an internal report carried out on reviewing controls actions on the night of the Lacknell fire.
00:27:06 This is the first time we've looked at it during the course of your evidence.
00:27:10 Can you confirm that the report was in fact submitted to the coroner?
00:27:14 Yes.
00:27:16 What was the reason for submitting this document to the coroner?
00:27:20 I'm saying that I believe it was submitted to the coroner.
00:27:23 I can't actually be quite as sure as that because I can't remember all the documents are eventually submitted.
00:27:27 But I'm pretty confident this one was submitted.
00:27:30 I'm pretty confident this one was submitted because it was our internal review of the actions of control on the night and therefore be relevant to the coroner's considerations.
00:27:38 Now if we go to page 51.
00:27:45 If we could look at the box under paragraph 303 in the lower half of that page and we see it's entitled recommendation one.
00:27:53 And what recommendation one said was this.
00:27:56 It is unhelpful to have two extant national guidance documents.
00:28:01 Fire Service circulars 1093 and 54 2004 alongside the fire service manual volume one.
00:28:10 And it is not clear what national guidance comprises and how the different advice fits together.
00:28:17 National guidance on fire survival techniques and training and its interaction with community safety literature should be reviewed and updated.
00:28:25 The commissioner should write to the department for communities and local government to prompt such a review and the issues identified in this report be provided as a contribution to the review.
00:28:36 Given DCLG's current stance on the provision of operational guidance that this is something for the FRS sector rather than government.
00:28:45 The brigade could offer to lead on such a review.
00:28:48 And below that action one following the conclusion of the inquest and depending on DCLG stance.
00:28:55 I left the either to contribute to a review or lead on a review of the national fire survival techniques and training.
00:29:03 After the inquest concluded, did you or anyone else discuss with DCLG to find out discover their stance on a proposed national review?
00:29:14 I didn't personally know.
00:29:16 Did you authorise or were you aware of anyone else from the LFB who had such a conversation with CLG?
00:29:22 I didn't personally authorise it but I wouldn't have been unhappy for it to take place.
00:29:26 And it was my expectation there would be a discussion with CLG, yes.
00:29:30 Are you aware of what the gist of that discussion was?
00:29:33 Well, no, except that it would have been as laid out in the recommendation in terms of the once again the conflict and issues of having more than one piece of guidance that is apparently extent.
00:29:45 You said would have been.
00:29:47 Because I'm not 100% sure the conversation did take place.
00:29:52 Thank you. No one reported anything back to you?
00:29:54 No.
00:29:56 Now, can we go to the lateral house board minutes for the meeting on the 30th of September 2013.
00:30:02 LFB trouble 0 84048.
00:30:22 Thank you.
00:30:23 We can see from item 3 you sent your apologies.
00:30:27 If we could look at action 5.1, item 5.1 on this page.
00:30:32 Thank you.
00:30:33 It says this.
00:30:34 Action plan item 13 letter to CLG.
00:30:39 Tim Cuthbill confirmed the decision was made by the commissioner that this letter was no longer required and was dealt with by the outcomes of the inquest.
00:30:49 First of all, is that a correct record of your decision?
00:30:53 Yes.
00:30:54 Why did you make that decision?
00:30:55 Because the device that I received from other board members was actually the coroner addressed most of the issues arising and found there for our letter was not necessary.
00:31:05 Would you agree that as a result it meant that the assurance that had been given to the coroner by way of recommendation 1 and action 1 in the lateral control report was not in fact carried out?
00:31:20 Yes.
00:31:21 Did you seek to update the coroner after the inquest hearings that the letter was not going to be sent and the review was not going to happen?
00:31:31 I don't believe we did, no.
00:31:33 Why not?
00:31:34 I think it was an oversight.
00:31:42 Can we move to action 10, which is to ensure that policy 539 complied with national guidance.
00:31:48 Can we go for this purpose again to the lateral assurance review, LFB quadruple 0 4801 forward slash 14.
00:32:04 Action 10, left hand column, middle of the page.
00:32:12 It said this, review brigade policy 539 emergency call management in order to ensure it complies with national guidance.
00:32:21 Now we know that 539 was reviewed in full and changes were executed on the 3rd of September 2010.
00:32:28 If we go to the minutes of the lateral house board of the 15th of September 2010, LFB trouble 0 55192.
00:32:48 Now we can see that you attended item 2.
00:32:53 If we can turn over the page to page 2 in item 5.7, the board, or the minutes record of the board being told, and I quote,
00:33:04 the appendix to policy 539 has been updated to align with other documentation.
00:33:11 And then at the meeting on the 22nd of December 2010, the action was marked as complete.
00:33:18 You can take my word for that. We can go to it if you want.
00:33:21 The reference should anyone need it is LFB trouble 0 84033 paragraph 5.7 and page 6.
00:33:29 The minutes do not show that the policy was approved or signed off by the board.
00:33:35 Can you remember was or were the changes approved and signed off by the board on the 22nd of December 2010 or at a later meeting or an earlier meeting?
00:33:48 I can't recall, but I also can't recall actually seeing the actual revised document at the board anyway.
00:33:56 Is there a possibility, if I can figuratively embolden underline that word,
00:34:03 is there a possibility that the policy wasn't formally signed off or approved by the action board?
00:34:10 There's a possibility, yes.
00:34:12 Now, both Scott Heywood and Joe Smith said in their evidence that they did not recall giving a presentation of the policy to the board
00:34:20 and taking the board through the newly amended policy and explaining the differences between it and its predecessor.
00:34:27 Does that accord with your recollection?
00:34:30 I certainly can't remember it now.
00:34:33 Given that the gap analysis had in fact identified a number of departures between the LFB's internal policy and national guidance,
00:34:44 didn't the board need to be assured that policy 539 did make good to those deficiencies and properly reflect national guidance?
00:34:53 With hindsight we could have done, but it wasn't the policy of the board to go through every document that was amended as a result of the work arising from the action plan.
00:35:02 We had heads of service and directors involved in the work to complete the action plan,
00:35:07 and I, the board, took their word that if the documents had been amended appropriately, then they had been amended appropriately.
00:35:15 And also it was always my intention to carry out a further audit of the actions anyway, which is what I did in 2012, in order to confirm or identify otherwise.
00:35:26 It wouldn't have been unduly onerous for the board to have seen a tracked change document,
00:35:34 by which they could have seen the changes that would have been made and satisfied themselves that national guidance was now properly reflected in 539?
00:35:43 No, I suppose not, but that would have required every board member to carry out their own analysis of the revised document against the actual extent guidance,
00:35:51 rather than just looking at tracked changes version because we needed to establish, and that wasn't what we did.
00:35:57 So long as the board had the assurance of the relevant heads of service, you were content to rely upon the assurances you were provided with, is that a fair summary?
00:36:06 In most cases, yes.
00:36:08 In which cases wouldn't you adopt that approach?
00:36:12 I can't recall exactly which ones, but there were things that actually we did take to the board in order to actually be clear.
00:36:19 Would those be relatively rare events?
00:36:21 Yes.
00:36:24 Could we now turn to action 12?
00:36:26 And if we could again go back to the assurance review, LFB quadruple 0 4801 forward slash 14.
00:36:35 Action 12, right hand column, bottom half of the page.
00:36:44 Action 12 provided thus establish a recurring programme of fire survival guidance, FSG, refresher training in accordance with the national guidance for all control personnel.
00:36:58 Do you recall that the programme of refresher training was to be a two year programme, with the first year as a full day of refresher training with active role play,
00:37:07 and half of which was to be delivered by the fire safety team, and the second year being an online CBT course?
00:37:14 I do.
00:37:16 Now action 12 is marked as completed by the Lacknell House Board at a meeting on the 8th of November 2012.
00:37:23 We don't need to go to it, but the reference is LFB, trouble 0, double 5, 2, 1, 3, forward slash 6.
00:37:29 Now once that action had been marked as completed, did you or the board take any steps in 2012 or 2012, 2011 or 2012, to ensure that it was being provided?
00:37:43 No, I didn't personally.
00:37:45 Was that because it was not the action board role, or was it that you assumed someone else was checking that the training was in fact being provided?
00:37:56 Both of those reasons.
00:38:00 By the stage you were preparing to give evidence to the inquest in the first quarter of 2013,
00:38:06 what steps did you take to assure yourself before you gave evidence that the training was in fact being provided on the basis that it had been agreed?
00:38:15 I asked for a review of the whole action plan to be undertaken at the end of 2012.
00:38:22 And you've referred to that in two answers now, and the purpose of that review was to ensure presumably that you were giving correct evidence to the coroner?
00:38:30 Yes, and because I generally wanted to know what state we were in terms of what actions had been completed and which ones hadn't.
00:38:36 Thank you. If we can go back to the Latlaw Control Report, LFB, quadruple 0, 4724, forward slash 53.
00:38:44 Now in relation to action 4.2, which is in the top part of the page, you'll see it starts on the third line from the very top.
00:38:58 It says this, completed.
00:39:01 A programme of refresher continuation training was implemented for all in-post control officers between May and August 2010.
00:39:10 Continuation training is provided annually to all control staff over a two-year cycle, with year one being a trainer-led course and year two being a computer-based training course.
00:39:22 The training includes A, role play, to ensure confirmation of learning was introduced into training.
00:39:29 This allows all new and existing staff to experience a number of FSG call scenarios in a safe, supportive environment.
00:39:37 B, inputs from brigade fire safety officers covering aspects of building design and construction, coupled with current fire safety advice to educate control officers on fire behaviour and building types.
00:39:51 C, FSG training has been extended to encompass whole-day training.
00:39:58 Does that summary reflect your understanding of the refresher training that was in place as of January 2013?
00:40:05 Yes.
00:40:08 Were you aware that as of January 2013, the only FSG training that had been delivered in accordance with national guidance had taken place in 2010?
00:40:19 No.
00:40:21 And that in 2012 the active role play element had been changed to a passive role play element?
00:40:26 No.
00:40:28 And in 2011 and 2012 the FSG training had been reduced from a full day to four hours?
00:40:33 No.
00:40:37 Did you seek to ensure that the coroner was aware of these changes in recommendations?
00:40:45 No.
00:40:46 Any information, rather?
00:40:47 I wasn't aware of them, no.
00:40:49 So the coroner wasn't updated?
00:40:51 No. Not by me.
00:40:53 Are you aware that the coroner was updated by anyone from the LFB about those facts and matters?
00:40:57 No.
00:40:59 Were you also aware that following the inquest in 2013, FSG refresher training largely fell by the wayside due to the focus on implementation of vision?
00:41:09 No.
00:41:12 Did Scott Heywood or anyone else report up to you that FSG training was being diverted by the need to concentrate on the implementation of vision?
00:41:22 No.
00:41:24 Did you check yourself or cause to be checked for you, whether before the inquest or afterwards, FSG training was actually taking place?
00:41:33 No.
00:41:34 Can you help us why not?
00:41:36 Because it was one of the actions on the action plan and I always had confidence in the officers working in control and their line managers to make sure this was taking place.
00:41:48 Could we now look at a separate question? That's training records and the MOPAC audit.
00:41:53 Again, we keep on coming back to this minute. It's the minute of the 15th of September 2010 of the Latimer House Board.
00:42:01 LFB, trouble zero, double five, one nine two, forward slash two.
00:42:06 If we could look at paragraph five ten, which we've looked at, I think this is the third time now, which apologies.
00:42:18 The third item that you'd identified, which is recorded here, is to ensure that refresher training is maintained for fire survival calls and recorded on step.
00:42:31 To your mind, what was the importance to be gained by recording training on step?
00:42:39 Well, firstly, to make sure that all staff that were required to have the training had the training taken place, to make sure that training had been successful and to be able to prove that the training had taken place at any time necessary in the future.
00:42:55 By recording on step, did you anticipate the automatic, automated recording of training on step?
00:43:02 The mechanism of recording on step wasn't actually in the forefront of my mind at the time.
00:43:08 You didn't have in mind, for example, the automated updating to step as happened in fire stations being reflected in practice and control?
00:43:16 I didn't think about it in those terms. I would have assumed that it would be, but I was aware that the process, the training recording that was in place in stations, wasn't in place in control.
00:43:28 I knew that, but I just assumed that the step process would be similar.
00:43:32 Did you treat the step process basically as being a synonym for automated record keeping?
00:43:38 Yes.
00:43:39 Could we go to HOM, quadruple zero, double one, two four, forward slash three one?
00:43:46 This again is the Latino control report, dated November 2012.
00:43:54 And under the heading E7, entitled Conclusion about Control Officer Training and Knowledge, paragraph 167 says this.
00:44:03 An incomplete database record of training provided by the LFB to the control officers exists covering the period from 1981 to 2011.
00:44:13 This record includes initial continuation and refresher training given to control officers.
00:44:19 Was it the incomplete database of training records that caused you sufficient concern to have it raised as an issue at the meeting on the 15th of September 2010?
00:44:30 I don't think it was actually this particular paragraph, but certainly, yes, it was. Concerns about the training records that caused me to revise it.
00:44:39 Had you been made aware of an audit carried out in August 2010 by station manager Kelly, off control?
00:44:49 Had you been made verbally aware or briefed to any extent on his conclusion that there needed to be, quote,
00:44:56 appropriate training records that support the cyclical training planning process, close quotes?
00:45:01 I hadn't been told that, no.
00:45:04 Would you have expected to have been given information like that at this stage, which suggested that record keeping was a chronic problem?
00:45:12 Yes.
00:45:14 And to whom would you have expected, or from whom would you have expected that information to have been provided?
00:45:20 The officer responsible for the control.
00:45:23 Is that most immediately Scott Hayward?
00:45:25 Yes.
00:45:27 At the meeting on the 8th of November 2010, which can be found at LFB Trouble 055213.
00:45:41 If we look at item 4.6, the last sentence says this.
00:45:47 All training records have been transferred onto STEP.
00:45:52 By that assurance, what did you understand, or what have you been led to understand was meant by that sentence?
00:46:00 That the training records are now complete and being updated on a regular basis when training took place.
00:46:05 And on the basis of the answer you gave previously, your understanding or assumption was that it would be automated, the process?
00:46:11 Yes.
00:46:14 After this particular meeting, did you have cause, was there any prompt for concern, to revisit the adequacy of controls training record keeping?
00:46:25 No.
00:46:27 Could we now go to the MOPAC audit, LFB Trouble 044640.
00:46:36 If we look at page 1 in the summary.
00:46:43 The opening sentence of the summary says this.
00:46:46 This report summarises the work carried out under the internal audit shared service agreement by the Mayor's Office for Policing and Crime, MOPACs,
00:46:55 Directorate of Audit, Risk and Assurance, in the third quarter of 2014-15.
00:47:03 So it would appear that there were arrangements between the LFB and MOPAC, whereby the latter carried out audits as and when required. Is that a fair summary?
00:47:12 That's fair, yes.
00:47:15 Were you aware of the fact of this audit?
00:47:20 Not that I reckon we could recall, no.
00:47:22 How frequently would MOPAC carry out an audit of the LFB, the entirety of its functions, or would it be particular departments that the LFB would ask to be audited?
00:47:33 As I recall, there was a regular programme of audits, sort of a cyclical thing, but they would also carry out audits, exceptional audits, if they were asked to.
00:47:42 Can you remember how frequently control would be audited by MOPAC?
00:47:47 I can't recall anyone other than this.
00:47:55 I'm assuming that you had no role, direct or otherwise, in the audit process itself. Is that a safe assumption?
00:48:02 Absolutely.
00:48:04 Could we go to page 25, which hopefully should be annex B in this document?
00:48:10 If we turn first of all to the left-hand side of the table on the screen, we can see that brigade control has been audited and a final report published in February 2015.
00:48:22 Is that final report something you're aware of?
00:48:25 Yes.
00:48:26 Did you read that report?
00:48:28 I'd be surprised if I didn't, because I used to take great care of reading all the reports that came to the Corporate Management Board, and this would have been one of those that came there in the general cycle before going to the audit committee.
00:48:39 Was control a particular area of concern for you? If something crossed your desk that was entitled control, would that be something you'd go to immediately?
00:48:51 Not really, no.
00:48:53 Can we look at some of the findings in the second column?
00:48:56 It sets out areas of effective control, and then reading rightwards in the third control, areas of risk recommendation and category, and then we see it goes on in the fourth column, responsibility and agreed action, and then finally a target date.
00:49:12 Now if we can look in the third column, it recorded the following risks.
00:49:17 Number one, the training spreadsheet may be completed inaccurately or even altered intentionally, which could impact upon the ability of brigade control to effectively monitor the provision of training.
00:49:29 This could in turn result in the reporting of incorrect information to senior management.
00:49:35 Two, if the spreadsheet is not completed consistently and accurately, then the ability to monitor training levels may become difficult and inappropriate decisions may be made.
00:49:46 If we look at the next box down on the same page, it said this.
00:50:04 Now those identified risks were allocated a medium risk rating. Is that a correct reading?
00:50:18 That's correct, yeah.
00:50:20 Do you recall reading these particular findings and noting the risk rating given to them?
00:50:26 I would have read this report, but I don't specifically remember it, no.
00:50:34 Is this the first time or the most recent time that problems with training records have been brought to your attention following Lacknall?
00:50:47 I believe so, yes. I don't think it's been mentioned with me following the Lacknall. What we've done around Lacknall, we spoke about earlier in this report.
00:50:54 Did the reference there to reputational damage give you at the very least pause for thought as to the nature and extent of the problems that the auditor identified and the consequential risk rating?
00:51:07 The way this report, as I understand it, certainly the way I read it and was intended to be read, was the middle column and the third column from the left identified potential risks.
00:51:18 Not necessarily those risks were actually being delivered or coming to reality. That was actually the risks that were there and a rating of how high they rated those risks.
00:51:28 So a rating of medium would be of concern to me, but not obviously of concern as a rating of high.
00:51:34 So it's necessary to look at the second column as well to see what the actual effective areas of control are and then what the result of that is.
00:51:44 So just because something is rated as a risk in the third column doesn't mean it's actually a risk which is actually taking place or being delivered.
00:51:51 Notwithstanding that, and reading this summary, there are clearly significant problems with record keeping at control. Would you accept that?
00:52:00 With recording training?
00:52:05 Yes.
00:52:06 Now we can see in the column that various actions to control those risks were agreed and assigned to the Senior Operations Manager with a target completion date of the 30th of June 2015.
00:52:20 Did you seek to discover whether those particular actions had been fully and effectively completed?
00:52:30 No, I was assured by the officers responsible for control and the officers responsible for control that came to the Corporate Management Board therefore that those controls had been put in place.
00:52:42 And you had no cause to doubt the assurances with which you had been provided?
00:52:46 No.
00:52:52 Would you accept looking at the nature and tenor of the findings here, the medium risk rating, that certainly still at the beginning of February 2015 the LFB had not yet got to grips with ensuring adequate training record keeping was taking place at control?
00:53:13 Yes.
00:53:14 Thank you.
00:53:17 Could we now turn to the Lindridge review which was carried out in January 2013.
00:53:22 And the starting point for the discussion this afternoon I'd like to go to your own witness statement, which can be found at LFB trouble 0 32157 forward slash 10.
00:53:34 If you look at paragraph 38.
00:53:38 As Commissioner, I had overall responsibility for ensuring the actions identified following the Lacknell House fire were implemented.
00:53:47 And in 2012 I instigated a review of the Lacknell action plan to date to be carried out by the operational assurance division.
00:53:55 That review was carried out by the head of operational assurance Danny Cotton and group manager Dave Lindridge.
00:54:02 This review is intended to confirm the actions that have been completed and to identify the actions that remained outstanding where further work or resources were required.
00:54:13 This review was reported to the commissioners group in January 2013.
00:54:19 At this meeting head of operational assurance Danny Cotton was tasked to discuss the findings of the review with each head of service in relation to each of the actions in the action plan for which their department was responsible.
00:54:34 Now, looking at the review carried out by group manager Lindridge, we find it at LFB trouble 033943.
00:54:50 Is that the audit to which you referred in your previous answers?
00:54:55 Yes.
00:54:56 So we can take it that you're very familiar or were at the time familiar with the context.
00:55:02 Can we look at some of the matters which relate to control?
00:55:05 And if we go to page five on which action five is considered at the top.
00:55:12 See what it says there underneath the heading is this.
00:55:15 The gap analysis did not include FSC 5404 as part of the national guidance for consideration.
00:55:23 FSC 5404 introduced a three stage call handling approach and included additional FSC questions or assessing the caller.
00:55:33 The gap analysis also identifies areas for improvement for the national guidance.
00:55:38 These recommendations have not been addressed or reflected in local policy.
00:55:43 So if we go to the bottom of this page and look at action nine revision of the FSC control reference information files,
00:55:51 the review said this.
00:55:55 The riff has been reviewed and has been amended to comply with FSC 1093.
00:56:01 The guidance introduced in FSC 5404 is not included.
00:56:07 It is relevant to explain that the purpose of this riff is to assist the call taker was performing a fire survival guidance call.
00:56:15 And the format received some criticism from control room operators and CROs.
00:56:20 The riff covers 27 pages, which can be navigated by hyperlinks.
00:56:25 A single page flow chart was to be developed for the CROs.
00:56:29 But no evidence of this has been produced.
00:56:32 If we turn over the page to page six, action 10 revision of PN 539 emergency call handling.
00:56:40 The text said this. PN 539 has been reviewed and it complies with FSC 1093, including making people safer control training guidance 1994.
00:56:51 The revision of PN 539 does not include the entire details from FSC 5404.
00:56:59 One recommendation of the control group gap analysis action five stated, and I quote,
00:57:06 The information is found in a number of LAP documents and needs to be consolidated.
00:57:12 But the structure of the brigade policy notes appears to be unchanged from pre 2009.
00:57:19 Specific observations made as a result of this view have been fed back to the ACOPR.
00:57:26 These will be considered in a forthcoming review of control FSC policy.
00:57:32 Polities having to listen to me for an undue period of time.
00:57:35 Stay on this page and look at action 12 FSC with Russia training control training records of no recorded FSC training for two watches.
00:57:45 Watches two and three in 2011 conversations with members of control staff and managers suggest that this is a recording error.
00:57:54 The computer based training CBT package was completed earlier this year.
00:57:59 It has not yet been accessed. It will be completed by all control room staff during 2013.
00:58:05 Due to the refresher training being conducted with a PowerPoint presentation in 2011, no one had access to CBT before November 2012.
00:58:15 Since the outsourcing of brigade training to Babcock, there is no official mechanism to maintain the CBT content for control room staff.
00:58:24 When you read this, were you concerned to read that a number of the actions about control had not been completed in full?
00:58:33 Absolutely.
00:58:35 You say in your statement that you tasked Danny Cotton to discuss the findings of the review with each relevant head of service.
00:58:42 Danny Cotton agreed with other witnesses that the Lindridge review was presented in a November 2013 meeting of the commissioners group.
00:58:50 And suggested that your recollection that she was tasked to discuss the findings with each head of service was incorrect.
00:58:57 What would be your response to that evidence?
00:59:00 When I wrote my statement, that was absolutely a true recollection of what had happened with the report.
00:59:06 I have since seen evidence that the inquiry has been presented with.
00:59:11 And I have seen emails indicating that the meeting did not take place and that I was in error.
00:59:15 So I apologise for misleading the inquiry in that place.
00:59:18 So you think November 2013 was the date at which this Lindridge review was presented?
00:59:24 Certainly the date. I think it was the date when it was formally presented to a formalised meeting of the brigade.
00:59:30 But it was not the first time that it was discussed by me with other officers.
00:59:35 The final version, as we say, was produced in November 2013.
00:59:40 And if you would like to see it, we can go see it.
00:59:43 No, it is okay.
00:59:45 We have heard an evidence that neither the January 2013 version or the November 2013 version were taken to the Lacknell House Board.
00:59:54 And that seems to be supported by the minutes of the Lacknell House Board.
00:59:59 Does that accord with your recollection?
01:00:02 Yes, it does.
01:00:03 I wish that we had a further meeting of the Lacknell House Board following the inquest, the Cromwell's inquest,
01:00:08 in order to actually sign this off and deal with matters arising from it.
01:00:11 But as the inquest had then been completed, and it was my recommendation to the authority,
01:00:16 the responsibility for monitoring the action plan, all aspects of the action plan from then on, will be taken over by ODCB.
01:00:22 I failed to have that last meeting.
01:00:25 Had you intended to submit the report to the Lacknell House Board at any stage?
01:00:31 Yes.
01:00:32 And why had that been your intention?
01:00:34 Because it was a review of the actions that we were all responsible for.
01:00:37 And therefore it was important that everyone saw the review.
01:00:40 I was able to account for the areas where they hadn't completed their actions.
01:00:54 The reason I'm pausing, just to give you, probably be helpful in relation to that answer,
01:00:58 could we go to LFB 00084017?
01:01:02 And it's yet another email chain, which apologies Mr Dobson.
01:01:07 It's a chain, 2nd October 2013 anyway, and we can see in the second email on that page,
01:01:19 Gary Reason sent an email on the 3rd October to Danny Cotton,
01:01:24 copying in Rita Dexter, Tim Cuthill and Dave Broad, saying this,
01:01:30 Following the Lacknell House Board meeting earlier in the week,
01:01:33 I've now had the opportunity to discuss with the Commissioner the handling of the thematic review report.
01:01:38 And was that the Lindridge review?
01:01:40 I believe so, yes.
01:01:41 The Commissioner would like the report brought up to date to take account of the fact that some of the outstanding ongoing actions,
01:01:47 detailed in the January version, would, should have progressed by now.
01:01:52 Once this work has been completed, the Commissioner will then organise a Lacknell House Board meeting,
01:01:57 where we will formally review and accept the updated report and hopefully close down the Board.
01:02:02 That's evidence, contemporaneous evidence of your intention to have that final meeting.
01:02:14 Apologies if I haven't covered this explicitly, but why,
01:02:22 why wasn't, why was the opportunity lost to put this final report to the Lacknell House Board more formally?
01:02:29 As I said, the coroner's inquest had been completed.
01:02:34 We had the Rule 43 letter and we were about to report to the authority with the outcome or the results from the coroner's inquest.
01:02:42 And the recommendation was that the monitoring of the action plan would in future be carried out by ODCB.
01:02:50 So whilst I wish we had had a final board meeting to do this, it was just one of those things that slipped by because other things had overtaken it.
01:02:58 Am I right in understanding that the report was also not submitted to the Lacknell House Working Group?
01:03:05 Yes, I believe so, yes.
01:03:07 Was that because that too had slipped by or was it a deliberate decision not to put the report before the Working Group?
01:03:15 No, it was not, it was not, it had not just slipped by.
01:03:18 As I recall, the Lacknell House Working Group stopped, concluded its work shortly around this time.
01:03:26 And therefore the Lacknell House Working Group were very keen on receiving the reports that related to their terms of reference and their ongoing work programme.
01:03:36 And whilst we reported the result, the update on the coroner's inquest, the Rule 43 recommendations, they hadn't had involvement in the other recommendations particularly anyway.
01:03:46 So I think we just see that it wasn't necessarily, it certainly wasn't the intention to keep it from them specifically.
01:03:54 Danny Cotton said that there was no qualitative review to ensure that the 34 pre-actions had in fact remedied the mischief they were designed to deal with.
01:04:05 Is that right, first of all?
01:04:07 Well, there was no, the ongoing review carried out by Mr Lindridge was to check progress and completion against the actions.
01:04:21 The ongoing review of whether or not those actions had actually achieved their objective was something that would have been reviewed over a period of time.
01:04:32 There wasn't a specific time scale for doing that and there wasn't a specific mechanism for doing that either.
01:04:36 You say would have been, was it?
01:04:39 Well, I believe it was, yes, through the general activities of ODCB and other reporting mechanisms.
01:04:48 Can I now turn to a separate and distinct topic, which is the LFB's response to the Rule 43 letter that you received from the coroner?
01:04:57 Yes.
01:04:58 Now, I think we discussed it earlier, but you asked Gary Reason to establish an action plan to respond to the Rule 43 recommendations.
01:05:09 Yes.
01:05:10 And when Gary Reason gave evidence, he explained that he in turn asked various heads of service to develop detailed draft responses to the Rule 43 recommendations.
01:05:21 And that those drafts then formed the basis of discussion, the commissioners group meetings.
01:05:26 Yes.
01:05:27 Where the final response was finalised. That's a very rough and ready summary of the process, but is it broad terms correct?
01:05:34 It's accurate, yes.
01:05:35 Thank you.
01:05:36 Now, can we go to another email chain? LFB trouble zero, 73406.
01:05:49 And we see that on the 11th of May 2013, Mr. Reason emailed you and other senior officers to this effect all ahead of next week's meetings to finalise the brigade's response to the coroner's Rule 43 recommendations.
01:06:04 Please find attached the completed proformers detailing our position on each issue.
01:06:10 The proformers have been completed by the four lead officers, Dave B. So that's presumably Dave Brown.
01:06:16 Yes.
01:06:17 Steve T. Churek.
01:06:18 Churek.
01:06:19 Jim K. Knighton.
01:06:20 And Danny Cotton.
01:06:21 Yes.
01:06:22 With the assistance of comms and detail a range of background information that supports their respective proposals.
01:06:30 We have also included indicative time scale for completing each activity and made recommendations on how the brigade could audit the effectiveness of this work.
01:06:40 The ease of review I've highlighted in yellow text, the sections that detail our considerations and corresponding proposals for responding to each of the Rule 43 recommendations.
01:06:52 If agreed, it will be this information that will form the basis of the commissioners response to the coroner.
01:06:59 Now the proformer document attached that email is at LFB 0034062.
01:07:15 Now was that the document that you and your directors relied upon for the purpose of concluding your response to the coroner?
01:07:23 Yes, it was.
01:07:26 Now we don't have any minutes of the relevant meeting at which the response was finalised.
01:07:32 Can you help us to why there were no minutes of that meeting?
01:07:36 Because this is a bit of document that had input from the heads of service as detailing Mr. Rees' email.
01:07:43 And it was something that we dealt with between the directors and myself, probably at a commissioners meeting.
01:07:49 Now the document contains a number of tables for four of the five recommendations.
01:07:56 The one recommendation that is not covered is recommendation four, which addressed FSG and control related training for operational crews.
01:08:07 Now, can we start by looking at the table relating to the coroner's instant command recommendations, which can be found at page 11?
01:08:17 Thank you. Now we see the first row of that table sets out the relevant recommendation and it separates them out into two parts, A and B.
01:08:27 A deals with the changes in instant commander during the course of an instant.
01:08:32 But for these purposes, could we look at B, which focuses on training and it reads as follows.
01:08:40 It is also recommended that consideration be given to training of ICs and potential ICs to enhance their performance in relation to the following.
01:08:50 One, use the dynamic risk management model and other management tools to enable ICs to analyse the situation and to recognise and react quickly to changing circumstances.
01:09:02 Two, to recognise when to escalate attendance by more experienced ICs.
01:09:09 Three, to anticipate that a fire might behave in a manner inconsistent with the compartmentation principle.
01:09:17 Four, to be aware of the risks to those above and adjacent to the fire flat.
01:09:23 Five, hand over from one IC to the next an effective deployment of outgoing ICs.
01:09:30 Six, the collection of information from all possible sources.
01:09:35 Seven, use of methodical search patterns.
01:09:39 Now, when you received that recommendation from the coroner, what was your initial response as to how best to address it?
01:09:48 Well, these are all things that I would agree with from the coroner, first of all.
01:09:54 The best way to address that was by this time we had an external training provider.
01:10:00 But in any case, if it had been still internal, the best way to address these would be to give these recommendations to the training department or the training provider
01:10:08 and ask them to carry out an analysis of existing training for incident command against each of these items.
01:10:15 Could we look at just two of these recommendations?
01:10:18 Yes. First of all, item one, which is the use of dynamic risk management model, and three, to anticipate that fire might behave in a manner inconsistent with the compartmentation principle.
01:10:29 What was your understanding of the reasons for the rationale for items one and three?
01:10:37 My understanding was that the evidence given to the coroner during the inquest from incident commanders who actually attended the incident,
01:10:45 I was not completely satisfied that these areas were covered off in their performance at the fire.
01:10:51 Would you accept that the London Fire Brigade needed to fundamentally rethink its incident command training
01:10:59 so that incident commanders could identify and test the assumptions underpinning their operational response?
01:11:06 I'm not sure. I don't believe that we needed to completely reassess or revise their incident command training.
01:11:13 But I certainly was agree that these items needed to be assured as to the level at which they were in existing training.
01:11:22 And inevitably, they would need to be enhanced in there where they already exist and also further training be developed to make sure they were completely embedded.
01:11:31 Now, immediately below those individual items, there's a summary of your evidence to the coroner, both in your witness statement and in your oral evidence.
01:11:43 Now, the evidence relates to recommendation A only, so I don't intend to take you through it.
01:11:48 And indeed, you can take it from me that the remaining pages deal predominantly, if not exclusively, with A.
01:11:57 Now, recommendation B is mentioned in one place, and that's at page 22.
01:12:04 And it's the second row on that page, if we can go to it.
01:12:09 And you'll see just below the halfway mark, B for Bravo, the LFB will engage with our training contractor to ensure the points specifically listed in recommendations one to seven
01:12:21 are addressed in the current review process of incident command training.
01:12:25 This work is aimed to ensure that the training provided enhances performance across the range of required skills and knowledge needed to support effective incident command.
01:12:35 The brigade will also introduce a case study which will incorporate the learning outcomes from Lackawanna House and from other high profile high rise incidents such as Shirley Towers, Hampshire and Harrogord, Hertfordshire.
01:12:47 Now, that suggests that you and your fellow senior officers were predominantly focused on the issue of command levels and intended simply to pass on training recommendations to Babcock because they were your contractual provider.
01:13:01 Would you disagree with that?
01:13:03 I would disagree with that, yes.
01:13:04 Can you help me in what aspects you disagree with?
01:13:06 The first recommendation, the one in which is described more here, is because we've made more progress with that at this point.
01:13:14 We've actually revised the command levels and they've been the subject to consultation with the Fire Brigade Union.
01:13:19 The second part had less coverage in this review because it was an ongoing action.
01:13:25 But it was equally as important, in fact, in many ways in my mind, more important because the issue around command levels and spans of control
01:13:34 or something that needed to be dealt with, but it wasn't a very pressing issue in my mind.
01:13:40 However, the second one was.
01:13:42 But we passed the recommendation of the coroner onto the training contractor.
01:13:47 That was being assessed by them in terms of existing training and also future training might be required.
01:13:54 And we were awaiting the outcome of that review at this point.
01:13:57 But it was certainly, in my mind, it was the more important of the two issues relating to this recommendation.
01:14:03 Now, Babcock's review of training was due, I think, to be complete in April 2015.
01:14:09 The impression is there's more than an element of kicking training into the long grass over this period of time.
01:14:16 What would you say to that?
01:14:17 I would completely disagree with that.
01:14:18 And why is that, given the time period that it would take to review that?
01:14:21 Well, because there's more than one thing going on here in terms of this recommendation, in terms of B.
01:14:28 So part of the contract was require the training provider to carry out a full review of all LFB's training in the first three years of the contract.
01:14:37 And part of that review would be to carry out a review of incident command training.
01:14:42 Now, when we passed over the recommendations from the coroner, it probably was too late to actually include those in the overall review of incident command training,
01:14:52 because that had already been done and was contractually required by a particular date.
01:14:56 But it was very clear that we asked the contracts to also carry out a review of items one to seven in the list to identify where they were covering an existing training,
01:15:07 to identify where they needed to be enhanced to bring more to the forefront,
01:15:12 and also what new training was going to be needed in terms of exercise and things for incident commanders to make sure they were properly covered.
01:15:20 Did you consider whether your request to Babcock ought to be expedited or some greater priority given to implementation of the LACNL-related recommendations?
01:15:32 Well, my belief was that they were, it would be expedited in that way.
01:15:37 But it's important to remember, once again, that the general review of incident command training was already in place because it was a contractual requirement within three years of the start of the contract.
01:15:47 This is an additional piece of work, but it was certainly my expectation that it would be carried out as a priority.
01:15:54 Mr Dobson, may I apologise in advance? Some of the next questions are going to be somewhat long, simply because I have to cover off and hope you do it fairly, evidence given by others.
01:16:04 So can I apologise in advance and ask for your indulgence and bear with me?
01:16:08 If at the end of the questions you've lost where I first started, please say so and I'll attempt to shorten it.
01:16:15 Thank you.
01:16:17 Now we heard in module five and from Danny Cotton most recently that Babcock's initial assessment of the LFB's training was that whilst the seven recommendations could be said to have been contained within the existing incident command training,
01:16:32 it was at times implicit and not tightly focused.
01:16:36 And whether any given individual received the relevant training depended upon their rank and the exercise scenarios that they happened to be exposed to.
01:16:46 Now, despite that, we heard that it was reported to both ODCB and Elphiper's working group that all seven issues were covered in the LFB's existing suite of command training.
01:16:59 I'm given the importance of that review. Did you ever ask any questions about Babcock's work or otherwise seek to assure yourself that its findings were sound?
01:17:09 I did. I mean, I questioned where we were with this recommendation, particularly as a result of receiving this report that's on the screen at the moment.
01:17:18 And I spoke particularly to Mr. Reason about this.
01:17:24 But it was my, I was told and accepted that whilst the areas one to seven were already covered in existing training, that they needed to be enhanced or brought forward in terms of training in certain areas.
01:17:42 I wouldn't be surprised to hear that officers received different levels of this in terms of their different level of whether they're level one, two, three or four, because they have different responsibilities and different pressures, et cetera, on the intranet ground.
01:17:55 So that would not be a surprise to me at all.
01:17:59 But I was certainly very keen to be interested and interested to find out how this recommendation was progressing.
01:18:07 The it's almost a euphemism the way enhance has been used in this document.
01:18:13 Were you given in sufficient detail information regarding the nature and extent of the issues or topics that required enhancement and why they required enhancement?
01:18:26 Not not in that level of detail.
01:18:28 No, you just took you knew this work was required and that they would be getting on with it.
01:18:32 A new work was required.
01:18:34 I knew that we were had been very clear the training provider.
01:18:37 This was my opinion.
01:18:39 This work was to be a priority.
01:18:41 But I didn't actually I didn't go through the training program to see exactly where that was going to be enhanced.
01:18:46 Now, clearly, the coroner considered that training needed to be improved in seven areas of activity, given that she'd heard considerable evidence on those topics.
01:18:57 Were you surprised or even concerned by the assurance that training was largely fine?
01:19:07 I wasn't surprised because I would have been surprised if these areas because they are things that the coroner found important.
01:19:13 So did I. But they are things that I would have expected to be in existing training programs.
01:19:18 I was concerned that we felt they needed to be brought forward in terms of their importance in existing training.
01:19:24 But I was also reassured to some extent and I've seen an email emails during the course of my preparation say that other training was going to be developed to enhance the way these these particular issues were provided.
01:19:36 At first blush and certainly coming to it cold.
01:19:40 There seems to be, again, I put this euphemistically, a tension between the coroner's conclusions on the one hand and the assurances you provide from Babcock that training was largely fine.
01:19:53 Did you identify such a tension at the time?
01:19:56 Not really, because I didn't I didn't see it as a comment that training was largely fine.
01:20:00 I would have taken that as a superficial and not not not acceptable comment.
01:20:05 However, having been involved in brigade training in the past, I was not surprised to hear that these things were covered.
01:20:12 But I was actually pleased to hear the training contracts and others accept that they needed to be enhanced in certain parts of training.
01:20:20 And then the training would also be designed and provided.
01:20:23 Now, we heard that a decision was taken to develop a command decision exercise to emphasize the lack of that.
01:20:31 And that this ultimately resulted in the production of what was called the whole Croft House.
01:20:36 Yes, exercise.
01:20:39 Orbit that wasn't complete until three years later in August 2016.
01:20:44 Now, explored the detail of that package with Danny Cotton and Gary Reason.
01:20:50 Mr. Reason accepted that the package did not satisfy the coroner's seven training related recommendations.
01:20:58 Bearing that in mind, did you ever seek to assure yourself of the adequacy of the whole Croft House training exercise?
01:21:05 And in particular, that it met the problems which have been identified by the coroner?
01:21:10 I didn't go through the training package personally because I wasn't surprised that one training package didn't meet all of the recommendations from the coroner.
01:21:19 And because that would be potentially a false way to actually do this.
01:21:23 So I was disappointed that the view was the whole Croft House presentation didn't cover as many as I hoped it would.
01:21:32 And therefore, but I was reassured that other training decision making exercises and training packages were also being delivered that would address all the recommendations in total.
01:21:43 Were you aware of the glacial race of progress in relation to the whole Croft House exercise?
01:21:49 I was.
01:21:51 What were you doing to speed matters up?
01:21:54 I had a number of discussions with officers.
01:21:58 One of the things that I considered and we discussed informally was the implementation of the key performance indicator regime that is included within the contract.
01:22:08 Because there are key performance indicators in the Babcock training contract which require things to be done within certain timescales.
01:22:15 And this one clearly wasn't being complied with.
01:22:18 So my consideration was whether or not those key performance indicators framework could be invoked in order to actually speed things up and expedite the matter.
01:22:27 Can you help us as to your understanding of the reasons why the whole Croft House exercise did not fully satisfy the seven recommendations identified by the coroner?
01:22:39 Just because of the nature of the incident itself I believe and the levels of officer that it was directed at.
01:22:45 But just to finish my answer if I may.
01:22:47 Yes please.
01:22:48 We considered the KPI regime because that was obviously a reasonable way in my view to expedite the matter and get the training contractor to provide in a quicker timescale.
01:22:59 However I was advised by officers that were part of the training contract that their view was that there was fault on both sides.
01:23:08 And that in fact had we tried to invoke the KPI performance regime the LFB would have been or we would have been found to be at fault in terms of the way we were doing things.
01:23:18 We interacted with the training contractor at the same time and therefore we held some of the blame for the delay in the provision of the packages.
01:23:25 Just before the break if I could just follow up on that answer.
01:23:29 What were the particulars of the extent to which the LFB was at fault? Were you given that detail?
01:23:35 I was, I was. I can't recall it all now.
01:23:37 But it was certainly in relation to provision of information to the training contractor.
01:23:42 Views and responses on things that were provided back to us.
01:23:46 So the contract required for the training contractor to go away, take teacaps away and come back with proposals in terms of exercises and content etc.
01:23:54 And there was certainly some unexplained delays in how quickly the training team and the team, the expansion department was going back and providing comments back to the training provider in those areas.
01:24:10 Mr Dobson, thank you sir. I think that's probably a convenient point.
01:24:15 Well I think we should have a break at this point. Yes, thank you.
01:24:17 Thank you. Mr Dobson, we'll have a break. We'll stop there and resume please at 20 to 4.
01:24:24 And as before I ask you not to talk to anyone about your evidence.
01:24:27 Of course, yes never. Thank you. Thank you very much.
01:24:36 Thank you very much. 20 to 4 please.
01:24:47 Thank you.
01:25:17 Thank you.
01:25:47 Thank you.
01:26:17 Thank you.
01:26:47 Thank you.
01:27:17 Thank you.
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01:28:17 Thank you.
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01:31:17 Thank you.
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01:32:17 Thank you.
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01:33:17 Thank you.
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01:34:17 Thank you.
01:34:47 Thank you.
01:35:17 Thank you.
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01:37:17 Thank you.
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01:38:17 Thank you.
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01:39:47 Thank you.
01:40:17 Thank you.
01:40:47 Thank you.
01:41:17 Thank you.
01:41:47 Thank you.
01:42:17 Thank you.
01:42:33 Would you ask Mr Dobson to come back in please.
01:42:35 Yes.
01:42:37 Mr Dobson.
01:42:39 Ready to carry on?
01:42:41 Thank you very much.
01:42:43 And you touched on, before the afternoon break,
01:42:46 the difficulties you were encountering with Babcock.
01:42:49 And when he gave evidence, Mr. Groves
01:42:51 told us that you'd met Babcock's chief executive
01:42:54 to discuss issues of concern, including
01:42:57 the delays the Hallcroft House exercise or the subject
01:43:00 matter that was covered by that exercise,
01:43:03 and the difficulty with Babcock's lack of instant command
01:43:06 subject matter expertise.
01:43:09 First of all, is it right that you met Babcock's chief
01:43:11 executive, first of all?
01:43:13 We had a regular program of regular meetings.
01:43:16 And did any or more of those meetings
01:43:19 cover the subject areas which I've just touched upon?
01:43:21 They did.
01:43:23 Can you help us?
01:43:24 What was the outcome of the meeting or meetings
01:43:27 when you set out your concerns about the delay
01:43:29 in implementing the training that was ultimately
01:43:31 covered by the Hallcroft House exercise?
01:43:33 Well, we had a discussion regarding the delay,
01:43:37 the causes of the delay, and also
01:43:40 where fault lie on both sides, actually.
01:43:42 Because the CEO was also not surprisingly
01:43:45 keen to say to me that the areas where
01:43:46 LFB had been slowing providing its responses
01:43:49 and fulfilling its responsibilities.
01:43:51 So we had debates about that.
01:43:53 But I made it very clear that it was a very important matter.
01:43:57 It was a result of Colonel's Rule 43 recommendations.
01:44:00 It was of fundamental importance to learn the fire brigade.
01:44:03 And things needed to be expedited as quickly as possible.
01:44:05 How was it resolved?
01:44:07 What the practical outcome of these meetings in terms
01:44:09 of setting the date?
01:44:11 I understand there's a keenness to answer.
01:44:14 Let me finish the question.
01:44:16 Was a date fixed or agreed by the two of you
01:44:20 by when the Hallcroft House training
01:44:22 exercise would be provided?
01:44:24 No, I don't recall agreeing an actual date.
01:44:27 But both sides and the CEO from Babcock
01:44:29 was very explicit to me that he would speak to the people that
01:44:32 worked for him.
01:44:33 And he would commit additional resources to it
01:44:36 as necessary in order to expedite them.
01:44:38 The issue of expertise is an interesting one.
01:44:41 If we could come back on to expertise.
01:44:42 Apologies for interrupting.
01:44:43 Sorry.
01:44:44 In terms of timing, were you content with the assurances
01:44:49 that you were provided with?
01:44:51 And secondly, did they improve their performance
01:44:55 after these discussions?
01:44:58 My recollection is yes on both counts.
01:45:00 I interrupted you for which apologies.
01:45:02 And in terms of subject matter experts.
01:45:03 Yeah, you've raised the issue of availability
01:45:05 of subject matter experts.
01:45:08 I think Mr. Reason might have been,
01:45:11 or it might have been somebody else,
01:45:12 mentioned the problem of actually
01:45:14 the lack of availability of subject matter experts
01:45:16 actually in the area of incident command.
01:45:19 Because you need people that have actually
01:45:21 worked at the level of what you're trying to train
01:45:23 or to actually inform the training process.
01:45:27 And they were in relatively short supply.
01:45:30 Babcock had tried to recruit ex-London Fire Brigade officers
01:45:34 to assist them with this.
01:45:36 But ultimately, there was a responsibility on us
01:45:38 as the London Fire Brigade to provide the subject matter
01:45:41 experts to enable them, to enable Babcock
01:45:44 to deliver the training that we wanted in an appropriate way.
01:45:46 Thank you.
01:45:48 Can I now move on to section 72 D visits?
01:45:52 No, that was also the subject of a recommendation
01:45:55 following Lacknell.
01:45:57 And if we go back to the LFB's pro forma document
01:46:02 at LFB trouble 0 34062.
01:46:11 If we turn to page 5, we can see in the bottom third
01:46:19 of the page, section 17 D, in the usual way,
01:46:25 the first row of the table sets out the text from the letter.
01:46:29 And just so that people know what we're discussing,
01:46:32 it said this, I note that the brigade now
01:46:34 has guidance as to how such visits should be conducted
01:46:38 and the type of information which crews should gather.
01:46:42 As you recognize, gathering of operational knowledge
01:46:45 has little value unless it can be stored, disseminated,
01:46:48 accessed, and updated when most needed, i.e. at instance
01:46:53 when the use can save valuable time and inform critical command
01:46:56 decisions.
01:46:57 It is recommended that the brigade review procedures
01:46:59 for sharing information gained as a result of section 72 D,
01:47:04 familiarization and home fire safety visits
01:47:07 with crews both within the station in question
01:47:09 and at other local stations.
01:47:12 Looking at the row below, information on the LFB's
01:47:16 policies training systems as at April, May 2013,
01:47:20 as at page 7.
01:47:24 Sorry, if we can turn to page 7.
01:47:26 And if we look at the second row down,
01:47:28 it's highlighted yellow by Mr. Reason.
01:47:32 And it said this, the incident at Lacknell House
01:47:35 occurred prior to the introduction of the ORD and MDT
01:47:38 system.
01:47:40 Consequently, we now have new systems, policy and training
01:47:43 in place, that address those comments.
01:47:45 We also now have a management process
01:47:47 which ensures appropriate service standards are maintained
01:47:51 with regard to gathering and recording premises
01:47:53 specific operational information and training staff
01:47:57 so that they are familiar with local tactical plans.
01:48:01 Now, it would therefore appear that the LFB considered
01:48:04 that the introduction of the ORD and the MDT
01:48:07 had satisfied the coroner's recommendation on this point.
01:48:11 Is that a fair, correct reading?
01:48:13 I think it's fair in terms of the coroner's recommendation
01:48:15 in terms of sharing of information,
01:48:18 because the ORD and particularly the MDT system
01:48:21 were most certainly industry best practice at the time.
01:48:24 I can't think of any other way of doing it that was more
01:48:26 comprehensive or more comprehensive than that.
01:48:29 So I think we certainly viewed that the coroner's
01:48:31 recommendation in terms of sharing information
01:48:33 was addressed by the MDT and the ORD.
01:48:36 But I think we took it as an opportunity
01:48:39 to look more broadly than just the sharing about also
01:48:42 the collating and collecting as well.
01:48:44 And that's demonstrated by the bullet points
01:48:47 in the box below that.
01:48:49 Now, if we could look at the recommendations which
01:48:51 are in the bottom row, and if we could in particular look
01:48:54 at the first bullet point, which says this,
01:48:57 undertake a review of the existing policy relating
01:49:00 to information gathering and contingency plans,
01:49:04 with a view to further clarifying
01:49:05 what operational crews should seek
01:49:08 to achieve when undertaking a Section 72D visit
01:49:11 and to outline how this fits with other pre-planning
01:49:14 activities, such as exercises, various community safety,
01:49:18 and other inspections.
01:49:20 Now, the impression, and I put it no more highly than that,
01:49:23 is that in 2013, neither the LFB nor its crews
01:49:27 had a sufficiently clear idea of what the purpose of 72D was.
01:49:32 What would be your response to that?
01:49:34 No, I believe the LFB certainly did,
01:49:38 and I believe the crews did as well.
01:49:39 Whether that will always follow through in terms of the way
01:49:42 and the quality of their inspections
01:49:44 and the recording of those is a different matter.
01:49:46 But certainly, I believe that the London Fire Brigade
01:49:49 and its operational personnel was aware
01:49:52 of the purpose of 72D.
01:49:54 They might not have been aware of it in its broadest sense,
01:49:57 as perhaps described by the letters
01:50:01 from the Chief Fire Rescue Advisor and from the HSE,
01:50:05 but we certainly tried, in my opinion,
01:50:07 to make them aware of the purpose, the importance,
01:50:10 and the importance of 72D visits
01:50:12 and why they should have carried them out properly.
01:50:15 It's just, I was looking at the words with a view
01:50:17 to further clarifying what operational crews
01:50:19 should seek to achieve.
01:50:21 It seemed to be raising a concern as to a misunderstanding
01:50:26 or an absence of an understanding
01:50:28 of what some 2D visits were about.
01:50:31 Okay, I think what that is relating to really
01:50:34 is that there was still, in some operational areas,
01:50:37 and we got, there was 440 or whatever,
01:50:40 different watches, different workplaces in the LFB.
01:50:43 Some of those, I think the understanding was still
01:50:46 that 72D visits were just the same as a 11D visit
01:50:49 from the previous Fire Service SACs,
01:50:51 but obviously, 72D visits were broader
01:50:54 than the requirement of 11D,
01:50:56 and we were trying to make crew crews aware
01:50:59 of the breadth of the whole of the 72D process
01:51:01 as opposed to one previous 11D.
01:51:04 Would you agree that there are two related
01:51:07 but slightly different aspects to these visits?
01:51:10 One is to obtain information about the building
01:51:16 or the people or whatever it is,
01:51:18 and the other is what's sometimes called familiarization,
01:51:21 which is for the crews themselves
01:51:24 to take in a visual and practical picture
01:51:29 so that if they're called out,
01:51:31 they will say to themselves,
01:51:31 I've been here before, I know how this works,
01:51:33 I know where that door leads to or whatever.
01:51:36 And they're rather different,
01:51:37 but both of those would be quite important.
01:51:40 They are, sir.
01:51:41 I believe that the previous 11D process
01:51:43 and the previous Fire Service SACs
01:51:45 really covered the second of what you've just described
01:51:48 in terms of just an awareness of the premise,
01:51:50 the layer, any unusual features.
01:51:52 The 72D broadens matters out for operational crews
01:51:55 in terms of collecting the other information
01:51:57 in relation to building type,
01:51:58 maybe types of construction, other hazards on site,
01:52:01 et cetera, et cetera.
01:52:02 So I completely agree, but I think it was different
01:52:04 between the way the two acts explain the purpose.
01:52:08 Thank you very much.
01:52:10 Now in module five, Dave Brown said
01:52:14 that it was his expectation that all high-rise buildings
01:52:18 should have at least have had an initial 72D visit
01:52:22 and should therefore have featured on the ORD,
01:52:25 the operational risk database.
01:52:27 However, we explored other items of evidence,
01:52:29 such as an article in operational news edition 20
01:52:32 and the changes to PN 633,
01:52:35 which suggested instead that that was not
01:52:37 a realistic ambition and that crews should focus
01:52:41 on high-rise premises which posed a,
01:52:44 quote, particular, close quote, risk.
01:52:47 What was your considered view on how many
01:52:50 high-rise buildings, residential buildings,
01:52:53 should be visited by crews?
01:52:54 Well, I was of the same mind as Mr. Brown at the time
01:52:57 following Lacknell House,
01:52:58 that crews should have at least carried out
01:53:00 at least one visit to all high-rise residential buildings.
01:53:04 I was also of the view that in future,
01:53:06 those visits might not need to be every year,
01:53:09 depending on the risk and hazards that are identified
01:53:12 when they actually carried out the visits.
01:53:14 But certainly in terms of initially,
01:53:17 they should have been, all high-rise buildings
01:53:19 should have been visited.
01:53:20 Did you have a considered view on how particularly
01:53:25 risky buildings could be identified and thereafter
01:53:29 the regularity of 72D visits to those buildings?
01:53:32 Yeah, I mean, I think the first thing would be
01:53:34 the number of calls received to particular buildings.
01:53:37 So actually, you know, many of these buildings
01:53:38 you would receive repeat fire calls to,
01:53:41 or other types of incidents.
01:53:42 So the number of calls received to individual buildings
01:53:44 would be an important consideration.
01:53:47 The level of housekeeping, whether it be good or bad,
01:53:51 at various buildings would be particularly interesting
01:53:53 in terms of how frequent they need to be visited.
01:53:56 Obviously, the type of persons that were
01:54:00 housed in those buildings,
01:54:02 and that's not always easy for social housing
01:54:04 because obviously you don't get to visit the people.
01:54:07 So, but we do know that there will be people
01:54:10 living in those buildings that might have
01:54:11 a number of disabilities or impairments.
01:54:13 And that would be obviously very important to the fire crews
01:54:16 in terms of if there was a fire,
01:54:18 how quickly they needed to be able to get those people
01:54:21 out of the building.
01:54:22 So it's a very basic, what I would call basic
01:54:24 firefighter indications.
01:54:26 And then of course, there was the other layer of detail
01:54:29 that came about from the porous guidance
01:54:31 and from what we then added to the 800 guidance.
01:54:36 Thank you.
01:54:37 Could we turn to your second witness statement?
01:54:40 And that's at LFB-000-555-138-7.
01:54:50 This section of the statement was dealing with the 2005 order.
01:54:55 And what you say here is that following the enactment
01:55:00 into force of the order, the LFB,
01:55:03 its emphasis was on visiting high-risk buildings
01:55:06 and previously unregulated buildings
01:55:09 due to the significant increase in the number of buildings
01:55:12 in which the brigade was required to enforce
01:55:14 the legislation and the limitations on funding
01:55:17 and resources available to do this.
01:55:19 Is that a fair summary?
01:55:20 It is.
01:55:21 Now, if we can turn to paragraph 22,
01:55:23 which is just over the page,
01:55:27 you say this, despite this change of focus
01:55:30 and the relatively low number of fires
01:55:32 in high-rise residential premises,
01:55:35 the brigade did maintain a keen interest
01:55:37 in the management of high-rise residential housing.
01:55:41 Now, that rather suggests that high-rise buildings
01:55:43 were seen by you, at least at a strategic level,
01:55:46 as low risk or relatively low risk.
01:55:49 Is that a fair reading of your perception?
01:55:51 It is, it is.
01:55:53 Did that perception change after Lacknell?
01:55:56 Yes, I think it did.
01:55:57 And was that change triggered by Lacknell itself
01:56:01 or was it later on as you came to encounter other fires
01:56:06 and broader concerns about non-compliance
01:56:08 of building regs and the rest of it?
01:56:11 I think it's hard to attribute it to one of those.
01:56:13 I think it was both, really.
01:56:15 And did you ever have calls to communicate
01:56:18 that change in perception to your senior officers
01:56:21 and to ask them what the consequences would be
01:56:24 of that change?
01:56:25 Yeah, we did discuss that.
01:56:27 I think particularly at performance CMBs,
01:56:28 we discussed where we set the level of risk
01:56:31 in terms of their inspection regimes
01:56:34 and contrasted that to the level of resources
01:56:36 we had available amongst particularly our
01:56:39 specialist fire safety officers that carry out the reviews.
01:56:42 And was that discussion confined to the higher ranks?
01:56:45 The reason I ask is there's no evidence
01:56:48 that that change in perception was communicated
01:56:51 down to operational crews, is that right?
01:56:54 It was a discussion that took place
01:56:56 at the performance CMBs, I recall,
01:56:58 and at that meeting would have been mainly
01:57:00 heads of service and above, so yes, that's correct.
01:57:03 Now, Steve McGurk, who's the inquiry's firefighting expert,
01:57:06 said that, and I quote,
01:57:08 the porous guidance placed a new and significant burden
01:57:11 on operational crews in every fire and rescue service,
01:57:15 but especially in London,
01:57:16 given the volume of risk sites in the capital city.
01:57:20 Would you agree with the proposition
01:57:22 that the LFB failed to confront,
01:57:24 or at least plan for, that significant increase in burden?
01:57:28 No, I wouldn't know.
01:57:31 Why?
01:57:32 Because at the time when the regulatory reform
01:57:35 fire safety was brought into force,
01:57:39 the brigade looked very carefully
01:57:40 at the amount of new premises we'd need to inspect,
01:57:44 what the inspections would involve in terms of differences
01:57:46 between the previous inspections that we carried out
01:57:48 under the Fire Precautions Act or the workplace regulations.
01:57:52 And an assessment was made there in terms of
01:57:55 the number of premises we needed to inspect,
01:57:57 and the consideration was given,
01:57:59 and in line with national guidance,
01:58:01 the risk level was set at a different level
01:58:04 than it was previously.
01:58:05 So I certainly, I don't believe,
01:58:07 I believe LFB took a very considered approach
01:58:10 towards the implications of the regulatory reform fire safety
01:58:14 order upon our statutory responsibilities.
01:58:16 Now that's the order which came into force,
01:58:21 I think April 2006 or thereabouts.
01:58:25 When porous came in,
01:58:27 what review did you make of porous
01:58:30 and the consequences for the burden
01:58:33 from the Section 72D perspective?
01:58:36 Well, the porous guidance brought in
01:58:38 a range of new expectations in terms of 72D visits,
01:58:44 which in my view, for London Fire Brigade,
01:58:49 introduced an element of potential duplication
01:58:51 between the reviews carried out by specialist fire safety
01:58:54 orders in terms of review and risk assessments
01:58:56 that then carried out by responsible persons,
01:58:59 and those duties that were the responsibility
01:59:01 of fire stations for operational purposes.
01:59:03 So there was more of a crossover between the two roles now
01:59:07 than there had been previously.
01:59:09 So the porous guidance,
01:59:12 I asked the porous guidance to be considered by officers,
01:59:17 and a report came back to the corporate management board,
01:59:20 where we made some decisions in terms of the guidance
01:59:22 provided to operational crews about how to carry out
01:59:24 72D visits as a result of the porous guidance,
01:59:27 and also the assistant commissioner for fire safety
01:59:31 continued his ongoing review of the resources available
01:59:34 to our specialist fire safety teams
01:59:36 to carry out their responsibilities.
01:59:38 So was specific updated guidance given to crews
01:59:42 as to how to discharge Section 72D
01:59:44 following this review of porous and its consequences?
01:59:47 I think it was, yes.
01:59:48 Can you pinpoint what that updated guidance was
01:59:50 and when it was published?
01:59:52 I can't actually, I think it was.
01:59:53 I'm sure it was a revision to PN 800.
01:59:57 That's what you had in mind.
01:59:58 I think so, yeah.
01:59:59 Now, would you agree with Rita Dexter
02:00:01 that getting crews to undertake enough 72D visits
02:00:05 of what she described a sufficient quality
02:00:09 was an uphill struggle?
02:00:11 Yes.
02:00:13 Why?
02:00:15 Because I think culturally on fire stations,
02:00:19 and I'm speaking from experience here as well,
02:00:22 was that crews saw the relevance of 72D visits
02:00:25 at harvest premises where they would see
02:00:27 they'd be hiring such things like chemical plants
02:00:29 or places where there were lots of people
02:00:34 that were immobile, those sorts of things.
02:00:36 They didn't necessarily see it as particularly relevant
02:00:39 to them in terms of a normal high-rise building
02:00:42 that they would probably be attending incidents in
02:00:44 on a regular basis anyway.
02:00:47 Could we stay in your second witness statement
02:00:49 which is on the screen?
02:00:50 Could we go to paragraph 23,
02:00:52 which is just at the bottom of the screen at the moment?
02:00:56 That paragraph says this.
02:00:59 Over a period of many years,
02:01:00 reductions had been made in the number of staff
02:01:02 employed by the brigade
02:01:04 in the role of fire safety inspecting officers.
02:01:08 These reductions had been made in light of the evidence
02:01:10 of reduced risk in buildings
02:01:12 covered by the previous fire prevention legislation
02:01:15 and also the preference to make savings in areas
02:01:18 that did not reduce the number of fire stations,
02:01:22 fire appliances or firefighters employed to attend incidents.
02:01:27 Now from 2005 onwards,
02:01:29 when you experienced a significant increase
02:01:31 in the number of buildings in which the brigade
02:01:34 was required to enforce the legislation,
02:01:37 why didn't you halt the reduction
02:01:39 in the cadre of fire safety officers?
02:01:42 Because up until London Safety Plan 5,
02:01:45 when in fact I did halt that reduction,
02:01:48 the figures were showing that the number of fires
02:01:50 were decreasing, so the risk was decreasing,
02:01:53 the number of incidents we were attending was decreasing.
02:01:56 We were increasingly looking for savings every year
02:02:00 in terms of the brigade's, the cost of the brigade.
02:02:03 And each year we asked heads of service to come forward
02:02:07 with their recommendations or proposals
02:02:09 for savings in their areas.
02:02:10 And there were some departments
02:02:12 that were more forthcoming than others,
02:02:14 it's probably the best way to describe it.
02:02:16 And the fire safety department,
02:02:18 because of the reduction in the number of fires
02:02:23 and the number of incidents generally,
02:02:24 and also because the profile
02:02:26 of our fire safety inspection officers had changed,
02:02:29 where we were introducing more non-operational
02:02:33 fire safety inspectors who had more specialist knowledge.
02:02:36 So historically, fire safety officers
02:02:38 had always been operational firefighters
02:02:40 that were seconded into fire safety.
02:02:43 We were now changing the profile,
02:02:44 and we were keen to get the profile during my tenure
02:02:47 to about 50-50 of previous operational officers
02:02:50 with previous operational experience,
02:02:52 and those that come from a more academic route
02:02:54 in terms of their fire safety qualifications.
02:02:56 And I was advised on a number of occasions,
02:02:58 I mean 2005 was before my time as commissioner,
02:03:02 but in the early years of my time as commissioner,
02:03:04 I was advised by various officers
02:03:07 that these savings were safe to be taken.
02:03:09 And we were looking for savings.
02:03:12 The fire authority was very clear,
02:03:15 they did not want to reduce the number of operational staff
02:03:18 held available for tending incidents,
02:03:21 for saving that to be made in other areas.
02:03:25 Was the institutional preeminence given to operations
02:03:29 to the detriment of fire safety
02:03:31 a factor in these considerations?
02:03:34 Yes, it was.
02:03:37 Well, not only to fire safety,
02:03:39 but to other areas as well, I should say,
02:03:40 it's a detriment to all areas.
02:03:42 So until the training contract was outsourced,
02:03:45 training was one area where repeatedly
02:03:48 we would make savings each year.
02:03:50 Now we also heard during Dove Brown's evidence
02:03:52 that there was a degree of confusion
02:03:55 as to where high-rise building information was located,
02:04:00 and namely whether it was on the ORD
02:04:02 or in a specific high-rise building database,
02:04:06 and also that some senior officers held concerns
02:04:09 as to the consistency of the application
02:04:11 of PN 800 by station staff.
02:04:15 Now, bearing the evidence we've heard
02:04:18 about Section 72D in mind,
02:04:21 would you accept that the LFB did not clarify
02:04:25 what operational crews should seek to achieve
02:04:27 when undertaking a 72D visit?
02:04:31 No, I wouldn't accept that.
02:04:31 I think we did clarify in terms of the production
02:04:34 of policy note 800.
02:04:37 I think my honest answer is I think perhaps
02:04:42 we made it too complicated for them,
02:04:44 made it too extensive, although we were trying very hard
02:04:47 to comply with the national guidance.
02:04:49 But my personal view was actually some of the expectation
02:04:52 became unrealistic given I know what their perception was
02:04:56 of the visits they were due to carry out anyway.
02:04:59 On the back of that answer,
02:05:00 could we go to appendix one and PN 633?
02:05:03 LFB quadruple zero, 1256 forward slash 19.
02:05:22 I suspect you're very familiar with this.
02:05:24 Indeed.
02:05:25 Appendix one, PN 633 in its post-June 2015 iteration.
02:05:30 In phase one, Danny Cotton said that some items
02:05:33 on this list were impractical, not realistic,
02:05:37 and that the list required rewording.
02:05:40 In module five, Dave Brown agreed
02:05:42 that the list required rewording
02:05:44 and that firefighters conducting these visits
02:05:46 did not have, and I quote,
02:05:48 the technical fire safety knowledge
02:05:50 to be able to look in depth at items
02:05:53 such as the likelihood and impact of any fire spread
02:05:56 beyond the compartmentation of origin
02:05:58 and the potential for multiple rescues
02:06:02 or the 12th bullet point floor layouts
02:06:05 of any building construction features
02:06:07 which may promote rapid or abnormal fire spread.
02:06:11 Do you accept that the adoption and promulgation
02:06:16 of an unrealistic policy which did not reflect
02:06:20 the skill set and expertise of those responsible
02:06:23 for executing that policy can only lead
02:06:26 to its incomplete and ineffectual implementation?
02:06:29 Yes.
02:06:32 At the very least, should your senior officers
02:06:34 have identified that focus training
02:06:37 needed to be provided alongside this policy
02:06:41 to ensure that crews knew what they had to look for
02:06:44 when carrying out these visits?
02:06:48 I do, but I think some of the items on this list
02:06:52 would have required very specialist training
02:06:54 to crews to actually be able to carry out adequately
02:06:56 and accurately, and I'm not sure with hindsight
02:07:00 that there would have been an awful lot of benefit
02:07:02 in carrying that training out to that extent.
02:07:07 The evidence of Dave Brown,
02:07:08 I think the evidence of Tom George as well,
02:07:12 was that crews would not have the technical ability
02:07:15 to look at a building to identify
02:07:16 whether its construction included,
02:07:18 for example, problematic cladding.
02:07:21 Given your answers, it appears that you'd agree
02:07:23 with your two former colleagues.
02:07:24 I would.
02:07:28 If crews lacked the relevant technical knowledge
02:07:31 and expertise to identify cladding during a 72D visit,
02:07:36 did they lack sufficient knowledge
02:07:37 to understand its role during an incident,
02:07:40 and so didn't know how to adapt
02:07:43 their operational firefighting tactics
02:07:45 to deal with a fire involving cladding?
02:07:48 Crews' expectation around cladding
02:07:51 and the way cladding would impact on fire situation
02:07:55 up until Grenfell Tower would be that they would have seen it
02:07:58 as a potential means for unseen fire spread
02:08:01 or less seen, I mean, you might see smoke spread, et cetera,
02:08:05 but certainly in that relation,
02:08:07 they would not be of the view,
02:08:08 and they certainly would not be able to identify
02:08:11 whether cladding was combustible
02:08:13 in the way that we saw at Grenfell Tower.
02:08:15 Now, Mr. Brown also told the panel
02:08:18 that operational crews carrying out 72D visits
02:08:22 didn't have technical fire safety knowledge
02:08:24 to be able to identify and assess the likelihood
02:08:27 and impact of fire spread beyond the compartment of origin,
02:08:31 and that instead, he would expect
02:08:34 the Brigade's Fire Safety Department
02:08:36 to pick up such issues via the building control process
02:08:39 or from subsequent audits.
02:08:41 Would you agree with that assessment?
02:08:46 Yes.
02:08:48 Essentially for the reasons given by Mr. Brown?
02:08:50 Yes.
02:08:51 Now, Dave Brown, Dan Daley, and Tom George
02:08:56 each told us that the flow of information
02:08:59 between the operational and fire safety sites of the LFB
02:09:03 did not always work well.
02:09:05 Words have been used such as patchy and the rest of it.
02:09:09 Now, would you agree that there was a failure
02:09:11 to optimize the LFB's pre-planning arrangements
02:09:14 in the eight years in which you were the commissioner?
02:09:18 In relation of information transfer
02:09:20 between the Fire Safety Department and operational colleagues,
02:09:23 yes, but not in other areas.
02:09:26 Why do you think there was that failure to deal
02:09:30 with the patchiness and the lack of effective communication
02:09:33 between those two arms of the LFB's operations?
02:09:36 I think it goes back to the issues we discussed
02:09:39 last Thursday, Mr. Kinnear,
02:09:42 which there was existing and probably still is
02:09:45 a cultural difference between those that work
02:09:47 in the Fire Safety Department
02:09:49 who see their role as very much a technical role
02:09:52 and those that work on fire stations
02:09:54 who see their role as very much an operational role.
02:09:57 And I think the level of information transfer
02:10:01 between the two, because of the difference in culture,
02:10:05 is not as effective as I'd like it to be.
02:10:08 Now, we also heard during module five
02:10:10 that information gathered by crews on 72D visits
02:10:13 would be stored on the ORD.
02:10:15 Yes.
02:10:16 Whereas information obtained via fire safety
02:10:19 was stored on a database called Farinor, is that right?
02:10:22 That's correct, yes.
02:10:24 Now, Mr. Brown told the inquiry that the initial decision
02:10:27 to have two separate databases was based on the concern
02:10:31 that it would be detrimental for an incident commander
02:10:34 to have too much information
02:10:36 at the early stages of an incident.
02:10:38 But if he was to start the brigade afresh from ground zero,
02:10:43 one database would be much better,
02:10:45 given the complexities of patching over information
02:10:48 between the two databases.
02:10:51 First of all, would you agree
02:10:53 with Mr. Brown's assessment in that regard?
02:10:57 I think if you had one database,
02:10:59 I think it inevitably would need to be divided
02:11:01 into two sections anyway,
02:11:03 because actually looking at some of the plans
02:11:05 and building plans,
02:11:06 there are two sections that fire safety officers
02:11:08 need to deal with as part of their role.
02:11:11 There is a level of detail there which is not necessary
02:11:14 and would be distracting to operational commanders
02:11:17 in the heat of, you know, at the beginning of an incident.
02:11:20 So I think there always needs to be a differentiation
02:11:22 between that which is needed for the very technical role
02:11:25 of the fire safety officer
02:11:26 and that which is needed for the very practical role
02:11:29 of the operational staff.
02:11:30 So there has to be a differentiation.
02:11:33 I'd like to think if we were starting again,
02:11:35 we'd achieve it better than we do up until recently.
02:11:39 I don't know if it's changed now,
02:11:41 but certainly I'd like to think we could do it better
02:11:43 than we did, but there are definite differences
02:11:46 between what fire safety officers need
02:11:48 in terms of information about buildings
02:11:50 and be recorded as operational staff.
02:11:53 Can you remember whether in your time
02:11:55 there was much detailed consideration
02:11:57 about the advantages and disadvantages
02:12:00 of setting up a single database?
02:12:03 Yes, we did.
02:12:03 We spoke about that quite a lot actually.
02:12:05 And from the sounds of it, you were never persuaded
02:12:09 of the virtues of a single database,
02:12:11 is that a fair summary?
02:12:12 Well, I think we were persuaded,
02:12:13 I think I was persuaded the virtues of a single database,
02:12:16 but the trouble was, as I say,
02:12:18 it would always need to be a number of sections anyway
02:12:20 because operational crews did not need the level of detail
02:12:25 in terms of building plans, et cetera, and other things
02:12:28 at the initial stage of an incident
02:12:30 that fire safety officers do.
02:12:31 So there always has to be a differentiation
02:12:33 between what's available to operational crews immediately
02:12:36 and that which is available to fire safety officers.
02:12:41 Could one approach have been to,
02:12:43 an earlier answer, intimate,
02:12:46 to have divided the database into two sections,
02:12:51 one which set out the information
02:12:53 that an incident commander needed,
02:12:56 supplemented by a more detailed section
02:12:58 which set out the information
02:13:00 that fire safety would require?
02:13:02 That doesn't seem an unduly technical solution,
02:13:05 would you agree?
02:13:07 I agree, but the implementation of that,
02:13:09 in practical terms, would be quite difficult
02:13:11 because of the amount of information
02:13:12 that is already held by the brigade
02:13:15 and the different formats which it's in,
02:13:18 and the need to actually review every building plan
02:13:21 held by fire safety department
02:13:23 to identify the elements that are appropriate
02:13:25 for operational staff.
02:13:25 So I'm not saying that's not a reason for not doing it
02:13:28 because it wouldn't be an appropriate thing to do,
02:13:30 but it wasn't something that we committed the time
02:13:32 and results to do at that time.
02:13:35 Were you aware of the provision in Porus
02:13:38 which recommended, and I quote,
02:13:41 that fire and rescue services should ensure
02:13:43 the integration of fire safety and operational data capture?
02:13:47 Yes.
02:13:51 With the benefit of hindsight,
02:13:53 do you think you should have done more
02:13:57 to achieve a appropriately calibrated single database
02:14:02 that gave the information to ICs that they needed
02:14:05 and the information to fire safety
02:14:07 that they needed for their task?
02:14:09 With the benefit of hindsight,
02:14:10 yes, I wish we had done that,
02:14:12 but I still refer back to the technical difficulties
02:14:16 of doing that, and our experience, my experience,
02:14:20 of implementing new IT systems was not a good one,
02:14:24 and therefore, whilst I would like to have done this,
02:14:27 it wasn't something that we decided
02:14:28 was an absolute priority at the time.
02:14:30 My priority was to make sure that we were trying
02:14:33 to improve the availability and quality of information
02:14:37 given to operational staff at incidents
02:14:40 in a way which we're gonna help them
02:14:41 to set an effective plan and deal with the incident.
02:14:45 Thank you.
02:14:46 Now, could we go back to your response
02:14:49 to the Lacknell House coroner,
02:14:50 which is at LFB-000-32150 forward slash four.
02:14:57 Now, we see the Section 72D recommendation
02:15:03 has the heading response,
02:15:06 and below that, the text, which says this,
02:15:08 the brigade's policies concerning the gathering
02:15:10 of operational knowledge are under regular review
02:15:13 and many have been modified to reflect the lessons learned
02:15:17 in the Lacknell House fire.
02:15:18 So, I'm gonna read the text.
02:15:20 Section 72D, section 72D, section 72D,
02:15:24 reflect the lessons learned in the Lacknell House fire.
02:15:29 Based on what we have explored thus far,
02:15:31 would you accept that the LFB's information
02:15:34 gathering practices and policies
02:15:36 did not reflect the lessons learned
02:15:38 at the Lacknell House fire,
02:15:40 and in fact never did during your tenure as commissioner?
02:15:43 No, I don't accept that.
02:15:44 I believe after the Lacknell House fire,
02:15:46 we did improve the way the information
02:15:48 was gathered and recorded,
02:15:50 and I think the actions that we took
02:15:51 as a result of Porris and others,
02:15:53 whilst not perfect by any means,
02:15:55 actually did improve the way that information should have been,
02:15:58 at least the way that information
02:15:59 should have been gathered by operational crews.
02:16:02 Now, looking at other actions listed in this letter,
02:16:05 the second bullet-pointed proposal was,
02:16:08 we can see there, create an inspection regime
02:16:10 that targets high priority residential
02:16:13 and non-residential buildings
02:16:14 with a view to increasing the number of premises records
02:16:17 which are available to the brigade's operational staff
02:16:21 on the operational risk database.
02:16:24 Now, we've heard that in December 2013,
02:16:27 Borough Commander John Elwell
02:16:29 produced a briefing paper in response to this action
02:16:33 which identified a number of key issues
02:16:36 relating to the Brigade 72D processes,
02:16:39 raised issues of consistency and integration
02:16:42 that we've already explored.
02:16:44 Now, could we go to LFB,
02:16:46 trouble zero, three two, eight two five?
02:16:52 Did or was that report submitted to you at the time,
02:16:57 so December 2013?
02:16:59 No.
02:17:01 Now, the report made eight recommendations,
02:17:05 including one surrounding crew competency and training,
02:17:08 greater use of brigade data,
02:17:10 and quantity and quality assurance for ORD entries.
02:17:14 Now, Dave Brown's evidence was that the Elwell report
02:17:18 and its recommendations did not fulfil the BDHC
02:17:22 brief of the Rule 43 action.
02:17:24 And while he accepted that the paper
02:17:26 raised some significant concerns
02:17:28 about the adequacy of the 72D arrangements,
02:17:31 his view at least was that the recommendations
02:17:33 were either already in hand or aspirational
02:17:37 or would not work in reality.
02:17:39 Now, we've seen no evidence to indicate
02:17:43 that any of these issues raised by John Elwell
02:17:46 were actioned, whether fully or partially by the LFB.
02:17:50 Would you take that failure as an example
02:17:56 of a failure of the brigade,
02:17:58 a failure to meaningfully engage
02:18:01 with identified improvements to its 72D processes?
02:18:05 I'd need to see the recommendations
02:18:07 in order to make a judgement, if I may.
02:18:09 Well, if we can go.
02:18:09 These are the concerns, aren't they,
02:18:12 that I've got on the screen here?
02:18:13 Sorry, I didn't catch that.
02:18:14 Are these recommendations or is it,
02:18:15 these are a number of concerns?
02:18:18 Both.
02:18:19 Well, we can go through the entire report, but.
02:18:23 Yeah, and I'm not saying I'm missing
02:18:24 any particular needs to do that,
02:18:25 but I didn't see Mr. Elwell's report at the time.
02:18:28 Okay, we're taking it, therefore, as far as we can.
02:18:32 Now, as we explored with Mr. Brown and Mr. George,
02:18:35 the result of this Rule 43 action
02:18:37 was the proposed creation of a banding arrangement.
02:18:43 And the detail of that can be seen
02:18:45 in LFB Trouble Zero 32833.
02:18:57 You can see at the bottom of the first page
02:18:59 of this email chain, there was an idea
02:19:02 that band one properties would consist
02:19:04 of those set out in the table.
02:19:06 And if we go into page two,
02:19:10 you get a flavour for the types of buildings
02:19:13 that fell into the less important bands.
02:19:20 Now, we understand that these bands were sent
02:19:23 via email to crews in May 2014,
02:19:26 but otherwise this regime was not incorporated
02:19:29 either into policy or into training.
02:19:33 First of all, were you aware of this banding process?
02:19:36 I knew that there was work being undertaken
02:19:38 to give further guidance in terms of banding
02:19:41 for want of a better term.
02:19:43 But I don't recall actually seeing it immediately.
02:19:45 I've seen it since,
02:19:46 but I don't recall seeing this immediately.
02:19:48 And when you say not seeing it immediately,
02:19:50 are you doing your time as commissioner?
02:19:51 No, I mean, at the time it was sent out.
02:19:56 Was your approval sought to sign off
02:19:59 on this banding regime?
02:20:00 Not that I recall.
02:20:03 Was it ever discussed with you on the basis
02:20:05 that this satisfied the recommendation
02:20:08 that an inspection regime be set up?
02:20:11 No, not in those terms, no.
02:20:14 Having considered it subsequently,
02:20:18 do you think that this proposed banding regime
02:20:21 satisfied the recommendation
02:20:23 that there be an inspection regime?
02:20:25 Not on its own, no.
02:20:27 Why?
02:20:28 Because all this does is to give guidance about,
02:20:31 if like a risk prioritisation of types of premises.
02:20:34 From an initial look at it there,
02:20:36 actually some of which I would disagree with anyway,
02:20:37 but certainly this just gives a banding
02:20:40 in terms of types of premises
02:20:41 that might fall into various bands,
02:20:43 one, two, and three.
02:20:44 It doesn't give any further detail there
02:20:46 about how to collect the information,
02:20:48 how to record the information, how to store it.
02:20:50 There's lots of things there that are missing
02:20:52 in just that simple table.
02:20:54 Mr. George's essential criticism of this regime
02:20:58 was that it was simplistic.
02:21:00 From the sound of it, you agree with him?
02:21:02 I would, yes.
02:21:03 Thank you.
02:21:04 Could we go again to the Lacknall Assurance Review,
02:21:11 which is at LFB quadruple zero 4801.
02:21:23 As you can see from its date,
02:21:24 it postdates your time as commissioner.
02:21:28 Could we turn to page 28?
02:21:34 Can we look at the penultimate paragraph
02:21:36 on the left-hand column?
02:21:42 And you'll see there, basically three lines from the bottom,
02:21:48 that as of October 2017,
02:21:52 some 1,700 residential high-rise premises
02:21:56 had a premises risk assessment recorded on the ORD
02:22:00 as against a total of approximately 6,900
02:22:04 residential high-rise premises in London.
02:22:08 If we accept those figures as correct,
02:22:12 do you accept that there was a failure
02:22:14 during your leadership adequately to gather
02:22:17 and to prioritize pre-planning information
02:22:20 in relation to high-rise residential buildings?
02:22:22 Could I just read this again?
02:22:24 Please do.
02:22:53 And the base of those figures, yes.
02:22:56 Thank you.
02:22:58 Sir, it is almost 25 past four.
02:23:00 Yes.
02:23:01 The next section of questions that I'd like to turn to
02:23:04 relate to a LFB commissioned review of the order
02:23:09 that was carried out by the BRE.
02:23:11 Those questions are going to take more than five minutes.
02:23:14 It's not a topic that I think is fair to Mr. Dobson
02:23:17 to leave hanging overnight.
02:23:19 We have more than enough time to answer those questions.
02:23:23 So, sir, I'd ask us...
02:23:24 You'd like to stop at this point?
02:23:25 Yes.
02:23:26 Well, that seems sensible enough,
02:23:28 subject to, I think, a little bit of reassurance
02:23:31 that Mr. Dobson would like,
02:23:32 and personally we would as well,
02:23:33 that he can expect to finish,
02:23:37 well, during the morning tomorrow?
02:23:39 Yes.
02:23:42 Well, Mr. Dobson, it sounds as though time
02:23:44 isn't too much against us,
02:23:47 and I'm afraid we're not going to finish
02:23:48 your evidence this afternoon.
02:23:50 So, perhaps it would be sensible to stop at that point.
02:23:53 And we'll resume, please, at 10 o'clock tomorrow.
02:23:58 Sorry to get you back again,
02:23:59 but I'm afraid that's necessary.
02:24:02 So, as I say, we'll resume at 10 o'clock tomorrow,
02:24:07 and again, please don't discuss your evidence
02:24:09 with anyone overnight.
02:24:11 All right?
02:24:12 Thank you, sir.
02:24:13 Thank you very much, and see you tomorrow.
02:24:14 Thank you.
02:24:19 Thank you, Mr. Cuneya.
02:24:20 Well, that's fine, and we'll resume at 10 o'clock tomorrow.
02:24:24 Thanks, sir.
02:24:25 Thank you.
02:24:49 Thank you.