Evidence from Assistant Commissioner Dan Daly regarding LFB's response to the Shepherd's Court fire (August 2016) and awareness of cladding risks before Grenfell. Intense questioning reveals LFB knew of widespread building regulation failures but took limited action to warn residents or operational firefighters.
00:00:27 uh
00:00:36 good morning everyone welcome to today's hearing
00:00:39 hearing today we're going to continue hearing evidence from assistant commissioner daley so would you ask mr daley to come back in please
00:00:54 [Music] good morning mr david morning we're ready to carry on yes yes absolutely thank you very much yes mr miller mr chairman good morning members of the panel good morning assistant
00:01:05 of the panel good morning assistant commissioner good morning uh as a brief reminder at the end of your evidence last week on thursday i had shown you the bureau veritas report that was produced by them in november 2016 after the shepherds caught fire
00:01:17 after the shepherds caught fire and you'll recall that it related to the testing of the panels that were on the outside of the building and they'd carried out those tests in august 2016. the reports dated the 3rd of november
00:01:29 the reports dated the 3rd of november and i'm just going to take you to it lfb608 please
00:01:39 and i i showed you quite a lot of text in this uh report on pages one and two um if we can pick it up at page three please at uh paragraph 3.4
00:01:52 please at uh paragraph 3.4 it says this the flame test showed that small ignition sources acting in a localized fashion would not significantly threaten the integrity of the panel and would be unlikely to ignite a panel
00:02:04 unlikely to ignite a panel however as a fire develops and grows further it is possible that a wide flame front could end up acting on the steel sheet of the panel the heat from the flames would be conducted through the steel sheet and would therefore melt away the blue foam layer underneath this
00:02:16 away the blue foam layer underneath this would occur in a progressive fashion as the fire develops and would ultimately lead to the steel sheet not being held in place by the by sufficient bonded blue foam the weight of the steel sheet would then ensure that it would become
00:02:28 would then ensure that it would become detached from the remainder of the panel likely fall away and expose the heat damaged blue foam and plywood layers to the developed flame front this situation is likely to have occurred to the panels
00:02:39 is likely to have occurred to the panels above the flat of fire origin when the living room windows of the flat of fire origin failed during the fire at this scene now would you agree looking at that that this report doesn't record specifically that what happened in the
00:02:51 specifically that what happened in the flame test on the incomplete panels that is the panels that didn't have the uh front metal sheet attached and where the blue plastic foam underneath it was completely it was completely exposed
00:03:03 completely it was completely exposed yes yes now after the report came in uh let's go to lfb double zero one two zero two eight six um after the report came in
00:03:14 um after the report came in uh charles ellie romer sent an email to bureau veritas peter cope there copy to charlie pugsley and gareth steele as you can see good morning peter and he makes if you go down to the third
00:03:25 and he makes if you go down to the third paragraph some comments on paragraph 2.2 of the report now
00:03:33 now just a little question here we can't find the version of the report at this time that has a paragraph 2.2 the one we have at lfb
00:03:45 the one we have at lfb i've just shown you only goes up to paragraph 2.19 my question is were there other drafts of the report that you're aware of to which the lfb had access around the 23rd of november 2016. so my
00:03:58 around the 23rd of november 2016. so my understanding is that an initial report was provided um at uttar around at the beginning of november and then a final report was submitted i believe at the end of november on the 30th november right but
00:04:09 november on the 30th november right but you can't help us with which version he's looking at at this point i suspect this is the interim version just looking at the date given that the final wasn't received until the 30th right now if you go to the third paragraph uh he says this we note the
00:04:22 paragraph uh he says this we note the paragraph 2.22 of the report does not include other effects which we witnessed on the sample for the second series such as
00:04:29 as and there are four bullet points increased flame size when compared to the first series of tests sustained burning following removal of the ignition source the formation of flaming droplets and the final test had
00:04:41 flaming droplets and the final test had to be stopped as there was concern regarding the flame height we recall that
00:04:45 that that view that the second series of tests behaved in a similar way with regards to the fame shrinkage but overall the behavior of the panel was different in a number of ways would it be possible to incorporate these significant differences in the report
00:04:57 significant differences in the report now when mr romeo refers that to the second series do you know if he's referring to the tests carried out on the incomplete panel with the in other words where the blue plastic phone was exposed
00:05:08 exposed sorry no i can't help you with that what i do know is that the tests were repeated to ensure that the validity of the results so it may well be um tests on both types of samples but you'd need a conversation with bureau veritas to
00:05:21 a conversation with bureau veritas to establish that i think were you aware that charles ali romeo had had this exchange with bureau veritas at all i was aware that there was ongoing discussion between fire investigation our fire engineers and the testing facility
00:05:32 facility um
00:05:33 um that would be quite normal really just to understand um the results as we had asked for the testing to be carried out right now bureau baritas went on to produce the second and final version of this report of the 30th of november as
00:05:44 this report of the 30th of november as you've just referred to that's at lfb 60s 91
00:05:48 60s 91 can we please look at that
00:05:55 and if we go to the bottom of page 3 paragraph 3.5 you can see that the updated report says and this is under the heading discussion towards the top of the screen but it says this the repeat flame tests
00:06:08 says this the repeat flame tests uh the repeat flame test with the ignition sources placed directly against the blue foam layer behaved as per the previous tests except the destruction of the foam layer was significantly accelerated and the flame
00:06:20 significantly accelerated and the flame heights generated was significantly higher than the first series of tasks the production of flaming droplets in the final test crib 6 ignition source was much more noticeable than with earlier tests
00:06:31 earlier tests and then if you go to paragraph 3.6 on the next page page 4 at the top it says the mechanism of fire attack on the front of the panels outlined above is likely to have assisted the fire in
00:06:43 is likely to have assisted the fire in spreading up the outside of the building as this mechanism progressively exposes a plywood surface to a developing fire
00:06:52 fire were you aware assistant commissioner of the results of the bureau of veritas investigations as soon as they've been carried out including this report of the 30th of november
00:07:02 november i think i've been briefed on the initial findings and then when the um final report come in um i certainly would have discussed this with members of the team right that time yes you'd be briefed on
00:07:14 right that time yes you'd be briefed on the initial findings was there concern within the foreign engineering department that the report in its true form in its final form should reflect the true extent of the risks posed by the materials used at shepherds called
00:07:27 the materials used at shepherds called i don't think we were surprised by the findings i think the fact we asked for the testing to be carried out was in recognition of the fact there had been some sustained flame development on the outside of the building that we would
00:07:38 outside of the building that we would not have expected to have seen
00:07:42 yes but you wanted to make sure dude is this right that the tests that they carried out reflected the uh true true extent of the risks
00:07:51 risks posed both to firefighters and to occupants by the materials used yes absolutely i think the purpose of the testing was to understand the mechanism by which we'd seen the external fire spread
00:08:03 we'd seen the external fire spread now let's get it and to understand what materials that may be attributable to yes
00:08:07 yes yes thank you can we go to eight lfb
00:08:11 eight lfb please
00:08:16 this is a letter sent on the 18th of october 2016 to the chief executive of hammersmith and fulham council about the shepherds caught fire and he was a man called mr nigel palace
00:08:28 called mr nigel palace now this is if you look at the date am i right this is before either version of the bv report had been provided to the lfb
00:08:37 lfb yes yes now if we look at page two of this letter it's signed um
00:08:43 um by rebecca burton as you can see for assistant commissioner fire safety does that tell us that rebecca burton sent the letter out on your behalf
00:08:54 sent the letter out on your behalf so routinely letters um sometimes having an electronic signature for himself but they would be generated within the teams and so on this occasion it would be as the i believe in her role at the time was
00:09:05 i believe in her role at the time was local team leaders part of the ongoing liaison with the local authority
00:09:10 uh were you involved in drafting this letter no it wasn't you weren't did you see it before it went i don't recall seeing it right now let's look at the letter can we go back to page one please if we go to paragraph
00:09:23 page one please if we go to paragraph three it says this in summary the tests demonstrated that the panel delaminated and exposed the insulation material once exposed the insulation as well as the wooden backing appears to
00:09:34 well as the wooden backing appears to contribute to the combustion process potentially increasing the size of the flames and fire therefore the facade system may have contributed to the external fire spread and in the next paragraph
00:09:45 and in the next paragraph she says at present the london fire brigade has concerns with regard to the combustibility of the products included in the panels and believe these panels have been used in the neighboring premises
00:09:57 premises now with those concerns that she speaks of rebecca burton speaks of their based on the lfb's own internal conclusions based on what the your officers had observed from the bureau of
00:10:08 officers had observed from the bureau of veritas tests rather than bureau veritas's own conclusions i think it's safe to say that they are the result of the ongoing liaison with bureau veritas the fire investigation team
00:10:19 the fire investigation team um
00:10:20 um working assumptions as the testing was being conducted and an attempt in this case to highlight to the relevant local authority where the materials were known to be present of a potential risk right
00:10:32 to be present of a potential risk right i mean it's clear from this i think as you'd accept that you were is this right keen
00:10:36 keen for the chief executive of hammersmith and fulham council to know about the dangers of this material even before bureau veritas had formally or even in draft reported yes i think we had witnessed external fire spread so
00:10:49 we had witnessed external fire spread so therefore it's important to share that with the person with responsibility for managing that building i think the further work was for us to understand the full mechanism and then as i'm sure we'll talk about at some point the further letter that went
00:11:00 some point the further letter that went out to local authorities to understand the extent to which this might be a common place uh within uh the built environment because i think as we said earlier um on thursday it's not always
00:11:13 thursday it's not always well it's not possible actually to look at
00:11:16 at an arrangement a spandrel panel and determine whether or not it possesses the same qualities so visually they may present the same but might have quite different qualities so that was the purpose of the testing and then the ask of local authorities to understand the
00:11:27 of local authorities to understand the extent to which this might be an issue yes i'm just picking up on that as you can see the letter as i've just read to you
00:11:34 you refers to the neighboring premises but doesn't suggest a wider review of other premises across the borough why was that because i think at this point it was limited to what we believed um we understood those panels were in that
00:11:46 understood those panels were in that block
00:11:47 block and i believe there was uh information to suggest they were the same panels used in the sister block but i think the letter that we sent out later was to ask then the wider question about what's maybe present in the built environment
00:12:00 did you yourself or anybody else involved in putting this letter together consider
00:12:05 consider advising
00:12:07 advising hammersmith and fulham council to reconsider the stay put policy for the neighboring premises or or some other kind of strategy evacuation strategy while it was confirmed whether they did or didn't have the same panels
00:12:19 or didn't have the same panels no i think the purpose of this letter combined a number of things so the discussions we had at the time was around alerting the responsible person to
00:12:29 to our initial working assumptions based on the testing but equally reflecting on the actions of the firefighting at the time of the incident there were people that stayed put in the building where some people
00:12:40 put in the building where some people had self-evacuated but the actions of the firefighters i believe at the time demonstrated an awareness of the issues they acted promptly to the risk they were presented with and i believe from the learning
00:12:52 with and i believe from the learning there gained from the lack of house presentation and didn't at that point pose a risk that suggested that an all-out evacuation was necessary and in fact
00:13:03 evacuation was necessary and in fact when you're weighing up those options against the facilities and the access for firefighters it is a bit of a balance in terms of the speed at which we could access and tackle the fire in this circumstance which
00:13:14 this circumstance which given the actions on on the 16th of august were manageable in terms of the way the firefighters responded and whether or not you then change the evacuation that strategy which would absolutely slow the rate at which we
00:13:25 absolutely slow the rate at which we could get to the scene of operations and tackle the incident now if you go to the fifth paragraph in the letter just above the bullet points it says this it is therefore our opinion that as the responsible person for this building
00:13:37 the responsible person for this building there is a need to demonstrate compliance with the applicable regulation and guidance in order to demonstrate compliance could we please be provided with the following information and there's a request for a number of documents now if we look at
00:13:48 number of documents now if we look at the covering email which attached this letter now let's do that it's at lfb403509
00:13:57 this is from rebecca burton to nigel palace
00:14:02 palace you're not copied in on it but if we look at it uh it says dear mr palace please find attached a letter from the london fire brigade etc and then she says for your information i
00:14:13 and then she says for your information i am also liaising with norman white health and safety manager compliance and health and safety team and have a meeting booked with him on 3rd november 2016 to discuss matters further do you know if that meeting took place i don't
00:14:25 know if that meeting took place i don't know
00:14:28 let's then move on to a slightly different but related topic and that's about what was going on within the lfb during the same period of the bureau veritas tests relating to specifically um approved
00:14:40 relating to specifically um approved document
00:14:41 document sorry
00:14:42 sorry functional requirement b4 approved document b and the scope of the lfb's duties under the rro could we go back then to lfb 3052135
00:14:55 could we go back then to lfb 3052135 52135
00:14:57 52135 this is the email chain we looked at on thursday of the 26th of september 2016. and can we go to page five in the email chain
00:15:08 the first full email on page five uh which is dated um the 26th of september
00:15:17 september uh from lindsay seal to andy jack and it's by way of a response to charlie pugsley's message of the 22nd of september a little bit lower down and she says uh to auntie jack and
00:15:28 and she says uh to auntie jack and rebecca burton he's also the recipient good morning fire engineering became involved in the above investigation post fire due to the external fire spread we were we were asked to attend bv that's bureau veritas
00:15:42 asked to attend bv that's bureau veritas to witness some fire testing of samples and we formed the below opinion i apologize that this was not passed to you earlier but i believe we were awaiting the bv test report to support our comments
00:15:53 our comments you will see that we are of the opinion that the external war materials were not of the required standard and therefore investigation by fire safety is recommended and the opinion then below that is charles ellie romey's email of the first
00:16:05 charles ellie romey's email of the first of september that we saw on thursday if we just flip to page bottom of page five you'll see it there and then page six just to remind you if we just go to page six
00:16:16 six there's the body of it there that's charlie ely charles e lee romeo's email reported the first of september on the late august bureau veritas tests
00:16:27 veritas tests now i'm going back to the lindsay seal email please at page five third email in the chain
00:16:34 the chain um we scroll that's it um looking at um where she says required standard in the second paragraph um do you can you help us with what she
00:16:45 um do you can you help us with what she was referring to there not in the technical detail of it but my assumption would be that it didn't meet the requirements set by the building regulations in terms of performance and external wall panel or system functional
00:16:58 external wall panel or system functional requirement b4 i believe so right um now you've i think told us that the lfb's enforcement function is limited to the the rro
00:17:09 the rro looking at this email chain was it the lfb fire safety's view that building facades fell within the scope of the rro at this time no i think we'd had clear guidance that it wasn't
00:17:21 we'd had clear guidance that it wasn't um
00:17:22 um i think i
00:17:23 i think i possibly expressed some frustration that i would like to be able to do more certainly the letter that ultimately went to local authorities the question that we asked at the time and we saw legal council's
00:17:35 at the time and we saw legal council's advice
00:17:36 advice on that to clarify with the position for the ro and lfb i would quite like that of letter to have been more forceful in terms of our enforcement ambitions around this if it
00:17:47 enforcement ambitions around this if it was a more widespread issue but it ended up happening to be more of an advisory asking local authorities to take stock of their buildings because the legal advice was again inconclusive and
00:17:59 legal advice was again inconclusive and largely fell back on the letters provided
00:18:03 provided back in 2013 confirming that the previous understood position that the external walls weren't covered by the rro now you refer to that am i right in thinking that the 2013
00:18:14 am i right in thinking that the 2013 confirmation is the letter written by louise upton of the dclg on the 6th of february 2013. yes that's the letter that
00:18:23 that which was shown to me at the time to demonstrate that we previously sought clarification on this issue yes and that despite the inconclusive legal advice that was the substantive position when you say to clear guidance are you
00:18:34 you say to clear guidance are you referring to that yes that was the line yes thank you that being the case assistant commissioner how would an investigation into the external wall at shepherd's court
00:18:43 court fall into the ambit of the fire safety department's work i think we had the expertise to form a view and to raise those issues with those who
00:18:54 and to raise those issues with those who do have responsibility so we work very closely with local authorities across london
00:19:00 london we have protocols in place and memorandum of understanding about how we work together and jointly and they have enforcement powers under the housing act and whilst we have some understanding of that i think we can
00:19:11 understanding of that i think we can usefully where we have um evidence like we did on this occasion to try and fully understand the mechanics of that particular situation and share that with local authorities to get the situation remedied right so the
00:19:23 get the situation remedied right so the investigation was going to happen because you wanted to understand the risks whether or not the external wall fell strictly within the rra yes because i think it's uh it poses a risk that
00:19:34 i think it's uh it poses a risk that that needs to be understood and certainly our knowledge of the building regulations this fell outside the performance we would expect to see now um the response to lindsay seal comes on
00:19:46 um the response to lindsay seal comes on the 26th of september at page four if we can just roll up to that bottom of the page uh andy jack writes back to lindsay seal same day 26 september
00:19:57 same day 26 september uh
00:19:59 uh and at 9 57 and at that time i'm right i think he was head of fire safety enforcement wasn't he he was yes and if we if we look and see what he says he
00:20:10 we if we look and see what he says he says this thanks linds i believe this incident is an archetypal example of the issue faced across the residential built environment due to lack of adequate guidance and consequent historic misinterpretation by building control
00:20:22 misinterpretation by building control bodies of function requirement b41 to the building regulations from other investigations it is apparent that while the second limb of b41 fire spread between buildings is known and
00:20:33 spread between buildings is known and applied the first limb resist the spread of fire over the walls is not and then he goes into what happened at la canal
00:20:43 la canal attaches some attachments including the rule 43 letter to the dclg and the dclg's reply and then he says finally the fourth letter is is a letter from dclg brian
00:20:56 letter is is a letter from dclg brian martin covering interpretation of adb now just from recollections purposes that was a letter written back to ron dobson i think some years before we saw earlier and
00:21:07 some years before we saw earlier and then he says this overall a new although a new version of the adb guidance is apparently due this year or next there is an ongoing issue for built environment for the construction and or refurbishment of
00:21:18 construction and or refurbishment of blocks that has taken place over the last 30 years or more in relation to materials used and the approvals potentially given including for window replacement involving spandrel panel replacement using competent person
00:21:29 replacement using competent person schemes david anything to add or correct me on and david is david kennett now that's the view of your head of fire safety enforcement shared as we can see with a number of colleagues in the fire
00:21:41 with a number of colleagues in the fire safety department were you aware that andy jack
00:21:45 andy jack was this concerned in the way he expresses himself about misinterpretation or potential misinterpretation of the building regulations i think i had an awareness whether it
00:21:56 i think i had an awareness whether it was as strongly expressed as that but certainly in the immediate aftermath of the shepherds caught fire i asked for a meeting with a team of individuals from the department that
00:22:07 individuals from the department that represented those sections that i felt would be actively engaged in our ongoing investigations right who did you meet uh it would have been with i believe gary steele represented our
00:22:18 i believe gary steele represented our engineering andy jack the borough commander for hammersmith and fulham the team leader the incident commander before me uh andy hearn was past that meeting there may
00:22:29 hearn was past that meeting there may have been others i think possibly some people from our comms department but essentially it was a group of individuals that i felt would have a supporting role in us understanding that incident and then sharing that
00:22:40 that incident and then sharing that understanding with relevant stakeholders who may then be able to influence a change where it was necessary now as we've seen this is what we've seen from this email is precisely the same
00:22:51 this email is precisely the same concern that the commissioner dobson had raised in his letter to brandon lewis mp in december 2012 yes wasn't it now in the context of and that was in the context of lachenal
00:23:02 context of lachenal and was it as a result of those concerns over misinterpretation of uh approved document b or particularly um functional requirement b4 that mr dobson had
00:23:13 requirement b4 that mr dobson had indicated that in the in the brigade's view further guidance was needed i i suspect it was one of those elements certainly so is it fair to say that the uh request was knocked back and was still a lingering
00:23:25 knocked back and was still a lingering concern to the brigade some four years on
00:23:28 on yes i think that's fair to say that now david kennett replies can we go up please to the top email on the same page uh same day and he's uh the team leader for the fire
00:23:40 and he's uh the team leader for the fire and safety enforcement team he says uh only to add that in 2010 we engaged adrian pressed to advisors on interpretation of b4 adrian had been head of building control for several
00:23:51 head of building control for several local authorities as i recall his advice was that the fire resistance of the external face of the building was only relevant with regards to distances from boundaries and unprotected areas we including paul jenkins took the view
00:24:03 we including paul jenkins took the view that the fr of the external face was a requirement in its own right hence the letter to brian martin who confirmed this to be the case brian was
00:24:14 confirmed this to be the case brian was also horrified that such an experienced bco building control officer should misinterpret b4 in this way i wondered at the time bearing in mind that lack of guidance on this issue whether his view
00:24:25 guidance on this issue whether his view was commonly held indeed adrian had checked his view with another senior colleague before providing us with written advice and that i think is the advice
00:24:34 advice from adrian press which i showed you from 2010 which you weren't able to help with
00:24:38 with um
00:24:40 um did you ever yourself discuss this question with andy jack or david kenneth i don't think i discussed that particular question but i think the understanding that was shared with me when i asked questions around this was
00:24:52 when i asked questions around this was the one that that lfb understood that there was a a requirement in terms of proximity with other buildings but there was also a requirement of the materials in their own rights and the buildings which they were attached were you were you
00:25:03 were attached were you were you concerned that mr prest's interpretation of functional requirement b4 uh
00:25:09 uh might have been more widely held having now
00:25:12 now see what mr kenneth's view was in 2016. i don't think i really had the exposure to make a judgment one way or the other but i certainly trusted the individuals right in my department who had many more years experience of it
00:25:24 years experience of it and did hold those concerns yes now going back to andy jack's email uh if we can please at page four first paragraph just which i showed you a moment ago
00:25:35 just which i showed you a moment ago he refers there to a lack of adequate guidance and consequent historic misinterpretation by building control bodies or function requirement that should be functional requirement b4 one to the building regulations were you
00:25:47 to the building regulations were you aware that andy jack thought that there had been a historic misinterpretation to use his words of requirement b4 by bcos i think certainly in the meeting we held subsequent to sheffield's court if not
00:25:59 subsequent to sheffield's court if not before
00:26:00 before um there was an expression of frustration around competency across the sector and i think uh you know looking back reflecting where we are now i think dame judith hackett has pointed to those same concerns in
00:26:12 has pointed to those same concerns in her overriding report about the um building safety regime the meeting you've referred to is there a date can you date it uh i can't but it was in the very shortly
00:26:24 i can't but it was in the very shortly after the incident itself right so late august 2016 late late august early september right and uh was it minuted uh i'm not sure if it was i can't record
00:26:35 uh i'm not sure if it was i can't record right but it was an ad hoc group was rather it was a group that i pulled together to provide some direction on my expectations around um what actions should be taken
00:26:47 around um what actions should be taken post-fire right with regards to the unusual um fast radar performance of the materials that was observed and at that mean the check expressed the
00:26:58 and at that mean the check expressed the views
00:26:59 views to you
00:27:00 to you who
00:27:01 who and the group that we have we can see in his email to lindsay seal of the 26th of september at page four here he may have done but i can't recall i know we spent a lot of time in that
00:27:12 know we spent a lot of time in that meeting discussing the extent to which the ro did or didn't apply because that for me was a fundamental issue that as i said we then went on to seek council's advice on again can we go to
00:27:23 council's advice on again can we go to andy jack's witness statement his second rule nine witness statement of the fifth of february 2021 lfb double zero one two zero three zero eight
00:27:43 and if we go to page 4 in that please paragraph 14 he says
00:27:49 in the second line however the adequacy of the adb in respect of b41 was a live issue for the investigation of offenses in respect of latino house and during
00:28:01 in respect of latino house and during the preparation for and the hearing of the latino house inquest certainly following the lack of inquest and the rule 43 recommendations made by the coroner on the 28th of march 2013
00:28:12 the coroner on the 28th of march 2013 it was a commonly held view at the lfb that the guidance to b41 was insufficiently clear would you agree do you agree with andy jack's evidence here that it was a
00:28:23 jack's evidence here that it was a commonly held view within the lfb that the guidance to functional requirement b41 of the building regulations was insufficiently clear at least by or as that 2016.
00:28:35 that 2016. in respect specifically to b4 i couldn't necessarily say but what i would say is that i was very clear that there was a view that the building regulations were overdue a refresh and an update i think that's
00:28:48 and an update i think that's they were a number of years since they had previously been reviewed and that would include b4 so i don't have any reason to dispute what he said
00:28:57 you say you couldn't necessarily say d d are you saying you disagree or you have any reason to disagree with mr j i have no reason to do it you have no reason to disagree now given that given
00:29:09 reason to disagree now given that given the clarity of the exchanges in 2010 that we've seen namely that there are two requirements in b41 the second of which the second limb relates to the spread of fire over the surface of the
00:29:22 spread of fire over the surface of the external walls why was it still unclear to the lfb martin had made it perfectly plain uh in 2011. yes absolutely but i think the
00:29:33 2011. yes absolutely but i think the what was being expressed was the fact that guidance hadn't necessarily been updated despite letters clarifying the position if the guidance isn't updated then that will leave those with responsibilities
00:29:44 will leave those with responsibilities for
00:29:45 for understanding and applying the guidance to misinterpret in the way that there were concerns expressed here yes i see now
00:29:52 now um uh
00:29:53 um uh he uh goes on to say if we can go to page seven please of the statement of paragraph 24 uh that
00:30:00 uh that um
00:30:01 um uh
00:30:02 uh it was a commonly held view second line at the lfb that there was a widespread misunderstanding by building control bodies and industry stakeholders at the scope of b41 as it applied to the
00:30:13 scope of b41 as it applied to the regulations governing spread of fire over the surface of a building and that this misunderstanding was fostered by a lack of clarity within the guidance and he refers to the
00:30:24 within the guidance and he refers to the letter from the commissioner to the dclg in december 2012 and september 2013 we've seen before in evidence do you agree with uh andy jack's evidence that there was a
00:30:35 andy jack's evidence that there was a commonly held view as he uh explains there i think that actually points to my last answer in that the guidance hadn't been clarified and therefore the concerns
00:30:47 clarified and therefore the concerns uh hadn't been addressed yet now can we go back to uh the email thread at page two this is lfb triple zero five two one three five page two
00:30:57 two which is the uh mid september email string this now takes us on page two and if we look at the third email uh down this is the second uh sorry the sixth of october and ejector rebecca burton
00:31:09 october and ejector rebecca burton copied to numerous people in the fire safety department at the lfb subject shepard's court sorry for the delay in providing this advice particularly given the fact that this fire was now some time ago
00:31:22 this fire was now some time ago this fire adds to the concern about understanding of b4 of the building regulations and the application of the building regulations and the standard of work by the construction industry consequently there is a need to gather
00:31:33 consequently there is a need to gather evidence and consider whether a fence may have been committed we should also be compiling evidence that allows us to lobby for improvement do you know what offences were being considered uh no i don't have the top of my head
00:31:45 uh no i don't have the top of my head now do you know what the potential lobby was to which andy jack was referring there
00:31:53 i think generally my direction had been that i would intend to to write to local authorities to understand the issue um and i also as i said earlier i think i was
00:32:03 i was hopeful of that letter being stronger around our potential enforcement role right but as i say that clarification wasn't forthcoming when he refers to lobbying does he mean
00:32:15 when he refers to lobbying does he mean talking to using a neutral expression perhaps talking to local authorities or talking to central government i think both both right had you yourself been involved in any discussions of the possibility of quotes
00:32:27 discussions of the possibility of quotes lobbying unquote um
00:32:29 um central government for improvement in this area no not at this time right he then goes on uh three paragraphs below that to say this the issue of external fast spread you
00:32:41 the issue of external fast spread you said do you see in terms of the investigation the issue of external fire spread is a difficult area in relation to fire safety law and there is no certainty that a prosecution will in ensure i think he
00:32:52 prosecution will in ensure i think he means ensue nonetheless evidence gathering will be needed if we are to consider that or if we wish to seek to put the issues to responsible persons for such blocks and to others such as the construction industry the building
00:33:04 the construction industry the building control fraternity and government for adb
00:33:08 adb um how can you tell us how andy jack or the lfb generally would quote put the issues to responsible persons so in terms of responsible persons would would be like let's be sent to local
00:33:19 would be like let's be sent to local authorities making them aware of the issues
00:33:22 issues more widely i think again you've produced an evidence earlier the letters from the commissioner to the wider sector and to government partners about our concerns and issues so my expectation was that we would
00:33:33 so my expectation was that we would follow a similar vein but using this particular incident as an example to evidence our concerns right so this was raising awareness
00:33:44 raising awareness but perhaps not taking much further action beyond that i think given the limitations of our role
00:33:50 role it's about educating others around our concerns or the evidence that we were able to get from this particular incident
00:33:57 incident i think what's um what is an issue for us in this regard is that these incidents are reasonably rare i think the example you showed the other day was from 10 11
00:34:08 showed the other day was from 10 11 years ago and then the example prior to that may have been lacking our house that in itself points the rarity of it and
00:34:15 and difficulty in generating an evidence base
00:34:19 base though which partners may will consider a priority for them given the other conflicting drafts they may well be managing
00:34:25 managing you say rare i think you said relatively rare
00:34:31 nonetheless when they happen they are a matter of grave concern aren't they absolutely now spencer sutcliffe responds to this email and this is the same email run at page one please
00:34:43 page one please same day 6th october 2016 second paragraph uh uh following lachnal and other high profile incidents the 10pf enrichment
00:34:54 profile incidents the 10pf enrichment comes to mind are we actually saying we still do not know whether we can enforce in this area uh
00:35:02 uh would it be right to say that this is exactly what andy jack is saying when he says there's no certainty a prosecution will ensue yes i think that's exactly what he's trying to convey
00:35:13 trying to convey as far as you were aware assistant commissioner was it the case at the time that these emails were being generated internally within the lfb early october 2016 that the lfb didn't
00:35:24 early october 2016 that the lfb didn't know whether they had the power to take enforcement action in relation to this issue
00:35:28 issue i think the understood view is that we didn't
00:35:31 didn't but at the same time there was a certainly because the direction i gave was to ask that question again because i think i was aware that there had been the previous exchanges that hadn't elicited the change we were
00:35:42 hadn't elicited the change we were hoping to see yes i see
00:35:46 i see now if we continue on this email um in the in paragraph the fifth paragraph down
00:35:51 down um he says please bear in mind can you do you see that he says please bear in mind that every time we does this there is a partnership at stake and a very key one for rebecca in this case
00:36:02 in this case bearing in mind the backdrop of a good news story where compliance with the previous en went some way to prevent internal fire spread and greater risk to occupants
00:36:10 occupants what is the partnership at stake that he's referring to there so i think that's the way in which we work with local authorities the partnership that we'd have in that regard
00:36:19 regard um
00:36:21 um certainly in the meeting that i had initially with that group i had urged discretion in the matters that we were dealing with purely on the basis that visually across
00:36:32 purely on the basis that visually across the built environment you will see this type of installation and what i didn't want to do was to suggest without evidence that this issue was widespread and cause unnecessary concern
00:36:44 unnecessary concern for residents and equally for local authorities given again
00:36:51 the number of issues they would be dealing with in the built environment and making sure that they spent their time attention and money in the right areas so
00:36:59 so i think that's possibly what andy is is alluding to that there is a need for discretion at this point until we have the evidence to suggest how widespread or or exactly how these materials had
00:37:11 or or exactly how these materials had performed
00:37:16 what sort of evidence were you hoping to get
00:37:19 get i think the test results was the first part of that i think and then i think the second part was by writing to local authorities and other registered social landlords
00:37:27 landlords was to understand the extent to which these materials might be present in the built environment as i say it's not possible to ascertain that visually so is it fair to say that your approach at this point was
00:37:40 approach at this point was a cautious one given the relationship that you wanted to preserve with london local authorities i think where we we took pre-emptive action with the local authority
00:37:52 action with the local authority responsible for shepard's court because we clearly had seen the evidence we didn't need to wait for test results there was evidence there of external fire spread and so it was right to move proactively with that local authority
00:38:04 proactively with that local authority but i was certainly urging caution elsewhere until we had the evidence and indeed the advice from council to understand again um
00:38:13 um our legal position as to what approach we would then take as we understood the wider issues yes
00:38:21 yes yes thank you now um if we then go to lfb 3033033
00:38:31 this is an email from gareth steele one of your senior fire engineers as you told us of the first of december 2016 to charlie pugsley lindsay seal charles romer spencer sutcliffe
00:38:42 romer spencer sutcliffe and you were copied into this as you can see with others and the subject is meeting requests from ac daily 6 december
00:38:49 december 2016
00:38:50 2016 uh and he says in the email at the start you'll have seen the invite from hannah on behalf of ac daily is that hannah lauer lua
00:38:58 lauer lua hannah
00:38:59 hannah she was my um personal assistant right i've been mispronouncing her name i think for some months but it's lauer is it
00:39:05 it great um and uh she says you'll have seen the invite from hannah on behalf of ac daily for tuesday next week we fire safety are preparing a response to hammersmith and fulham which will include recommendation
00:39:16 fulham which will include recommendation on investigation assessment remedial works regarding the external clouding and its performance in fire any direction we provide to h and f uh will be equally applicable to most
00:39:28 uh will be equally applicable to most other local authorities and private blocks and could involve significant expenditure this could be the proverbial cat out of the bag on this issue but ac daily has asked that we consider what the advice should be the implications of
00:39:40 the advice should be the implications of the advice if we enforce or advise and how we get the message out amongst other things i'm paraphrasing somewhat but ac daily will provide us an introduction on the strategic implications for us to
00:39:51 the strategic implications for us to consider
00:39:53 consider now the first question is is this the meeting that you pulled together yes i believe it is yes right is this the first time that it met or was there an earlier meeting of this group
00:40:05 an earlier meeting of this group looking at this i would suggest it's the first meeting right so later than i suggested earlier all right now when mr steele says that the advice to hammersmith and fulham will be equally applicable to most other local
00:40:16 applicable to most other local authorities and private blocks does that tell us that the lfb knew or at least suspected that there were widespread failures to comply with building regulations across london in
00:40:27 building regulations across london in respect of external wall fire spread i think i suspected that this wouldn't be an isolated case but again part of writing to local authorities was to understand that completely rather than
00:40:39 understand that completely rather than work on
00:40:40 work on on an assumption so visually whilst they may look the same that's no guarantee of performance and he says this could involve significant expenditure was the fire safety department anticipating in any
00:40:52 safety department anticipating in any way that the shepherds caught fire could prompt the kinds of widespread reassessment of external clouding and de-cladding of buildings that's taken place follow following the grenfell tower fire
00:41:03 tower fire i don't think we could have ever envisaged what we're seeing now and how widespread the issue is but certainly i think my working assumption was this wouldn't be isolated
00:41:14 wouldn't be isolated and in any any regard it would be an expensive process regardless of the number of buildings
00:41:23 is that why the response to the shepherd's court incident could be the as it were cat out of the bag yes i'm not sure whether i use that phrase it could easily have been me but i think that points to me urging
00:41:34 i think that points to me urging discretion in the handling of the information in the matters yes and indeed gareth steele in his witness statement suggests that it was your expression just for our reference purposes that's
00:41:47 just for our reference purposes that's zero three nfb2012030 nine page four paragraph thirteen but um what did you mean by a cat out of the bag i think london fire brigade are largely a respected organization and if there
00:41:59 a respected organization and if there was
00:42:01 was unfounded concerns raised without the evidence to support it that that could cause distress for residents
00:42:07 residents living in these types of buildings it could
00:42:11 it could trigger a disproportionate response from building owners i'm very conscious of the fact that there are significant pressures on housing budgets to improve housing conditions in a number of areas and
00:42:23 conditions in a number of areas and provide housing in the first place so what i wanted was to provide the evidence and understand the scholarly issues so that any response was targeted to meet the risk as opposed to based on unsubstantiated rumor for one
00:42:35 based on unsubstantiated rumor for one of the expression i mean the use of the expression uh is what it did by using it did you mean that the lfb's knowledge of the dangers
00:42:47 that the lfb's knowledge of the dangers of external first spread particularly up cladding systems and the widespread use potentially widespread use of combustible materials in cladding systems was up to that point
00:42:58 in cladding systems was up to that point a closely guarded secret no absolutely not i think what i was trying to suggest that we were now uh working on an assumption that that we'd seen well not an assumption we'd actually witnessed in that particular
00:43:10 actually witnessed in that particular block external file spread and there was a working assumption this may not be an isolated case and that what we needed to do was have a formal position and understanding of that before we communicated that issue
00:43:22 that before we communicated that issue further and more widely i see so by the expression cat out of the bag did you forgive me for that did you really mean opening a pandora's box or a can of worms or the floodgates
00:43:34 or a can of worms or the floodgates i think i was more concerned that there'd be an uncontrolled and untargeted response as opposed to withholding information if that's what you're suggesting mr daley
00:43:45 mr daley it strikes me as though what you were saying was that the knowledge or belief of the fire brigade that this was a widespread problem was the cat
00:43:56 was the cat and you were concerned with letting that out of the bag until you were sure what the color of the cat was
00:44:03 to a degree i think it was more about related to the information from this particular incident rather than the longer held issues that we've covered here this morning
00:44:14 morning right understanding that particular incident yeah thank you
00:44:21 [Music] right
00:44:24 right uh did the i think you've told us this meeting took place
00:44:28 place it did actually take place yes yeah do you know what very very generally was decided at it can you tell us in general terms i think there was uh
00:44:40 i think there was uh further further asks of legal clarification to understand that position so whilst we had the previous guidance i wanted to revisit it to understand that because i say i wanted
00:44:51 say i wanted um
00:44:53 um in effect a stronger letter to be able to be sent to local authorities and social landlords if there was an issue that we could then understand it better
00:45:04 that we could then understand it better there was
00:45:05 there was equally the issues around the fire started in the white goods and that was a significant campaign for us at the time around total recalls we experienced around 300
00:45:16 we experienced around 300 fires uh in that starting white goods in london
00:45:20 london um so when you set that against the context of six thousand twelve fires a year it's about five percent and that is an event that i would refer to as a common event and therefore was an important issue to use the evidence of
00:45:31 important issue to use the evidence of this incident to keep moving that campaign forward
00:45:38 there was also the liaison with the local authority the initial local authority hammersmith and fulham on the issues as we understood them at that point and again the the understanding of what
00:45:49 and again the the understanding of what i wanted to come next which was that letter to local authorities and to registered social landlords now let's go to lfb double zero one two zero
00:45:59 zero one
00:46:01 one [Music]
00:46:03 [Music] which is
00:46:04 which is nigel palace's response to rebecca burton's 18th of october letter this one's dated the 3rd of november 2016.
00:46:13 it's addressed to you as you can see and if you look at the first paragraph uh mr palace suggests some sort of surprise that the facade panels have been shown to have contributed
00:46:24 to have contributed to the fire spread and they asked for he asks for further information about the lfb's testing of panels i've summarized that there is this what prompted your request for an internal meeting with the fire safety
00:46:35 an internal meeting with the fire safety department in december 2016 as we've seen
00:46:38 seen [Music]
00:46:40 [Music] i don't think it was i think i wanted that meeting anyway right
00:46:45 right and then if you go please to lfb uh 403511
00:46:54 this is rebecca burton's letter to nigel palace
00:46:57 palace uh responding to nigel palace's letter of the 3rd of november 2016. this is dated 6th february 2017 and
00:47:06 and again if you look please um at page three
00:47:12 i'm sorry page two i apologize page take page two you can see it comes from rebecca burton again for uh you assistant commissioner fire safety again
00:47:23 assistant commissioner fire safety again did you see this letter or have any input into it before it went i don't recall but i may have seen it right let's look at the letter in the first paragraph on page one um
00:47:33 um she says
00:47:34 she says we are writing to you in response to your correspondence dated 3rd november 2016 requesting the results of our preliminary tests on the facade panels of shepard's court these were undertaken by the london fire brigade scientific advisors bureau
00:47:46 brigade scientific advisors bureau veritas please finally close the report from bureau veritas as well as a summary from the london fire brigade explaining further the issues raised and then if you go to the foot of the page she says this we also note
00:47:59 page she says this we also note uh that these panels have been used in the sister buildings identified as bush court roseford court and woodford court which are also hammersmith and fulham council premises and then there's a recommendation on the
00:48:10 and then there's a recommendation on the top of the next page we consider that the council needs to review the use of the panels for this building at its sister blocks at the earliest opportunity in the light of the tests by bv in the first instance we would suggest
00:48:22 in the first instance we would suggest the bv report be reviewed and a fire risk assessment is undertaken for each building taking into account advice from a suitably qualified and competent fire risk assessor and the council's old own building control department it is our
00:48:34 building control department it is our general expectation that a strategy to assist the risk and implement short medium and long term action in shepherds court and the sister buildings listed above should be implemented this
00:48:45 above should be implemented this assessment will need to take into account the fire safety measures already in place in the building as well as potential mitigation measures to ensure that the potential vertical fire spread does not pose a risk to health and
00:48:57 does not pose a risk to health and safety
00:48:59 safety and then there's a final paragraph which prefigures writing in general terms to public and private sector housing providers
00:49:09 providers um
00:49:09 um what sort of measures did the lfb think should have been undertaken by hammersmith and fulham in the short medium and long term so i think the initial ask would be to
00:49:20 so i think the initial ask would be to carry out a survey of their housing stock to understand the issue there was clearly information that suggested some blocks some sister blocks had the potential to have the same systems installed
00:49:32 systems installed so understanding the scope of the issue then considering what immediate or immediate what medium term actions may be required to ensure the safety of residents and again that would
00:49:44 safety of residents and again that would be driven by their risk assessment and then the longer term in my view would be to remediate the issue do you know why those expectations weren't spelled out in this letter
00:49:55 weren't spelled out in this letter because i think it is an issue for the risk assessment in terms of how
00:49:59 how the other systems within the building may support the risk as it's as it's laid out i think when you look at the issue of fire risk assessment it's not a general process it is building specific and
00:50:12 process it is building specific and there may be other [Music]
00:50:15 [Music] mitigating factors in terms of systems and facilities available in a building that may offset the risk as it's understood so it's not necessarily the job of the fire service to
00:50:26 fire service to say
00:50:27 say how each individual building should be addressed but certainly something that we would work in partnership with the local authority if they came up with a course of action and wanted to ask our opinion on whether or not the course of
00:50:38 opinion on whether or not the course of action was suitable and sufficient we may well take a view and provide advice as part of the protocol and our partnership with local authorities i think
00:50:46 think the letter as you i think you'll agree doesn't
00:50:49 doesn't suggest a temporary change to the state put policy in place at the neighboring blocks which had by then i think being confirmed to have the same external panels as president of shepherd's court
00:51:00 panels as president of shepherd's court can you tell us why that was because that may not have been an appropriate course of action i think it needs to be understood that in buildings that are not designed to support stay put it's not
00:51:11 it's not a desirable situation to have people evacuating down the single staircase that may well be used for firefighter access and egress it doesn't necessarily take into account
00:51:22 it doesn't necessarily take into account the vulnerabilities of people in the building as well in terms of how they would be managed and supported in an evacuation in the building that's not designed for that so i think what that needs is fuller consideration of the risk assessment of the building
00:51:33 of the risk assessment of the building as a whole and the other passive and active systems that may or may not be present in that building
00:51:39 building when you say it needs to be understood that in a built in buildings that are not designed to support stay put it's not a desirable situation to have people evacuating did you mean that what did you mean buildings that are designed
00:51:51 you mean buildings that are designed to support and stay put sorry buildings that are designed to support stay put yes sorry yes um now um again the letter doesn't give a time scale for the fire risk assessments to be completed or or ask that they should
00:52:03 be completed or or ask that they should be provided to the lfb why was that i think at this stage it was a general uh ask to the council there's ongoing discussions and partnership work and i'm sure that would have formed part of
00:52:15 sure that would have formed part of of the issue as it developed did this event trigger a fire safety audit for the three neighboring blocks uh i can't recall i would assume it would have done but i can't recall whether it did or whether there was recent audit activity
00:52:27 whether there was recent audit activity that was relied upon to understand the risk in those buildings right now you say you assume it would have done and that's consistent with your your witness statement just for your information paragraph a
00:52:38 information paragraph a um
00:52:39 um we we haven't i think found any evidence that one was carried out can you explain or it may well have been as i say there may have been recent audit activity that was relied upon it was recent enough to
00:52:50 was relied upon it was recent enough to understand but uh i don't uh i don't have that detail on that right but at any rate your evidence is that one should have been carried out should have been or so i think i would have accepted recent audit activity in a
00:53:01 accepted recent audit activity in a similar way we do now for the building risk review which is the national piece of work that's ongoing now while we got this letter on the p on the screen i referred i think in general terms to that last paragraph
00:53:13 that last paragraph finally please note that the lfb will also write in general terms to public and private sector housing providers to draw their attention to the issue our recent experience from a number of fires is that the issue of external fire
00:53:24 is that the issue of external fire spread is not isolated to this particular block or to hammersmith and fulham council now that's early february 2017 to be clear what was it specifically
00:53:35 to be clear what was it specifically that led you to the view by this time that what you discovered at shepherd's court might be a london wide problem or at least not confined to hammersmith and fulham
00:53:46 confined to hammersmith and fulham i think just as i said visually that type of arrangement in terms of the the glazing system that was installed visually does not look like it's isolated and
00:53:57 isolated and so reasonably there's a chance that similar materials are similar construction of spangled panels existed elsewhere but that took me back to my point that it was important to understand the
00:54:08 it was important to understand the testing and the mechanics of how those windows performed to then fully understand to what extent it did apply to other installations across london what would the performance
00:54:20 what would the performance characteristics of these particular panels tell you about how widespread the presence of the panels was over london i think from the testing we would get a specification for how those
00:54:31 those panels were constructed and that specification is something that others could possibly use to understand and so the bureau veritas report i think does go into some detail around the
00:54:42 detail around the materials and the construction of those panels
00:54:46 panels now we know that after the letter of the 6th of february 2017 from rebecca burton to hammersmith in fulham you did write a letter to all the local authorities and housing providers uh two months later
00:54:59 housing providers uh two months later sixth of april we'll come to that in a moment
00:55:01 moment before i do that i just want to show you your
00:55:04 your police witness statement at met307774
00:55:10 at page four at the very bottom
00:55:16 you say [Music]
00:55:19 [Music] um the fire was in august and i think we got the final report in around december 2016 or january 2017 from bureau veritas who are our scientific advisors we're just pausing there i think you wrote
00:55:30 just pausing there i think you wrote this statement before you've seen the the reports is that right i'm not sure the date of uh particular interview and no of the interview no and you say
00:55:42 and no of the interview no and you say from that i determined that i wanted to write to local authorities to make them aware because these things are everywhere it doesn't mean that because they're upvc with a spandrel panel that they are
00:55:53 upvc with a spandrel panel that they are all constructed the same but that was the point of the letter to ask people to take into account what their construction is and whether it poses a risk now when you said there these things are
00:56:06 now when you said there these things are everywhere what exactly were you referring to i think i was referring to the fact that visually there are similar installations elsewhere visually yes visually i mean it's uh as i say it's
00:56:17 visually i mean it's uh as i say it's not possible to simply look at a panel and understand how it's constructed the materials used and when you say that was the point of the letter to ask people to take into account what their construction is and whether it poses a risk were you
00:56:28 whether it poses a risk were you essentially saying that the brigade had no way of knowing whether the panels that you say were everywhere were combustible or not but that was something that building owners and occupiers needed to check so when i say
00:56:39 occupiers needed to check so when i say what was everywhere i mean the the type of installation of double glazed windows with a spandrel panel so just be clear that that's the point of what i'm saying is everywhere not these particular panels are everywhere
00:56:51 these particular panels are everywhere and then i think the point of the letter was to share the findings of the testing and then ask people to qualify what materials and what construction their particular buildings may have on them
00:57:03 particular buildings may have on them did you have any sense of how widespread the use of combustible panels in external wall construction on high-rise residential buildings was across london at the time no but my experience was it was still a
00:57:15 no but my experience was it was still a pretty rare occurrence and so
00:57:18 and so that in itself because fires are mercifully fairly rare it doesn't qualify that the issue may not be a hidden risk elsewhere so whilst i couldn't quantify it i think it was important to do the work to understand
00:57:30 important to do the work to understand the issue when you say it was a pretty still a pretty rare occurrence you mean a fire on such a building or the presence of these materials what we witnessed in terms of the fire behaviour in external fire spread now if we go then to the letter of the
00:57:42 now if we go then to the letter of the 6th of april 2017 that is that rbk302688
00:57:52 and if we look at paragraph two uh you say my predecessor assistant commissioner steve turek wrote to housing providers in march 2009 about a variety of matters relating to fire
00:58:04 variety of matters relating to fire safety and residential housing blocks one of those matters was replacement double glazing of the associated replacement of spandrel and phillip filler panels on the external faces of blocks of flats with floors above 18
00:58:15 blocks of flats with floors above 18 meters in height in the case of this fire we believe such panels were a contributory factor to the external fire spread now you refer here only to spandrel panels and filler panels
00:58:27 panels those are specifically panels around windows
00:58:29 windows yes yes they are yeah um are you referring to spandrel panels and filler panels because at shepherd's court those were the only the only cladding panels were spandrels around the windows
00:58:40 around the windows yes so that's what we which shepherds caught and i believe the the previous letter
00:58:45 letter was referencing and the experience of black and how liking our house now we saw in your or other rebecca burton's 18th of october 2016 letter to nigel palace at hammersmith and fulham that
00:58:56 palace at hammersmith and fulham that you'd refer to the panels as a facade system we can go back and look at it if you like but the word phrase facade system was used was it your own view or understanding that spandrel panels round
00:59:07 understanding that spandrel panels round windows are a kind of facade system i think they make up the external wall and therefore where i would expect them to meet the the functional requirements
00:59:19 the functional requirements b4
00:59:21 b4 yes
00:59:24 was that a general lfb view i think my view had certainly been informed from discussions with people in department with more experience and technical knowledge of the issue yes
00:59:35 technical knowledge of the issue yes and had the fire safety department identified the fact that some high-rise residential blocks for example grenfell tower had been or were being clad across the full external
00:59:47 were being clad across the full external surface of the building i think we were aware that the buildings were being clad but in terms of how that relates to this particular issue is very different
00:59:58 is very different because we are talking about different um systems and this was particularly an issue that we'd witnessed that shepherds caught that related to the performance of spandrel panels
01:00:09 of spandrel panels and those glazing systems that would be covered by a competent person scheme in this case the fencer scheme but our understanding was that that certification process
01:00:20 certification process only applied to the glazing elements and not necessarily the full installation i think that's what was leading to our concern i see is there any reason why you didn't uh tell the recipients of this letter
01:00:32 uh tell the recipients of this letter that they should not just focus on spanish panels and filler panels but any cladding system i think this was based on our experience at that point in time but given that um
01:00:43 at that point in time but given that um you knew that there were cladding systems going up which would actually involve a far greater more widespread use of potentially combustible materials why not mention full-blown cladding systems as opposed simply to limiting it to spandel panels
01:00:55 simply to limiting it to spandel panels and filler panels i think it was important to focus on where we had experience of the risk right
01:01:01 right would you agree in any event that if combustible materials are being used in external panels whether they're spat whether they're spandrel panels or a whole building envelope the risk is the same
01:01:11 same namely the risk to a greater or lesser extent
01:01:15 extent of external fire spread yes i think given what we know now but at the time the experience was around spandrel panels and that was informed as i say from both the lack of air house fire and what we'd observed at shepherds called
01:01:27 what we'd observed at shepherds called did you perceive a time at the time that there was a risk that some recipients of this letter to whom you were writing might take a reductive view of what you were
01:01:38 reductive view of what you were concerned about and limit their reading their understanding of this letter to spandrel panels so they'd say to themselves well we've got a full-blown system here i can ignore that because this is just about
01:01:49 ignore that because this is just about spanish panels did that occur to you no i don't think it did occur to me i think that the letter was focused on the issue that we had evidence of to support our concerns
01:01:59 concerns um so i don't think some reason had they done that i think had we had events not overtaken us had we still been pursuing this issue through and found more widespread issues i think that then would have formed the basis of
01:02:11 that then would have formed the basis of some evidence to support our work to lobby around what we can see or perceive to be a wider misunderstanding if that if that's helpful sorry did you yes mr dave just help me with this i mean
01:02:24 dave just help me with this i mean would it not be right to say that the the risk that jude had identified arose not from the fact that they were spandrel panels which simply i think you
01:02:35 spandrel panels which simply i think you understood mean they fitted below some windows
01:02:37 windows but they're from the nature of those panels
01:02:40 panels namely that they were composite panels with a combustible core i can concede exactly what you're saying here yes um but i think again what we
01:02:51 here yes um but i think again what we are pointing to is what we had evidence of and the evidence that we had of failing
01:02:55 failing um
01:02:57 um systems around double glazing was what was driving this piece yes but you you had experience of them in one particular location of the building did it ever occur to you that they might
01:03:08 did it ever occur to you that they might be used or similar panels with a similarly combustible core might be used in other locations on buildings i'm not sure it did at that time though
01:03:19 i'm not sure it did at that time though all right thank you
01:03:22 if we go to paragraph three of this letter
01:03:26 you say we've seen a number of cases i just want to focus on those words we've seen a number of cases where it appears on the basis of information available to us
01:03:35 us that the level of fire protection to the external face of the building did not comply with the requirements of part b of the building regulations insofar as they seek to limit the speed with which a fire can travel and spread over the external face of a building or may
01:03:47 external face of a building or may contribute to a fire which cases were you referring to when you say a number of cases there i don't think there were specific cases that were being referred to i think lacking our house will obviously be one
01:03:58 lacking our house will obviously be one of those
01:03:59 of those but i think there had been some earlier communication and sharing of information around
01:04:04 around failures of double glazed systems elsewhere
01:04:08 elsewhere but i don't think i could tell you what specific ones were being referenced when that letter was drafted in the fifth paragraph you say well it starts in many cases how these panels came to be used is not clear and if you
01:04:20 came to be used is not clear and if you look at the sixth paragraph um you can see at the bottom of the page it starts uh in
01:04:27 in in the light of fires plural that have occurred
01:04:31 occurred my question really is well what other cases
01:04:33 cases are you drawing on there well if we're simply looking at fires plural there's luck in our house and there is shepard's call right to say there had been previous um communications around the failure of
01:04:44 communications around the failure of double glazed units in terms of in some instances where they form a more extensive external wall to a flat that had failed in in the event of a fire now if we go to the last paragraph of the
01:04:56 if we go to the last paragraph of the letter on page two you say this i would therefore strongly urge you to consider i would strongly urge that you consider this risk as part of the fire risk assessment process for premises under
01:05:08 assessment process for premises under your control i suggest that you make sure all relevant information about any replacement window and facade schemes is fully available to fire risk assessors where no reliable information is given for a given property it is our general
01:05:21 for a given property it is our general expectation that the strategy to assess the risk and when necessary implement short medium and long term actions to address the risk this assessment will need to take account of other fire safety measures
01:05:32 account of other fire safety measures already in place in the building as well as potential mitigation measures to ensure that any potential fire spread does not pose a risk to health and safety
01:05:43 safety now the letter doesn't refer there as you can see i think to the degree of risk to property and life from uncontrolled fire spread in a cladding system
01:05:53 system despite what your fire safety teams had been told in the slide presentations from july
01:05:59 from july and october 2016 we saw those on thursday do you know why that is this is i think the
01:06:08 the the presentations i tried to to convey on thursday was an assurance if you like that
01:06:14 that we have the regulations in place that these systems will not will not pose that risk now whilst we had concerns around how those things were interpreted what we didn't have at
01:06:25 were interpreted what we didn't have at that time was evidence of those type of system failures what we did have was the evidence here around spanish panels and focusing the issue very much on those at the moment because that was the known
01:06:36 the moment because that was the known risk that we had evidenced and seen here in london and in terms of of that paragraph
01:06:42 paragraph the wording at the start is very deliberate and it doesn't mention fire risk assessment it's about risk assessment because it is asking those local authorities as part of their own risk assessment process that would carry out as
01:06:53 process that would carry out as responsible personal sort of building to understand that risk and for that risk to then be provided to fire risk asses to understand in the context of the wider fire risk assessment i think that is a
01:07:04 fire risk assessment i think that is a nod to the fact that we understood that under the ro we couldn't enforce on that particular issue i see so was that a deliberate decision by your department it was a deliberate decision the word in there is
01:07:16 deliberate decision the word in there is is quite deliberate i think had we received different advice different legal advice in terms of acquisition uh i think that may have been stronger and would have talked specifically about the fire risk assessment aspects right but
01:07:27 fire risk assessment aspects right but nonetheless you are actually um aren't you telling local authorities to get to as responsible persons to perform an rro assess risk assessment
01:07:38 assess risk assessment on their replacement window and facade schemes aren't you i'm asking them to carry out a risk assessment of their premises as they would under the housing health and safety rating system and any findings any risks that would be
01:07:49 and any findings any risks that would be there should then be shared with a fire risk assessor and i think again on thursday we did cover the fact that where there are known risks we would expect to be taken into account as a fire risk assessment so we don't are we
01:08:00 fire risk assessment so we don't are we not to take it from this letter that the view of the lfb by this stage was that external walls fell within the scope of the rro for the purposes of a risk suitable and sufficient risk assessment they're under yes now our position was
01:08:13 they're under yes now our position was our understanding was at the time that the ro did not apply right now there's no reference in this letter either to the difficulties that uncontrolled fire spread could pose to firefighters who would attend premises
01:08:25 firefighters who would attend premises expecting it to be compliant with the requirement b4 again was that a deliberate choice i think the letter was was focused um in as succinct away as possible to draw the attention to the issue for which they
01:08:36 attention to the issue for which they would be able to concern themselves right in terms of the performance of the firefighters on the day of shepard's court i think the the firefighting actions that i certainly witnessed by the time i arrived and what was conveyed
01:08:47 the time i arrived and what was conveyed to me by the previous incident commander was that firefighters had responded to the
01:08:53 the fire spread in in a manner in which i would have expected possibly informed by the previous uh learning from from black and our house i dare say um to a certain extent the
01:09:04 um to a certain extent the incident was over resourced but again i wouldn't criticize against the commander for that i think that was the instant commander
01:09:10 commander providing enough resources in a timely fashion should the issue escalate but in fact the actions that were put in place were sufficient to arrest the spread of fire at an early stage because we are talking about something very very
01:09:21 talking about something very very different to what we later witnessed at grenfell tower right so would it be right to characterize the warning in this letter as narrow focused and incremental and based entirely and
01:09:34 and incremental and based entirely and solely on what you could empirically observe from the shepherd's court fire yes i think our experience of trying to raise the issues more broadly in the past had met with little success what i think i was hoping to achieve
01:09:45 what i think i was hoping to achieve here
01:09:46 here was to get a focused and targeted awareness of what was going on in the london building stock which then in turn may well provide us with evidence to take issues further now presumably at this stage neither you
01:09:58 now presumably at this stage neither you nor anybody else in the brigade had broadcast an internal message to all fire all officers down to watch manager level who might be incident commanders that they should not expect
01:10:10 that they should not expect that external cladding system was would always comply with the functional requirement b4 no i think the previous learning had had obviously been uh
01:10:22 obviously been uh successful in the operations that were applied at shepherd's court um there were learning packs that talked about that
01:10:28 that in our internal um staff magazine the fire was referenced both in september and october uh visually with some supporting um commentary around the fire it was
01:10:39 commentary around the fire it was focused on the white goods element of it because that was an active and live campaign at the time and something that was common in our experience in terms of a cause of a fire
01:10:50 a fire against cladding external fire spread systems relating to the scandal panels which you know i would suggest at that time the numbers of those we might evidence in a single year would be in single figures so far from a common occurrence
01:11:05 right i mean why didn't uh why wasn't there any brigade-wide message to all putative incident commanders that when they turned up at an incident uh on at a clad building they should not
01:11:17 uh on at a clad building they should not necessarily expect that that cladding system complied with the building regulations i think when we look at the incident learning
01:11:25 learning the observations from that particular incident was that the crews had acted in a way that was just you know would have expected
01:11:33 expected and that the previous learning had clearly
01:11:36 clearly filtered down to watches so
01:11:39 so i think there was a general sharing of the information but there wasn't i don't think anything specific that went out to uh watching crew managers now there's also no reference in this letter is there to the risk that
01:11:50 in this letter is there to the risk that a stay put policy may not be appropriate for a building which doesn't comply with requirement b4 we can see that it's not there my question is had the fire safety department identified that problem by
01:12:02 department identified that problem by this time early april 2017 had we identified which particular problem sorry the i the idea that a stay put policy or the risk that a state policy might not be appropriate
01:12:14 policy might not be appropriate for a building which doesn't comply with requirement b4 no i don't think we had formed a view in terms of the risk for each building because i say the risk has to be assessed on a building by
01:12:26 has to be assessed on a building by building basis um and it's to apply a blanket approach i think uh is is dangerous in terms of what that could mean for occupants in terms of
01:12:38 not being proportionate to the risk posed in that particular building i think there were already guidance in our high-rise procedures that talked about the need to
01:12:49 that talked about the need to potentially assist with evacuation if uh if the situation warranted it and didn't support people staying put in their flats
01:12:57 flats we'd seen on thursday that by early june 2017 there was a slide presentation by kevin hughes ac hughes
01:13:07 ac hughes showing the effects of rapid fire spread upper cladding system and the concomitant effect on the suitability of maintaining a staple policy in that building we'd also see that that
01:13:18 building we'd also see that that document had been circulating earlier in the year
01:13:21 the year from january my question is given that in internal intelligence within the lfb why doesn't this letter simply come out and say
01:13:32 you need also to consider the appropriateness of your stay put policy when you take into account or when you perform your risk assessment taking into account
01:13:43 account uh the risks posed by replacement window and facade schemes why doesn't it do that so i think if you if you consider the work that's ongoing now and a network has been informed by some
01:13:55 and a network has been informed by some considered views around how we manage the risk
01:13:58 the risk as we know it now after grenfell tower that the advice that is provided to building owners now does not move straight away to changing their evacuation strategy it points to many other mitigating factors and steps that
01:14:10 other mitigating factors and steps that they may take prior to taking that course of action and that course of action is quite a serious course of action in terms of changing the strategy because the building design wouldn't necessarily
01:14:21 building design wouldn't necessarily support mass evacuation from the buildings they're not designed with that intent that's a building design concept and i won't rehearse that i'm sure the inquiry is very aware of those things so it has to
01:14:32 it has to adopt the approach that it's a building by building approach and an understanding of all of the mitigations that could be applied in that building or may already be present before they're making what is you know an extensively
01:14:45 making what is you know an extensively last ditch i would say uh resort to change the evacuation strategy for the building and then support
01:14:52 support all residents to be able to achieve that yes but following a significant step yeah i mean following up on that i understand that but why not just simply tell the local authorities just to think about it
01:15:02 about it not necessarily change it but to think about it in the context of the individual risk assessment for each building because the role of the fire risk assessor is to consider the evacuation strategy for that building
01:15:14 evacuation strategy for that building based on the holistic risk assessment of the building the responsible person will set the strategy for their building based on that advice so i think it's it would have been wrong
01:15:25 so i think it's it would have been wrong to set in people's mind that the first course of action should be to depart from that without considering all other more proportionate mitigations that may manage that risk now i'm right in
01:15:37 manage that risk now i'm right in thinking i will say that neither you nor anybody else within the brigade had had broadcast an internal message to potential watch uh managers who might be incident commanders and anybody above that rank that when they
01:15:50 anybody above that rank that when they see or suspect a cladding fire in a residential high-rise building they should consider and monitor consist constantly whether a stay-put
01:16:01 consist constantly whether a stay-put strategy for that building remained appropriate i think that information was already available in policy and i don't think we saw um
01:16:09 um any evidence from that particular incident that led to a learning outcome that would point to that i think there was general communication about the fire as there is with most major fires in london they would
01:16:21 london they would receive
01:16:21 receive um coverage through the online website and through the internal magazine they feature on a daily bulletin that's available to operational crews as well so i think there is it's
01:16:32 crews as well so i think there is it's not that the issue would have been uh failed to have some publicity within brigade but there wasn't a specific message no you were at that incident um can you confirm for us
01:16:44 can you confirm for us that that in fact uh shepard's court was partially evacuated
01:16:50 evacuated there was some self-evacuation from uh residents on the arrival of the cruise is my understanding and then there was some supported evacuation from the immediately affected floors because there were concerns from
01:17:02 because there were concerns from residents where smoke uh had traveled through some of the internal corridors largely due to the actions of firefighters accessing the fire floors yes
01:17:13 yes now mr chairman we're going to go on to an earlier draft of this document uh it might be convenient moment to take the break now yes very well thank you very much well mr daily that sounds as though
01:17:24 much well mr daily that sounds as though it's a good point to have a break we'll stop now we'll resume please at 25 to 12 and as before please don't talk to anyone about your evidence or anything to do with it thank you all right thank you very much
01:17:42 [Music]
01:17:47 thank you 25 to 12 please
01:36:11 could you ask mr daley to come back in please
01:36:25 all right mr daily ready to carry on yes absolutely thank you very much yes mr millet yes mr chairman thank you very much mr daley and can i now please go to a slightly different topic but it's still shepard's court
01:36:36 still shepard's court um i just want to ask you about fire resisting compartmentation in the context of that incident and specifically a report that we understand you and andy jack prepared
01:36:47 understand you and andy jack prepared together for the commissioners management board in august 2016. um it's at lfb double zero one two zero three zero one let's have it up
01:36:58 let's have it up it's not dated but
01:37:01 but i can tell you that andy jack has dated it as the 23rd of august 2016. uh and in his witness statement he says i'll quote rather going to without going
01:37:13 i'll quote rather going to without going to it that it was part of a a wider piece of policy work that i had started to work on with ac daily some months earlier this policy work run parallel to the work we were doing in relation to
01:37:24 the work we were doing in relation to shepard's court and that's his paragraph 61 at page 18 of his witness statement at lfb double zero one two zero three zero eight now um looking at what's on the screen
01:37:36 now um looking at what's on the screen in front of you do you remember that you had a hand in compiling this draft document
01:37:41 document i certainly would have reviewed it and made comment yes right now we can see from the top of the first page that it was drafted for the performance management board is that the same departmental management board that you referred to in your evidence yes it is
01:37:54 referred to in your evidence yes it is and you chaired it and i think it was attended by the heads of the different functions within your department yes yes now can we go to andy jack's witness statement at page 18 paragraph 61
01:38:05 paragraph 61 uh
01:38:06 uh where i want to show you lfb double zero one two zero three zero eight uh and and then he i can read it to you at 61 he says
01:38:17 read it to you at 61 he says [Music]
01:38:19 [Music] sorry page 18. uh he says it's quite long um but he says on first of december i emailed gareth steele charlie pugsley lindsay seal charles remains spencer
01:38:30 lindsay seal charles remains spencer cycling for andy hearn in response to an invitation and we've seen that invitation and
01:38:37 and in that email in response to the issue as to the appropriate action to take in respect of shepard's court i refer to a paper on compartmentation between flats state that the scope of the paper extends to the envelope of the building
01:38:48 extends to the envelope of the building and that the paper does cover options for education stroke enforcement this paper was a draft document entitled fire resisting compartmentation flats dated 23rd of august 2016 and he goes on
01:38:59 dated 23rd of august 2016 and he goes on with a bit i've just quoted uh and uh he goes on to say in the second in the last third of that paragraph
01:39:07 paragraph uh the draft i was referring to in my email of first december had been considered already by the principal management board pmb and had been amended following their comments the principal management board
01:39:19 principal management board was a regular meeting to consider policies and departmental issues which was chaired by the assistant commissioner for fire safety regulation at the time of sending the email it had not yet been it had not yet been considered i cannot now remember whether
01:39:32 considered i cannot now remember whether or not it was considered by the cmb and then he exhibits the email chain now um for clarity did first when andy jack refers to the principal management board
01:39:43 refers to the principal management board did he mean the performance management board
01:39:46 board uh no the principal management board is the meeting in the department right so
01:39:52 right so because we've seen from the top of the document that it was going to go to the performance management board is there are there two boards no i think that's possibly a typo oh i see so it should say principal management board not performance
01:40:03 management board not performance management board i believe in the in the draft yes
01:40:07 yes right i see thank you now he says here as i've shown you that he doesn't know whether the report was ever in fact considered by the cmb the commissioner's management board do you know whether it was ever seen by the commissioners
01:40:19 was ever seen by the commissioners management board i can't recall but if we can return to the paper that might help you let's do that as a recommendation let's do that let's go back to the document please uh at um lfb doubles
01:40:30 doubles so what i what i do know is we never got to
01:40:32 to fully uh implement everything we intended from this paper because events unfortunately overtook us right uh lfb double zero one two zero three zero one
01:40:44 just looking at the first page of it again uh do you know whether it was ever actually considered by the cnb the commissioner's management board that was my question yes i was hoping
01:40:56 that was my question yes i was hoping the recommendations may help me with that but i i can't remember whether it was or it wasn't do you know whether it was considered by any other senior board in parallel to or above the fire safety
01:41:07 in parallel to or above the fire safety department i would suspect that if uh having gone through the performance management board it may well have gone to the directorate management board before cmb that would be the usual route right so the operations directorate when
01:41:18 right so the operations directorate when you say performance management board do you mean principal sorry yes i'm doing the same thing right apologies okay so it's principle would it be right to summarize this report by saying that
01:41:30 by saying that as in relation to the potential application of the rro to exterior walls the legal question of whether the rro applied to the walls ceilings and floors that separate flats from one another
01:41:41 that separate flats from one another that legal question had never been tested
01:41:44 tested i'm not sure if he'd never been tested but it was certainly a live issue um that we were concerned about so
01:41:51 so the ro applies to the common parts and doesn't have demise within individual dwellings and i think the concern that was being raised was um
01:42:01 um actions undertaken to run services and other facilities through a building may well breach compartmentation either through the flats floors and ceilings and the adjoining walls between flats right and those are areas beyond
01:42:13 flats right and those are areas beyond which um our inspectors would not be able to assess right so walls floors and ceilings and that that is what is supposed to achieve fire resistant compartmentation yes they're integral to that yes now if we go to page two
01:42:25 that yes now if we go to page two bottom paragraph you can see that it says this the compartmentation issue as a heading the compartmentation between flats is of vital importance to prevent the spread of fire through a building containing multiple dwellings
01:42:37 building containing multiple dwellings and is essential if an evacuation strategy based on defending place is to be utilized in the building in the absence of adequate fire resisting compartmentation fire and all the products of combustion are liable to
01:42:48 the products of combustion are liable to spread into other dwellings in the block and or the means of escape in the absence of an early warning of fire persons in those premises may be overcome or prevented from making a safe escape this assumes an even greater
01:43:00 escape this assumes an even greater significance in premises occupied by vulnerable persons who may need insistence to make an escape or otherwise be slow to do so due to infirmity or lack of awareness of danger for example in sheltered housing blocks
01:43:13 for example in sheltered housing blocks and then if you go to the first paragraph on page three
01:43:19 it says the ongoing experience of the authorities inspectors is that fire risk assessments rarely consider compartmentation in areas of the building away from the means of escape and rarely consider services that
01:43:31 escape and rarely consider services that run through run through flats for example soil pipes and ventilation consequently scant factual basis is available to justify or validate use of a stay put emergency plan
01:43:42 a stay put emergency plan now just pausing there in this report would it be right to say assistant commissioner that the point being made here is that that stay put as an evacuation strategy should only be relied upon
01:43:54 should only be relied upon where it can be established that a high-rise residential building's compartmentation is effective yes i think this paper is broader than just high-rise residential i think it's it's more about the the importance of
01:44:07 it's more about the the importance of compartmentation generally in supporting that principle because it's heavily relied upon so yes and and is it also saying that in practice the extent to which the compartmentation of a
01:44:18 which the compartmentation of a high-rise block is effective is not usually considered by the responsible person carrying out a suitable and sufficient fire risk assessment so could you say that again
01:44:30 so could you say that again is it also saying that the extent to which the compartmentation of a high-rise block is effective is not usually considered by a responsible person so it should be considered and i think our concerns were
01:44:43 considered and i think our concerns were one
01:44:44 one that the areas where there may be breach and compartmentation are beyond the scope at which our inspectors could look and therefore where we had concerns whether or not fire risk assessors were also gaining access to individual
01:44:56 also gaining access to individual premises in order to make the assessment of compartmentation as a whole right would you say that generally within the lfb this reflects an underlying working assumption that compartmentation will invariably hold
01:45:08 invariably hold now i think our work shows and i think the start of this paper it suggests that some of the audit regime regularly pointed to compartmentation issues as some of the
01:45:19 compartmentation issues as some of the issues around which the fire service would give advice or issue a non-statutory notification of deficiencies or in a more extreme case an enforcement notice
01:45:30 an enforcement notice yes and that would suggest wouldn't it that that to pres for anybody whether um well for anybody attending an incident that it would be wrong to proceed on the assumption the working assumption that
01:45:42 assumption the working assumption that that compartmentation in a high-rise residential block of flats would invariably hold i think the design principles behind which these buildings are constructed is exactly that it assumes that
01:45:53 is exactly that it assumes that compartmentation has been properly maintained yes probably so properly maintained so if built as her original design compartmentation would be intact
01:46:04 be intact but we all know over the years that buildings will have other services and improvements done normally in in the
01:46:11 in the honest intent of trying to improve conditions in those buildings um and that those works when undertaken should be properly fire stopped to reinstate the compartmentation so i don't think it could follow that
01:46:23 so i don't think it could follow that there's a wide assumption that buildings are fundamentally flawed in that way if that was appointed it's the other way around that there shouldn't be a fundamental assumption that they're not
01:46:34 fundamental assumption that they're not i think there's an assumption that they are
01:46:36 are that and less conditions and the dynamics of instant points otherwise right so that's a qualified assumption now the report goes on to cite examples
01:46:47 now the report goes on to cite examples of fire safety breaches that have compromised complementation of previous incidents and the first of which i think was lacking and you can see that on page three
01:46:56 three uh if you look a bit lower um lower down at the second paragraph in the first bullet point there
01:47:06 it although it doesn't think well it refers to
01:47:09 refers to the communal ventilation system at lacanal which allowed products of combustion to percolate from flat to flat
01:47:15 flat but if uh so that's one example but if we go to page eight at the very top the um report goes on to record its conclusions
01:47:25 and here it says this there are significant examples of compartmentation issues posing high levels of risk to the public more examples are very likely to be discovered and so rectified as a
01:47:37 be discovered and so rectified as a result of fire risk assessment before fires occur pushing the boundaries of the rrfsa to ensure that this happens is in the interests of public safety now do you agree
01:47:48 now do you agree that that would appear to suggest that these
01:47:52 these types of compartmentation concerns were in fact relatively widespread i think i know from our audit activity and we sample
01:48:03 and we sample i think roughly only about two percent of the building environment to which the ro applies um
01:48:08 um that's
01:48:09 that's normally when enforcement notices are issued it would point to issues around compartmentation that could include fire doors are in a building that are an integral part of that so yes
01:48:20 integral part of that so yes a lot of our enforcement activity is predicated on compartmentation because it is a significant risk uh where we find it's being breached yes and of course that would it would follow from that there may be plenty of cases
01:48:33 from that there may be plenty of cases where it had been breached but you hadn't found it or hadn't yet found it i think when we are only sampling two percent given that the resulting position that we have it's hard to extrapolate those
01:48:44 it's hard to extrapolate those exemptions those assumptions out with such a small sample set but i suspect that compartmentation won't always be complete i think my own experience in firefighting is that you
01:48:56 experience in firefighting is that you can find products of combustion in building where you wouldn't expect to do so sometimes that's the result of firefighting breaching those compartmentation in order to gain access and others it's because the building hasn't performed in the way we'd expect
01:49:08 hasn't performed in the way we'd expect now this is late 2016 august
01:49:13 august putting ourselves in this is a draft of course and the project ran at least until december we know that in parallel as we've seen already this morning there's an examination of what happened at shepherd's court so far as the use of
01:49:26 at shepherd's court so far as the use of combustible materials on the external face of a building was concerned
01:49:33 did you or did anybody in the first safety department consider the potential cumulative effect of those two separate risks coming together i think that speaks to my earlier point
01:49:45 i think that speaks to my earlier point really that it's about a building by building basis because the nature of the risk has to be properly assessed against the other aspects in the building so whether that be the fight the passive fire safety measures or in some case
01:49:56 fire safety measures or in some case active fire safety measures and to what extent they either mitigate or exacerbate the issue and the risk that's being identified yes um put it in a slightly different way then did you did the lfb did you particularly consider
01:50:08 the lfb did you particularly consider the potential effect of external fire spread
01:50:11 spread because of use of combustible materials on the exterior combined with inadequate compartmentation within the same block i think where we've issued prohibition
01:50:23 i think where we've issued prohibition notices in the past it would be because significant risk has been identified either in terms of the compartmentation being so flawed that it would allow products combustion to pose a risk to people's lives
01:50:35 to pose a risk to people's lives i don't think we had the extensive evidence of external fire spread in the way i described earlier to necessarily make that assumption but clearly
01:50:43 clearly any risk to a building will be more significant if the other features that are building are compromised yes i'm really just asking you whether the lfb
01:50:55 the lfb uh
01:50:57 uh put these two risks together risk
01:51:00 risk of failure of compartmentation for whatever reason yes in a building in respect of which you you knew that there was a risky cladding but to use a
01:51:10 to use a a general expression had those two risks been amalgamated uh within the lfb's mind so as to so as to form a single heightened risk that people should be aware of i can i can
01:51:22 people should be aware of i can i can see the point you're making i i don't think it had generally um but i certainly i think um in my considerations around shepard's call i felt one of the one of the reasons
01:51:33 i felt one of the one of the reasons that
01:51:34 that the operations were were successful in terms of resting that fire is that we had carried out previous enforcement activity
01:51:42 activity that pointed to compartmentation issues and issues with lobby doors all of which had been actioned and i think i mentioned in my statement i felt that that
01:51:51 that whilst i couldn't prove it i felt that had to have been a positive impact on the way that incident progressed if that's helpful
01:52:04 yes it's partly helpful i just want to see if i understand it are you saying that in fact one of the reasons why these two risks were not put together and assessed as a heightened risk was because in the event at shepherd's court
01:52:16 because in the event at shepherd's court there was a partial evacuation which which solved the the problem no what i'm saying is i think the way in which the building performed internally
01:52:27 which the building performed internally with the external fire spread that we saw i believe would have would have been better as a result of the previous enforcement action to reinstate the issues of concern around compartmentation
01:52:38 compartmentation so
01:52:40 so whether or not i then took a view that's i think when we think about fire safety we would consider all risks and how the issues within the building support that and the other
01:52:51 that and the other measures we're in the building would support the management of that risk so hypothetically you can consider any number and range of issues to concern
01:53:03 to concern how a building may or may not perform but i think what we draw from is our experience of that to provide the evidence to inform what are the priorities for the organization in terms of what we consider and how we prepare
01:53:16 of what we consider and how we prepare let me just see if i can have another go at this
01:53:18 at this by the last quarter of 2016 it's right to think as we've seen that the lfe was aware of two generic risks one the generic risk of failure of compartmentation at least from those
01:53:30 compartmentation at least from those cases where you'd been enforcing number one and number two risks prevented presented
01:53:36 presented to the occupants of buildings by the presence of combustible material on the exterior
01:53:41 exterior yes
01:53:42 yes given that the presence of those two potentially generic risks what i'd like to know is why the lfb didn't then stand back and say right we actually now have a heightened risk for
01:53:53 actually now have a heightened risk for those buildings where there may be not only uh combustible cladding but also potentially a problem with that buildings compartmentation that is something both operational officers and
01:54:05 something both operational officers and building owners need specifically to be alerted to again i think it's about the evidence of that and i think it's about the understanding of the risk assessment process which is to consider the risks
01:54:17 process which is to consider the risks on a building by building basis in every case i don't think we had the evidence to suggest there is a generic issue across the built environment i think that's that's the point i've tried to to
01:54:28 that's that's the point i've tried to to make this morning that is is about building specific circumstances and and that risk assessment of the building needs to consider all aspects including the needs of residents right
01:54:39 including the needs of residents right when you um wrote your sixth of april 2017 letter did you go back and look at this draft report that you are 90 jack had pulled together six or seven months previously i think this report was still being produced at the time because i think it
01:54:51 produced at the time because i think it was one of those issues that that followed on after the activity around shepard's court it was being produced at the same time i think it's timetabling fell down the order if you like behind
01:55:02 fell down the order if you like behind the issues we wanted to raise around shepherd school right i see so nobody thought to put the issues in parallel and write a single letter to the local authorities not only warning them about spanish panels and facade schemes as
01:55:14 spanish panels and facade schemes as we've seen but also about the risks posed to occupants by potentially defective compartmentation i think i think the letter suggesting that there is a need to review your risk assessments puts in place
01:55:27 assessments puts in place the same measures that you need to consider this risk that we've now been uh made aware of with your wider risk assessment process and as i say the risk assessment process does consider the holistic risk to the building and the
01:55:39 holistic risk to the building and the associated hazards that that building may present but isn't the problem with that that the that all that hammersmith and fulham themselves only have a
01:55:47 have a a relatively limited pool of empirical evidence to go on you as the brigade for the whole of london some 30 odd authorities have much more and therefore why not why not give them
01:55:59 and therefore why not why not give them the benefits of what you were seeing so far as compartmentation is concerned as reflected in the draft report we're looking at i think hammersmith and fulham had been subject to enforcement and would be
01:56:10 subject to enforcement and would be aware of those issues because it applied to some of their buildings but i can i do see your point as well all right okay now um
01:56:19 now um did you take any steps to the brigade take any steps to approach central government at this point and alert them to the specific concerns reflected in the draft report and then the later emanations of of this project
01:56:30 emanations of of this project i think the intent of this report was to seek corporate support for uh and ask into central government about to clarify these particular issues in terms of the flat walls and ceilings and floors
01:56:42 flat walls and ceilings and floors i think the work that we sought to undertake after shepherd's court was to build the evidence basis on a very targeted area of work to try and support the earlier attempts
01:56:54 to try and support the earlier attempts for the clarification of the guidance around external walls did anybody think to seek urgent clarification from the dclg
01:57:03 dclg that external walls did fall within or didn't but clearly didn't fall within the skates of the rro so we'd already had clarification previously and i think our steps first
01:57:14 previously and i think our steps first of all was to ask council's advice which is what we sought and one of the reasons why the letter was somewhat delayed and then i took a a decision that the letter would go out as an
01:57:25 that the letter would go out as an advisory rather than delay it further because the legal advice was inconclusive i see and was any thought given to urging on central government this question that whether or not
01:57:37 that whether or not or the solution to this question whether or not the external wall fell strictly within the scope of the rro any risks presented by the use of combustible cladding
01:57:48 combustible cladding would inevitably fall to be assessed by the responsible person because of the dangers posed to people in other parts of the building who were on the premises and therefore undoubtedly within the scope of the rro
01:58:00 the scope of the rro no i don't think a specific question was asked now do you know why not again i think the approach to government is about building the evidence base for the ask as opposed to
01:58:11 the ask as opposed to um posing questions to which um
01:58:15 um i suspect the response would have been to point us to previous guidance found so without new evidence to try and prompt
01:58:23 prompt a
01:58:24 a different response i think it's fair to say previous attempts had pointed to to exactly that that
01:58:30 that requests had been met with restating a position that was already known yes uh that is uh that is a fair observation but given the development of the thinking contained in this draft report did you
01:58:41 report did you or auntie jack or anybody else within the brigade think of going back to louise upton at the dclg or anybody else at the dclg for that matter asking her to reconsider her advice on this issue which had been
01:58:53 her advice on this issue which had been contained
01:58:54 contained in her 6th of february 2013 letter for ron dobson no as i said i think this this this particular report was seeking the corporate support to do to ask the question in relation to this
01:59:06 to ask the question in relation to this and the further work was to gain the evidence to ask again we have a body of evidence to try and sway that opinion in terms of giving proper and full consideration to what was a concern
01:59:18 consideration to what was a concern around the guidance i see so i think in a nutshell the answer to my question is yes but it was a work in progress yes i think that that's sufficient was ron dobson aware of this draft
01:59:29 was ron dobson aware of this draft report do you know i'm not aware wherever he was or not i mean this was around the time that we were transitioning to a new commissioner at the end of 2016
01:59:40 at the end of 2016 and to a new director of ops i think in march 2017. did you at what point they crossed over i i'm not sure do you remember having or do you
01:59:51 do you remember having or do you remember bringing the topic the subject of this report draft report and the subject of the project that we've seen uh mr jack refers to paragraph 61 of his witness statement to
02:00:04 paragraph 61 of his witness statement to the attention of ac cotton uh as part of her preparations to take on the role of commissioner from january 2017.
02:00:13 2017. no it would have been in terms of my discussions would have been with the director of operations and the work that we were progressing um and why we were undertaking that work in the way that we were who was that at
02:00:24 in the way that we were who was that at that time that would have been dave brown up until um i believe march 2017. um so at the time at which the letters went out to the local authorities
02:00:36 went out to the local authorities um that was in the time that danny cotton was commissioner and tom george by this stage was the director of operations yes now coming back to the question of compartmentation failures in buildings and the extent to which that was a
02:00:47 and the extent to which that was a recurrent or generic problem you referred last week to a report produced by adrina parkin coates i think we've got the name right yes um that you remember being produced
02:00:58 yes um that you remember being produced shortly before you became head of fire safety
02:01:01 safety um and you said it was in the assistant commissioners in tray when you began that role in march 2016. now i'd like just to look at that with you it's lfb triple zero two five six five four
02:01:20 and if we go to um the first page at the top of the page you can see that it was produced for a meeting of the performance management board on the 26th of november 2015 authored by
02:01:31 authored by uh the business support group manager and i think that's or was adrena parking coach it was in dangerous um and the business support group was part of the fire safety department it is uh uh do
02:01:43 fire safety department it is uh uh do you know who commissioned this report i don't know do you know what you don't what prompted it you know i think what prompted it was concerns within the fire engineering group so
02:01:54 within the fire engineering group so adriena park and coates why she headed up the business support group is also a qualified
02:01:59 qualified fire engineer right thank you now let's look at the summary and the title indeed the title is compartmentation issues within the built environment summary
02:02:08 summary compartmentation is the subdivision of a building by far resisting walls or floors for the purposes of limiting fire spread within the building that's actually a quotation from the lga
02:02:19 that's actually a quotation from the lga guide
02:02:20 guide 2011
02:02:22 2011 for a bit for a given period of time the success of many building evacuation strategies are heavily reliant upon adequate compartmentation especially in buildings where the majority of occupants other than those directly
02:02:33 occupants other than those directly affected by fire stay in the building in the event of fire
02:02:38 and then it goes on fire safety officers are increasingly aware of fire stopping issues in new and refurbished buildings this awareness has been raised as a result of post-fire reviews of buildings where there has been unusual fire and
02:02:49 where there has been unusual fire and smoke spread through partnership work and through investigative work by other fire and rescue services the general conclusion is that compartmentation issues within the built environment are widespread due
02:03:01 the built environment are widespread due to either poor workmanship or a lack of oversight of build quality by building controlled bodies and main contractors an overall strategy to address fire stopping issues in london's building stock is needed the london strategy will
02:03:12 stock is needed the london strategy will benefit from coordination with other stakeholders to integrate our work with any proposed national strategy and if you go to the bottom if we can scroll up a little bit please to the bottom of page one
02:03:24 bottom of page one recommendations you'll see there they're twofold first one the the development of a strategy to reverse the trend of compartmentation failures and fast stopping issues as part of fire safety
02:03:35 stopping issues as part of fire safety regulations lsp six proposals london safety plan six proposals letters being sent out to all nhs trusts and local authorities to raise awareness
02:03:46 and local authorities to raise awareness of compartmentation issues in pfi schools and hospitals as an immediate short-term measure a pfi stands for private finance initiative why were those concerns about adequate compartmentation particularly acute in
02:03:58 compartmentation particularly acute in pfi projects i think there had been some evidence in those types of developments um where
02:04:08 um where issues have been found more readily would it be accurate to say that those concerns weren't confined to pfi projects
02:04:14 projects uh yes i think so page two please uh under the heading background um paragraph one the issue of substandard fire stopping is endemic in capital letters endemic
02:04:26 capital letters endemic within the construction industry in the uk and has been known about for the past 10 years that's a quote from wilf butcher the chief executive officer for the association of specialist fire protection
02:04:39 specialist fire protection and then it goes on the quote above highlights the scale of fire stopping issues within the built environment for new and refurbished buildings there is also a greater awareness of the problem within the authority as a result of
02:04:50 within the authority as a result of post-fire reviews of buildings where there has been unusual fire and smoke spread or through partnership work and investigative work by other fire and rescue services this has highlighted failures to comply with the building
02:05:01 failures to comply with the building regulations either during construction or refurbishment phase in relation to fire stopping now um the association for specialist fire protection what was that
02:05:14 fire protection what was that it's one of the um wider fire sector organizations right and would you agree with ms parker coates assessment in paragraph two there that that um the uh
02:05:25 uh at least from the quote that the problem of inadequate compartmentation was endemic
02:05:31 endemic whether i'd agree with the term is never hindered out i suppose from our experience of the audits that we undertook compartmentation was a reasonably regular outcome bearing in mind however about 70
02:05:45 outcome bearing in mind however about 70 of the order activity that we undertake buildings were to come out as broadly compliant
02:05:50 compliant so
02:05:51 so i think endemic focuses on where issues are found it's a common issue but whether that's a statement that could qualify the condition of the wider building stock is
02:06:02 condition of the wider building stock is possibly
02:06:04 possibly one for mr butcher to answer right now let's look at the section of the report that relates to residential buildings please at page three if you go to paragraph
02:06:15 if you go to paragraph 10 on page three underneath the heading residential building issues you'll see it's the second paragraph down says this residential buildings are designed to have a stay put policy whereby only the residents within the flat of fire origin
02:06:27 residents within the flat of fire origin eventually evacuate in the event of fire all other residents remain within the building unless directly affected by heat or smoke the standard of compartmentation is therefore critical as it limits fire spread within the
02:06:38 as it limits fire spread within the building to protect other residents from the effects of fire now this at my right is the same point that was made in the draft report produced by you and andy jack the following year in and from august
02:06:49 the following year in and from august 2016.
02:06:51 2016. yes yes yes namely the state book can only be an appropriate strategy in a building if if the compartmentation in that building is known to be completely reliable yes i
02:07:02 is known to be completely reliable yes i think the point we made earlier is that compartmentation is a principle that underpins that strategy and the degree to which compartmentation is breached is also
02:07:13 is breached is also something that needs to be considered as part of the risk assessment because compartmentation breaches could range from from small drill holes in a compartment wall through to much larger breaches and so
02:07:25 breaches and so it's not just about the compartmentation it's also the position and the extent of those compartmentation breaches and their impact on escape routes in a building is also a critical factor of consideration
02:07:36 consideration in terms of the overall risk assessment now the report goes on to consider two important case studies as she refers to them
02:07:44 them uh on page three and you can see london case study one national case study two if you scroll down you can see it down there um london case study is uh a fire
02:07:55 there um london case study is uh a fire in bush house baker road woolwich in the basement parking area and it continues the fire penetrated into a service shaft which rose vertically through all floors of the six story
02:08:06 through all floors of the six story building fire and combustion products spread from the surface shaft into other parts of the building even though the surface shaft should have been constructed to prevent this this resulted in a number of occupants of the building not being able to escape from
02:08:17 building not being able to escape from the building as smoke had spread to the solar escape route from the building three residents were rescued from the balconies of their apartments this building is one of three built by the same developer countryside properties
02:08:28 same developer countryside properties and had been given building control approval by nhbc in 2006. the two other buildings on the site were under construction at the time of the fire the authority prosecuted countryside properties and that talks about
02:08:39 properties and that talks about that
02:08:40 that um the bill and then it goes on the building control body nhbc were also scrutinized however due to inadequate uh
02:08:48 uh sorry we're also scrutinized however due to inadequate evidence gathering at the time of the incident prosecution proceedings were not pursued as a result of this fire and other incidents around this time i should just pause to say
02:08:59 this time i should just pause to say that was a fire in february 2007. the authority engaged with key stakeholders at the highest level the commissioner held a meeting on the 21st of april 2010 to discuss the authority's
02:09:11 of april 2010 to discuss the authority's concerns a commissioner's briefing note for the meeting is attached in appendix d
02:09:16 d and i'm going to go to that in a moment as a result of these discussions it was agreed with nhbc that they would engage in national training sessions in association with cfoa to raise awareness of fast stopping issues this was rolled
02:09:27 of fast stopping issues this was rolled out in 2011. now first would you agree that the point that appears to be made here is that incidents such as this raised concern about concerns about why buildings were being constructed with
02:09:38 buildings were being constructed with such inadequate compartmentation in the first place and then why that wasn't picked up as part of the building control approvals process yes i think that's the point of the paper yes
02:09:49 the paper yes um
02:09:50 um and if we go to page 28 in this document sorry paragraph 28 in this document let us look at that page five
02:09:59 page five [Music]
02:10:01 [Music] um we we can see there's a merseyside frns proposals to cofa with some recommendations and there are four bullet point recommendations there so training of
02:10:12 recommendations there so training of fire safety officers to identify failings and build quality fire safety officers carrying out full building inspection as opposed to non-forensic audits responsible persons of all major
02:10:23 responsible persons of all major construction projects built in the past 10 years
02:10:26 10 years or responsible persons in general being asked to undertake full structural surveys as part of their fire risk assessment process cfoa need to raise the issue of quality assurance within the construction industry with central government
02:10:37 industry with central government building control bodies in the construction industry council um did you know about those recommendations only when i read this paper when did you read it
02:10:48 read it so it was as it was in my intro when i came into the department in fact the version we've got here isn't the final version that went through my
02:10:56 my principal management board because one of the one of the observations was it was part of me
02:11:03 of me gaining a wider understanding of the reference i'd been given it prompted a conversation and i think i also asked for the paper to be redrafted with some local actions that we could do
02:11:15 with some local actions that we could do in lfb as well as simply pushing the issue
02:11:19 issue nationally in terms of so for example the the full building inspections carried out by inspecting officers so it's probably fair to say under the fire precautions act it was a
02:11:31 under the fire precautions act it was a more intrusive type of inspection that was carried out but under the rro it was much more of an audit and a sample i think i would have had some concerns about that particular recommendation in so much as many of the issues
02:11:44 so much as many of the issues that we are concerned about if they're not picked up during the building control phase of the building they then become hidden under the finishes within a building and of course the fire safety audit does
02:11:56 and of course the fire safety audit does not allow us to go in and start to dismantle the building for the purpose of the check-in so it's it was about more i think the the final version of this document includes some stuff that we're
02:12:08 document includes some stuff that we're working with building control bodies and engaging with them on our concerns and our issues as that would be the appropriate body to pick up those
02:12:17 those issues that are being built into the fabric of the building that would be beyond the scope of our offices to pick up right in their audit process
02:12:27 looking at paragraph 29 conclusions would you agree but it says this paper highlights some of the issues associated with poor build quality within the built environment which have an adverse effect on the occupants of a
02:12:39 an adverse effect on the occupants of a building in the event of fire particularly where there's a sleeping risk of vulnerable persons the problem is not limited to london as research carried out by merseyside fire and rescue services highlights it is
02:12:51 rescue services highlights it is estimated that property developers have set aside 150 million pounds for carrying out remedial works to the substandard premises that f and rs have been made aware of it is
02:13:03 f and rs have been made aware of it is considered that this is only a very small fraction of what would be necessary if the full picture were known
02:13:11 uh now when you read this in march 2016 what did you think of that it's clearly a cause for concern it's certainly in terms of the work we
02:13:23 in terms of the work we seek to undertake in our regulatory role it points to a number of issues that no matter how well we do our job there are i think that was part of the reason i asked for the paper to be reworked to
02:13:34 asked for the paper to be reworked to also provide some actions we could undertake within london in the london context
02:13:39 context and also how we would elevate the concerns
02:13:43 concerns um beyond the department um and through um to cmb which i believe ended up at the corporate management board after the paper had been reworked with those additional recommendations
02:13:54 with those additional recommendations um
02:13:56 um towards the end of 2016 it dates escapes me but certainly at that point in time would you agree that incidents like this particularly the one in bush house in 2007 would would raise concerns and
02:14:08 2007 would would raise concerns and learning points for operational firefighters because the question they would face is what is the appropriate operational response to a fire in a building that may have this kind of inadequate compound compartmentation yes i would
02:14:20 compound compartmentation yes i would and i think i can see that in my statement that we have an organization always learnt as much as we could from fire safety interventions
02:14:31 could from fire safety interventions and i think that sorry if i may sorry i think
02:14:35 think that's something that we had sought to address it's something that's bringing
02:14:39 bringing firefighters back into the role of understanding regulatory work was important to do that because of their interactions with building will be far greater than the two percent we could actively sample and get if you like eyes
02:14:51 and get if you like eyes inside more buildings to alert us to more issues where they might be present but again it's the context of this issue in terms of compartmentation
02:15:02 compartmentation um
02:15:03 um is not the only learning that that we could have taken from not just our protection work but our preventative work as well now um would you also agree and would it follow from what you've just told us
02:15:14 follow from what you've just told us that one key point that would arise in relation to an appropriate operational response
02:15:19 response is whether an incident commander can assume that occupants in a block of flats should be told to stay put in the event of a fire or whether an alternative strategy should be adopted in the light of the fact that compartmentation can't be relied on
02:15:32 compartmentation can't be relied on like i said we're basing our assumptions here on very small amounts of of
02:15:38 of all the activity and the vast majority of our activity does point to buildings being broadly compliant
02:15:45 compliant and so if we were to make a working assumption i think the assumption is that the building strategy as determined by the responsible person in conjunction with their fire risk assessor is the appropriate strategy for that building based on their activity and their work
02:15:57 based on their activity and their work but there should always be an assumption that based on what you're faced with at the incident the dynamic situation in front of you and the behaviour you may observe that there may
02:16:08 behaviour you may observe that there may be a need for that strategy to change in the course of the incident yes but the beginning of that answer you said that you were basing your assumptions on very small amounts of audit activity would you accept
02:16:19 audit activity would you accept nonetheless that even though the percentage of voltage activity may be small relatively speaking
02:16:26 speaking the findings were significant enough for at least merseyside fire and rescue services to make some pretty far-reaching recommendations and for your brigade the lfb
02:16:37 lfb uh to want to take those forward yes i think it does point to concerns that
02:16:43 that needed to be raised and we were hoping to raise those but again in the context of that audit activity i think what you're suggesting is whether or not there should have been a wider policy position that
02:16:54 that didn't support or accepts they put maybe a strategy to be adopted but i think from the limited audit that we did undertake the vast majority of buildings turn out to be broadly compliant and so it's
02:17:05 it's you could actually turn it around the other way and simply say that that supports the strategies in place more than it doesn't now let's look at appendix d which was
02:17:16 now let's look at appendix d which was referred to paragraph 17 as we saw page 13
02:17:20 page 13 of this document
02:17:24 but this is a note uh to commissioner ron dobson from steve chirrick dated the 15th of april 2010. it formed as part of the of the um
02:17:36 it formed as part of the of the um parker coats report
02:17:40 now steve turek was neil orwell's predecessor of head of as head of fire safety wasn't he he was yes and therefore he was your pre-predecessor i think yes
02:17:49 think yes we did you read this um this note this appendix d as part of your reading of the report when you saw it yes i believe it yes
02:17:56 it yes um now it's it says in the first substantive paragraph on page 13 uh you at ron dobson are due to meet with representatives from the construction of building control sectors
02:18:08 construction of building control sectors on 21st of april that's 2010 to discuss our concerns about the quality of construction and checking of new build and refurbished residential premises
02:18:17 premises and you can see the attendees who are expected
02:18:21 expected and
02:18:21 and costing one's eye down there you can see for example paul everal from nabc at the time brian martin clg and and others
02:18:33 and and others from government central government and also andy jack and simon davis as well as steve turek to be attending uh and um
02:18:44 uh and um if you then go to page 14 background to the issues the note says in the first bullet point there a significant number of recent fires over the last two years or so have exhibited unusual fire spread and or
02:18:55 exhibited unusual fire spread and or smoke spread investigations have often found this to be due to failures to comply with the building regulations either during construction or during refurbishment the fires concerned have resulted in persons becoming trapped and
02:19:07 resulted in persons becoming trapped and requiring rescue by the brigade building collapse and other unnecessary damage to buildings firefighters being placed at unnecessary risk similar failures to comply with building regulations have been found as a result
02:19:18 regulations have been found as a result of standard audits and follow-up to alleged fire risks around 50 significant cases in the london area have come to our attention over the last two years or so in each case the building defects are
02:19:29 so in each case the building defects are raised at the time of construction or refurbishment most cases involve large and major construction companies in each case the building defects appear to either have not been identified by
02:19:40 to either have not been identified by the building control body or to have been noted but not followed up on to ensure the defects were remedied before the premises come into use it is now a matter of significant concern whether the construction and approval process is
02:19:52 the construction and approval process is being enforced with sufficient rigor vigor to reasonably ensure new residential buildings in london are fit for purpose a further issue is that the buildings involved so far
02:20:03 involved so far can can have been built at any time over the last 10 or 15 years consequently we are concerned about how many residential premises with significant building regulation defects may be in use in
02:20:14 regulation defects may be in use in london
02:20:16 london now
02:20:18 now uh
02:20:19 uh when you you read that clearly we've seen this report refers to discussions resulting in an agreement that the nhbc would engage in national training sessions with the cfoa to raise
02:20:31 training sessions with the cfoa to raise awareness of fire stopping issues and that that was rolled out in 2011. i don't think i showed that to you but that is you'll recall that can you do you know anything about those national training sessions no i don't know
02:20:42 know um do you know whether anyone from the lfb's operational departments attended this meeting uh no i've only got the list that's on this this letter right do you know if these discussions were brought to the attention of the operational side of the
02:20:54 attention of the operational side of the lfb at all no i don't know you agree though that these issues directly impacted on operational firefighting as well as on fire safety
02:21:05 fire safety uh so far as different for the same reasons we've already looked at namely that if a compartmentation system in a block of flats fails or is it there's a risk of failing then that has an immediate effect on the appropriate
02:21:16 immediate effect on the appropriate operational response yes i think if there are concerns of that nature then the
02:21:21 the um policy position around responding to the dynamic situation would probably alert those crews more quickly to that scenario yes
02:21:31 now let's go back to the text of the report please at page 3
02:21:35 3 paragraph 11 which is the the case studies uh and a paragraph 11 there's a reference there to the case studies then it goes on to say however the structural
02:21:46 it goes on to say however the structural fire safety failures quarterly stroke annual reporting paper see appendix c outlines a number of other fires where structural defects were noted between 1st of april and 30th september 2014. so
02:21:57 1st of april and 30th september 2014. so this is more more recent and if you go to the report it's at page 10 of this document let's look at that you can see that uh there it is appendix
02:22:08 you can see that uh there it is appendix c title structural fire safety failures quarterly stroke annual reporting meeting deputy commissioners director at management board uh
02:22:18 uh march 2015 is the date of this report and it's by neil orbell ac orbital fire safety regulation so it's a year before you came into post um
02:22:28 um and um it's for uh the deputy commissioner's director at management board that would have been shared by rita dexter wouldn't it at the time i think
02:22:36 think just yes possibly certainly by the time it was the director of operations that would have cheered that right are you familiar with this report or at least did you read it when you saw it in your in tray i have seen this report yes right
02:22:48 i have seen this report yes right now let's look at summary page 10. um the report is the first in a series of thematic thematic reports produced by the fsr policy policy group on a quarterly and annual basis for the assistant commissioner fsr
02:23:00 basis for the assistant commissioner fsr to report to the directorate management board the mb the reports will be derived from the post-fire review process from april 2015 and identify any themes or trends that are evident to enable a
02:23:11 trends that are evident to enable a strategic overview to be achieved consideration of further analysis straight investigation and opportunities to reduce risk in future by fsr cs or apr interventions where appropriate this specific report and spreadsheet
02:23:23 this specific report and spreadsheet covering the period first april 2014 to 31st december 2014 provides an overview of incidents where fire investigation senior fire safety officers or fire safety inspecting
02:23:34 officers or fire safety inspecting officers has been identified that structural fire safety failures may be present that could have contributed to the significant spread or development of a fire
02:23:43 a fire it identifies who has been advised of the structural failures what remedial action has been subsequently undertaken by them and recommendations for further action by nfb as appropriate
02:23:54 action by nfb as appropriate do you know who invest who instigated this series of thematic reports in 2015. i don't know do you know whether those reports continued to be produced during your time as head of fire safety
02:24:07 your time as head of fire safety no i think we would look to review the process in terms of the papers that we were drafting so the having read this paper i thought there was more we could do in a london context and say i think the
02:24:18 london context and say i think the latter version points to an action plan about how we might address those things right when you came into post were those thematic reports being produced i don't recall seeing one um that was
02:24:30 i don't recall seeing one um that was recent when i came into post but that's um that doesn't mean it didn't exist right uh now um if you um go to the end of the first paragraph you could see a reference to opr what is opr and who are opr officers
02:24:45 is it operational performance response well
02:24:49 well it could well be sorry
02:24:53 we have quite a few acronyms but i'm sorry i can't necessarily help you with that right okay um now someone may be able to looking onto the content of the report at page 11 under the heading background the report says
02:25:05 the heading background the report says this
02:25:06 this one a post-fire review process has recently been introduced by fire safety regulation the purpose of the review is to develop a greater understanding of the contradictory factors of incidents to identify trends
02:25:17 factors of incidents to identify trends and themes that may be influenced straight communicated by lfb to prevent similar incidents reoccurring and improved fire safety these outcomes may influence future fsr and community safety initiatives
02:25:30 safety initiatives one of the categories of incident is this paragraph two one of the categories of incident that will generate such a review is those where serious structural issues have played a significant part in the spread or development of a fire the
02:25:41 the spread or development of a fire the review is intended to identify breakdowns in consultation or scrutiny processes
02:25:46 processes by building control local authorities and or approved inspectors quality of refurbishment works and or the competence of contractors issues relating to fire risk assessments and or management failures and need for
02:25:57 management failures and need for alterations notices and below that there's a big um passage entitled structural fire safety i'll just show you one or two of those
02:26:08 i'll just show you one or two of those i want to see parts of that 25 incidents occurred over this period and three were identified as significant and having potential deficiencies in structural fire safety features that may have contributed to the spread or development
02:26:20 contributed to the spread or development of fire all were in residential blocks of flats two of these were local authority-owned buildings and one was privately owned and you can see what they are campbell court daleston square and holcroft house
02:26:31 and holcroft house which will be familiar to those following last week's evidence um now um
02:26:37 um now um fire investigation officers and senior fire safety officers don't attend every fire incident today no they don't and even where sfsa's attenders i think you told us last week it's not unusual for them to be assigned a
02:26:48 unusual for them to be assigned a different role an operational role in the course of the incident yes that's correct so how realistic what was it to expect incident commanders to discuss potential structural defects with fire safety personnel on the fire ground
02:27:01 personnel on the fire ground i think the process that's in place is if a fire safety officer is used then they can request another officer i think also
02:27:08 also we can't overlook the the work of our fire investigation teams who have an understanding now of regulatory fire safety and would in the course of their duties alert the incident commander
02:27:20 incident commander where they thought there may be issues that wanted further investigation from fire safety but did it in fact happen as a matter of practice that during an incident there'd be a discussion between the incident commander and a
02:27:31 commander and a safety or structural professional my expectation is where there was a need to it would happen right the process is there to make that information and that expertise is available what i can't
02:27:42 expertise is available what i can't speak to whether every incident commander took advantage of that opportunity because i'm not at every incident right can we look at paragraphs 13 and 14 on page 13 of this dot of this document which forms
02:27:54 of this dot of this document which forms part of the adreno parker kate's report and
02:27:58 and if you go to that that's um uh
02:28:05 excuse me a moment i think i want page 12 actually my mistake page 12 the very end of this appendix
02:28:13 appendix paragraphs 13 and 14. however although not all are likely to pose significant risk to warrant an entry on ord that's the operational risk database it currently appears that even the more
02:28:25 it currently appears that even the more critical structural defects are not being identified as potential risks and entered onto the ord a review of the current policies template and instructions for the station notification forms and pra forms
02:28:37 station notification forms and pra forms used by opr has identified that these risks are not well explained it is recommended that fsr officers develop with opr officers additional guidance to ensure that all
02:28:49 additional guidance to ensure that all staff are aware of the risks and relevant priorities for notification and recording on ord now is is the reference to the current policies
02:28:58 policies uh there a reference to policy 784 which is the lfb's policy on notification of fire safety information that would be my assumption yes and is the reference to station notification forms the a form
02:29:09 station notification forms the a form and b form that we saw last week which is dexter yes now can you explain in very short broad terms what it was about the policy and the template forms that your
02:29:21 policy and the template forms that your department considered to be lacking in terms of this report no but certainly i can reflect on my own review of that and i think we touched on it last week that i felt the performance was patchy in that regard
02:29:33 in that regard there were in different areas where there was more operational expertise inside the fire safety department it was more likely that they would be uh attuned to the issues that would be of concern to
02:29:44 issues that would be of concern to operational firefighters and therefore more notifications would be made and similarly i think from stations depending on how good their liaison and close working was with their fire safety
02:29:56 close working was with their fire safety colleagues would determine whether or not there was sufficient interchange it was one of the factors when i took over the department and did an assessment if you like of where i felt
02:30:07 where i felt protection um sat in the oval organization and
02:30:12 and as part of my leadership role championing the need for protection to have a higher status and support was about introducing the fire safety regulation training for
02:30:23 fire safety regulation training for firefighters and equally for our inspecting officers to be given an awareness of station based activity and the sort of
02:30:34 station based activity and the sort of information that firefighters may need as part of that implementing the policy and changing the policy will have a limited effect if my view we haven't invested in the people to help them with their
02:30:45 people to help them with their understanding of those issues and just building on that in relation to the recommendation that fsr officers develop with opr officers additional guidance
02:30:57 additional guidance you can see that whose benefit was that for was it both for operational personnel and fire safety
02:31:06 safety i i've been very clear and and so with colleagues in fireside fire safety is as much about firefighter safety as it is around residents and and those those people who who live work and
02:31:17 those those people who who live work and play in buildings um so it's it's of mutual benefit because you know my my firm view is that we do everything we can to prevent fires we then do what we can to
02:31:28 we then do what we can to ensure buildings behave for our protection activities and then as a last resort we should be responding but we need to be able to respond in in the most appropriate way and the most informed way so it's mutual benefit in
02:31:39 informed way so it's mutual benefit in just a short answer yes but the additional guidance referred to in paragraph 14 i i think you're accepting was for the benefit or as much for the benefit of
02:31:51 benefit or as much for the benefit of operational officers as it was for the fire safety department yes i think that guidance points to providing station-based personnel with a better understanding of
02:32:02 a better understanding of the issues that they might reasonably notify for our safety of i think what we've developed what i've started developed since then was a stage on from that and actually give station-based personnel training in
02:32:15 station-based personnel training in basic
02:32:16 basic regulatory fire safety aspects such that they could undertake building safety checks and as i said earlier improve our knowledge and awareness of issues in the built environment do you know whether that
02:32:27 do you know whether that additional guidance was in fact developed
02:32:30 developed i don't know do you know his responsibility it was to ensure that the information referred to here potential defect structural defects were captured on the ord
02:32:41 were captured on the ord so normally entries on on the operational risk database are entered by station based uh personnel normally station managers oversight of the records for their particular station yes
02:32:54 records for their particular station yes but it would sometimes fall to watch officers to actually up upload or input that information and to what extent were station-based staff who had control over oversight over the in inputs into the ord dependent on fire
02:33:07 inputs into the ord dependent on fire safety personnel from your department to identify the relevant information and tell them tell them about it i think that's the purpose of notification form is to point to the issues um for them
02:33:20 is to point to the issues um for them then to have the understanding and carry out whatever local actions were appropriate so it's back to it's back to that
02:33:26 that we discussed on thursday yes yes um now there's a third report i think or at least a further report based on the 2015 report which is at lfb
02:33:38 which is at lfb 50155
02:33:42 we can just go to that
02:33:46 uh it's um entitled
02:33:50 entitled compartmentation issues within the built environment for a meeting of the corporate management board by assistant commissioner fire safety and the date is 21 december 2016. so this is your report is it yes this will be the
02:34:03 is it yes this will be the the reworked version of the earlier report that i asked for yes thank you that was my first question that that's helpful
02:34:09 helpful uh
02:34:11 uh if we go to page six paragraph uh 37 on that page underneath the heading potential lfp action plan
02:34:22 potential lfp action plan um you can see a long list of uh
02:34:26 uh items there that runs from a on page six to j on page seven uh if we can just scroll down to page seven and see where it ends up
02:34:39 uh let's just look at the earlier ones in the list at page six uh review
02:34:46 uh review any review internal documentation to ensure that any identified premises complementation issues are essentially collated both national brigade returns ensure brigade inspecting officers are provided with salient learning
02:34:59 provided with salient learning and development opportunities on the identification of compartmentation issues whilst carrying out audits etc
02:35:06 etc an e engaged with building control bodies through the london district surveyors association etc to discuss our concerns and requests these concerns are disseminated through to their membership um i've taken some of those really
02:35:18 um i've taken some of those really almost at random but do you agree that those potential action points indeed all of these potential action points focus on actions that could be taken to improve knowledge and understanding on the part of fire safety personnel
02:35:30 the part of fire safety personnel yes the intention here was to work with the wider sector but also to improve
02:35:36 improve our own processes yes now one thing you'll you'll note in this list is what's missing uh and that is uh the involvement of the operational side of the lfb i.e firefighters
02:35:49 of the lfb i.e firefighters there's no action there's no element of the action plan which involves them am i right about that yes i think um when we talk the first point here is also that notification
02:36:00 point here is also that notification process if we understand the issues and then how we share that information there isn't a specific action for operational college now do you know why there was no mention of in any of these action points of involving
02:36:12 action points of involving frontline firefighters i don't think it was a deliberate omission i think it's just where we got to
02:36:18 to right do you know whether any of these points in this action plan were pursued i believe we'd started on them to what extent we were we'd move through that i don't have a memory of it now
02:36:30 memory of it now i'd like to turn to a different topic next which is organizational learning can i start with your police statement met
02:36:40 met 30774 at page three
02:36:45 and i'd like to look at the third paragraph on that page you say this one of the things that i tried to take on in my role as assistant commissioner for fire safety which is a
02:36:57 commissioner for fire safety which is a role i took on about a year before the fire at grenfell tower was to try and open up more avenues for organizational learning around concerns around the built environment how did you go about doing that
02:37:08 how did you go about doing that i think some of the things i've already described in terms of opening up better awareness amongst operational crews to support that um the paper we've just talked about in terms of
02:37:21 just talked about in terms of um bringing to life those issues i think i was
02:37:24 i was having read that paper and that paper then led me into the sort of history of concerns that have been raised over time by both mr dobson and mr turret over over their time in roles gave me
02:37:36 gave me food for thought in terms of what we were proposing in the lsp for fire safety and there is stuff there around improving the competence of our officers i think we had been
02:37:48 had been largely a performance-led department in terms of a pursuit of numbers of audits rather than necessarily looking at the quality of the audits
02:37:59 quality of the audits i undertaken and great expression bringing out the learning from those interactions uh across the organization so i think it was those kind of concerns that i think i was taking on board my interactions with
02:38:10 interactions with section leads there was clearly some frustration around their concerns that they'd had and the extent to which their voice had been heard and i saw that as one of my key roles was to bring their concerns
02:38:22 key roles was to bring their concerns and their professional expertise to better on the wider organization now um if if you go please to uh
02:38:33 uh one your
02:38:35 one your i think i want paragraph uh
02:38:39 uh i'm so sorry page 13 of this witness statement paragraph two on that page
02:38:46 page um you describe the learning from shepherd's court yes that's it and you say this
02:38:51 say this however in terms of the learning from shepard's court i made a proactive effort to communicate both externally and internally through the available mechanisms to get the learning out i recognize that there are other competing priorities priorities and the
02:39:03 competing priorities priorities and the board making decisions for operational news have to take those into account whether the whole process had taken place and this issue had been considered prior to the fire at grenfell tower or whether it was not prioritized at the
02:39:15 whether it was not prioritized at the time because there were other issues they felt were more pressing or relevant i do not know a frustration within the lfb and the fire service nationally is that learning is not shared quickly
02:39:26 that learning is not shared quickly enough at times sometimes this is due to legal processes that need to take place but other times this is not a factor my personal determination was to get the message out and i made every effort to do so
02:39:39 do so now was it was legal process an issue within the learning from shepherd's court
02:39:45 court no i think i was referring to some historical incidents in london that weren't necessarily fire safety based but from which there was legal processes that prevented
02:39:56 there was legal processes that prevented learning being disseminated across the organization and are you talking about learning from previous incidents yes the particular one i had in mind when i discussed that was the um tragic loss of two
02:40:07 was the um tragic loss of two firefighters before green the bethenny green july 2004 i believe that was a day yeah and are you talking here about sharing learning both internally and externally
02:40:18 learning both internally and externally i think my frustration was about the internal um learning because this the critical issues there for firefighter safety
02:40:25 safety and whilst i understand legal processes have their place um it's somewhat frustrating that we can't or
02:40:31 can't or didn't seem apparent to be able to circumvent that and make sure the learning was available we were you satisfied that the learning from shepard's court was fully communicated internally i think as i said earlier we reviewed
02:40:43 i think as i said earlier we reviewed shepard's court and the the performance on that day did not give rise to concern around the operational response
02:40:51 response we certainly would have discussed what other actions may have been necessary and i think we reviewed the rnp report i think with hindsight one of the things that we possibly could have done
02:41:02 that we possibly could have done was was remind crews of the learning from black and our house because i think that had very much more in common with the circumstances of shepard's court than anything else yes thank you
02:41:14 yes thank you now as assistant commissioner from for fire safety i think it's right that you were a member of the operational directorate's cooperation board or odcb yes uh and uh
02:41:26 yes uh and uh i think also it's right that the odcb was intended to provide opportunities for the different nfb departments to share information together yes yes yes now as head of fire safety
02:41:37 yes yes yes now as head of fire safety were you able to use the odcb as a mechanism to bring fire safety concerns to the wider attention of other elements of the brigade
02:41:47 brigade i think that was the intention of it i think when that board was first set up um there was a discussion around whether or not fire safety would sit on that board or the the working group or one of expression
02:41:59 the working group or one of expression whose name i forget where
02:42:02 where issues were raised for initial discussion and then elevating to the board if they were going to be progressed and as head of fire safety did you were you successful in using the
02:42:13 did you were you successful in using the odcb to bring these concerns to wider attention within the nfb i can't think of any particular issue during that initial time um that
02:42:23 that i would have raised
02:42:27 i know certainly in terms of the working group where most of that consideration was done i did delegated that to one of my dacs who attended that board and would have raised our concerns in that
02:42:38 would have raised our concerns in that arena and that was dic drawbridge now can we go back a page in this statement please to page 12 and look at the first paragraph on that page
02:42:48 page um you
02:42:51 say the second line in my experience in the lfb and the role of assistant commissioner for fire safety i think it would be fair to say that issues raised through fire safety are
02:43:03 issues raised through fire safety are not always at the top of the list i think that all fire and rescue services have not necessarily fully valued the learning that can come through protection and prevention routes it is normally driven by the response
02:43:14 it is normally driven by the response element which is the largest part of the job so while shepherd's court revealed some external fire spread it was not hugely dramatic or spectacular it did make the news because it was unusual but fortunately no one died
02:43:26 unusual but fortunately no one died whilst this should not be a metric for learning in incidents where that happens it can drive or focus people's attention the issues were very technical in their nature delamination of buildings exposing an internal internal flammable
02:43:38 exposing an internal internal flammable core while it sounds technical and geeky it has huge implications for firefighting tactics part of my role now is to try and improve the national fire service's acceptance of learning through
02:43:49 service's acceptance of learning through that root
02:43:51 that root now just breaking that up first when you say it's normally driven by the response element
02:43:56 element which is the largest part of the job are you referring to the operational response to an incident yes and what is normally driven by that response element i think organizational learning
02:44:08 i think organizational learning um
02:44:09 um tends to flow more readily through that route
02:44:13 route um
02:44:14 um in terms of the broader part of this statement what i'm trying to convey is i think
02:44:20 in the environment in which we operate with the governance that we operate people's expectations of the fire service is how quickly we respond often the
02:44:30 often the for me there are three functions we are there to prevent protect and respond and i think those primary functions are given less weighting both politically and societally because
02:44:41 both politically and societally because people's expectation is it's about fire engines as opposed to the wider role [Music]
02:44:47 [Music] so are you saying well there's another way of putting it that articles which are for operational news and which are disseminated to frontline responders through operational news are normally informed by the
02:44:58 news are normally informed by the operational side of the organization yes and
02:45:02 yes and potentially some some more pressing political concerns at this particular time for example there was quite a lot of activity around understanding the counterterrorism
02:45:13 understanding the counterterrorism threat
02:45:14 threat and our response and knowledge of that as an example of of issues that would have been competing um at that time right
02:45:23 right and i think you're referring in this part of your statement specifically to your attempts to have the lessons learned from shepard's court addressed in operational news is that is that right i think what i'm talking about here is the more broad
02:45:34 talking about here is the more broad concepts i think i've used shepard's corp
02:45:37 corp um at the time but not necessarily as the prime example i think more generally i was determined to do that and certainly
02:45:44 certainly um in the role undertake now one of the things that we have done is to think about national organizational learning rather than national operational learning and that's something we're considering now so that we bring those strains together more
02:45:55 we bring those strains together more readily right can we go back a page to page 11 in this witness statement i just want to look at the last paragraph there with you
02:46:02 with you um you you say uh there was something in operational news i'm sorry the foot of the page you referred you referred in the previous paragraph to something in operational
02:46:14 paragraph to something in operational use in august 2018 about firefighter high-rise firefighting that's of course post-grenfell in the last paragraph you say this in terms of what we tried to do for the shepherd's court learning and operational news it would likely have
02:46:26 operational news it would likely have been one of my direct reports who put this issue forward i do not recall who held responsibility for operational news or for the staff who did at the time but it may possibly have been deputy assistant commissioner lee drawbridge
02:46:39 assistant commissioner lee drawbridge now um
02:46:41 now um you have you didn't sit i think on well you did sit on the operational director it's called nation board and therefore i think one of its main functions was to determine what should
02:46:52 functions was to determine what should go into operational news yes the recommendations came through a subsidiary board of that yes and in terms of uh my position on that board that was
02:47:04 my position on that board that was something that was shortly um shortly after it was established was to look at that attendance and reduce it because the board was too large for a board in a
02:47:15 too large for a board in a decision-making board and so our input substantively came through the subsidiary board of ocd right but wasn't one of the core functions of the odcb to decide what themes what learning what
02:47:26 decide what themes what learning what lessons should go into operational news it was to receive the recommendations and then provide challenge if there was others
02:47:32 others right can we take it from your statement that you didn't raise the shepherd's court fire at any of the odcb meetings that you attended in and after august 2016. no i think the
02:47:44 2016. no i think the um
02:47:45 um issues were raised more through the prc process and the learning that would come from that um in terms of whether or not there was space to get information into
02:47:56 space to get information into operational news and i think you said it was august 18 but actually i now know that to be august 19 so just as a clarification um and i think when that item did
02:48:07 um and i think when that item did uh finally go into operational news it talks obviously much more broadly from the events of both shepherd's court and then what would subsequently taken place at grenfell tower and considerations
02:48:18 at grenfell tower and considerations of what was happening in the wider building environment around residential high-rise in terms of those buildings that were changing their evacuation strategy as a result of what was now known uh to be on
02:48:31 result of what was now known uh to be on the outside of their buildings and the risk that posed right i mean why didn't you as a member of the of the odcb raise with the odcb the need for operational news to carry something about
02:48:42 news to carry something about compartmentation or something about external fire spread because of combustible materials or both so i'm not sure i was sitting on the board at that point in time as i say i think initially when it's first set up there was a
02:48:53 when it's first set up there was a rationalization of that board and one of those was that i wouldn't sit on that board at that time and that we would be represented on the subsidiary board right that that's that's unless you
02:49:04 you again help me with the timeline if you have i'll try to do that let's look at uh lfb3040714
02:49:12 this is a meeting of the odcb in september 2016. as you can see from the date the 23rd of september 2016
02:49:23 september 2016 and you are in attendance as you can see from the list you're the sixth named attention okay so this is sorry i don't think i've quite captured what you saw so this is our directorate management
02:49:35 so this is our directorate management board
02:49:36 board um this is not necessarily the board that i was referring to which was the training commissioning board and i can't remember the title again with the acronyms they're very similar so i apologize this is our uh directorate
02:49:48 apologize this is our uh directorate board that yes i absolutely sat on indeed um
02:49:52 indeed um right
02:49:53 right in light of that correction uh
02:49:59 let's look at the minutes um you can see that you attended um we can spend a little time looking at the minutes if you like but take it from me that there's no mention here of you raising any of the issues
02:50:11 any of the issues uh at that meeting that had arisen at shepherd's court um let alone any discussion of the tests and early conclusions from the fire um
02:50:22 um would that not have been an appropriate time to raise with the odcb the need for training through or need for education through operational news in relation to the lessons so far
02:50:33 in relation to the lessons so far learned from the shepherds caught fire yes i can see that uh that would be a formal route through which i would have done that um but i
02:50:44 which i would have done that um but i i'm
02:50:45 i'm quite comfortable certainly in the conversations i would have had in the margins of that and with my line manager of the other ac groups that we were having active conversations around what work we were undertaking uh
02:50:57 around what work we were undertaking uh following shepard's court right right um you say if that would be a formal route but you're having active conversations where sorry i didn't quite catch a date
02:51:09 where sorry i didn't quite catch a date in the margins we have uh regular meetings where the ac group
02:51:14 group will discuss ongoing issues and issues concerning our own departments there would have been one-to-one discussions with my line manager and i you know as i said whilst i can't
02:51:25 and i you know as i said whilst i can't give you the exact detail or dates of those i'm pretty certain given the nature and the size of the issue and the significance it had in terms of the work at that time that would have been an element that we would have discussed yes
02:51:36 element that we would have discussed yes but do you accept that in fact this would have been the perfect forum in which you could raise with the odcb the need for operational news to carry a specific shepherd's court lessons learned article as soon as possible yes
02:51:49 learned article as soon as possible yes sir i do excited yes and why wasn't that done
02:51:52 done maybe because i felt at the time we were having discussions elsewhere and i can see your point that this is the formal board
02:51:59 board and so it would have been appropriate to have raised it there as well right now would it also not have been the appropriate time to raise your early views that you and andy jackard had come
02:52:10 views that you and andy jackard had come to about
02:52:11 to about external walls and compartmentation i think that was a work in progress in terms of how we were developing that paper and the approach to which that was going to move forward
02:52:24 going to move forward i don't think it's necessarily at the point at which i would raise work in progress without corporate sign-off and what we were about to do uh this directorate would know to what extent were um fire safety
02:52:36 to what extent were um fire safety issues ever addressed at odcb meetings so far as you remember them i think we've grown um impact over time certainly um in my first year in post
02:52:49 certainly um in my first year in post one of the um one of the core parts of my role as i saw it was to continually champion and push for fire safety to to get more air time if you like and to
02:53:00 to get more air time if you like and to be
02:53:01 be more
02:53:02 more represented in the considerations of the wide organization now let's go back to your police statement if we can please at page 12 and um
02:53:14 and um i've read this to you already i'm not going to read it again but you say in the last part of the first paragraph on that page
02:53:20 that page um the delamination you refer to delamination uh sounding technical and geeky but with huge implications for firefighting tactics and when you when you refer to issues of
02:53:32 and when you when you refer to issues of delamination of building materials exposing an internal flammable core as having a
02:53:37 having a as you put in huge implications for firefighting tactics can you explain what those implications for firefighting tactics were so i am referring to what happened to
02:53:49 so i am referring to what happened to the panels at shepherd's court because that's says it was described to me from the
02:53:53 the testing
02:53:54 testing and in terms of the implications it's being aware and noticing the external fire spread and responding to it
02:54:02 to it now in the case of shepard's court as i say the response from the incident commander was as expected and i i believe i can't evidence it but i believe that would have been on the learning from the lack of house the package that was delivered there
02:54:14 package that was delivered there so
02:54:15 so in terms of without that awareness that fire
02:54:20 that fire would not have been dealt with as successfully as it was so i think that's it drove the incident commander to reconsider and reappraise their original tactics the original tactics would be to assume a fire in a
02:54:32 tactics would be to assume a fire in a single compartment they very quickly adapted and flexed those um tactics and then tackled the fire across multiple floors so that's that's the point of which i'd say has huge implications um having seen
02:54:45 say has huge implications um having seen that and i think as i said earlier with hindsight i think one of the things that i could have considered and should have considered is that we should have reminded crews to
02:54:56 is that we should have reminded crews to refresh their knowledge of the lucknow package because i i genuinely feel that that was what possibly informed the actions on that day yes
02:55:08 one might say but only to the extent that the lachenal house training package actually addressed questions of rapid and uncontrolled external fire spread
02:55:19 uncontrolled external fire spread i i think it was well known that that was part of the consideration it wasn't um
02:55:24 um it was something that was commonly discussed
02:55:27 discussed amongst operational colleagues uh was it your view at the time that the nfb ought to have been reviewing its high-rise firefighting strategies more generally in the light of what happened
02:55:38 generally in the light of what happened at shepherd's court to ensure that all watch come command all watch managers incident commanders throughout the brigade across london could respond adequately
02:55:49 could respond adequately and
02:55:50 and intelligently to uncontrolled external fire spread when confronted with it i don't think it was necessarily my view i think it was my view that we would share the information from the incident
02:56:01 share the information from the incident for consideration in terms of where that should go as i say i think we find i would have pressed a bit more for
02:56:10 for previous learning so to be refreshed would one of the huge implications for firefighting tactics that you refer to here be
02:56:19 here be the potential reversal of stay put at an incident i think that has to be in the consideration of an instant commander yes yes and would you say that there was perhaps an under appreciation
02:56:30 there was perhaps an under appreciation of the impact of such technical issues on practical operational firefighting at the time
02:56:35 the time i think that's a difficult one for me to to give a
02:56:38 to give a a response to i my personal view is that there was
02:56:42 there was um
02:56:43 um an awareness of of external fire spread because that was evidence from the actions on the day and i think the policy did allow latitude for incident commanders to assess the need for
02:56:56 commanders to assess the need for potentially acting to support an evacuation if the situation dictated i mean given that station-based training is delivered by operational officers at station level was there a risk as you perceived it at
02:57:07 was there a risk as you perceived it at the time that the training on matters like this the lessons from la um from both latino house and shepherd's court was likely to be perceived as technical and
02:57:18 perceived as technical and geeky as you put it and therefore less effective no i think in terms of the level of understanding needed from an operational officer is if they're observing external fire spread
02:57:30 they're observing external fire spread that the process and the way in which that has come about is of less
02:57:35 less less concern to them other than the fact that there is something evolving in front of them in that dynamic incident that would require their response so
02:57:46 so it's it's part of the role of having a training department is to is to
02:57:51 is to look at all of the information available and make sure that the training only contains that information that makes it accessible and readily available for the purpose which is intended so i wouldn't i wouldn't expect
02:58:02 intended so i wouldn't i wouldn't expect training to include the technical details of the panels or the mechanics by which it might become exposed just the fact that if there is external fire spread how you might reasonably respond to that
02:58:14 respond to that no that's helpful so yeah yes it sounds from what you're telling me drawing the threads together so far that
02:58:21 that because the incident response that lack at shepherd's court uh as it were passed the tests there were a few lessons learned to be
02:58:32 there were a few lessons learned to be learned from it to disseminate to operational firefighters yes i think it's fair to say um and again a hindsight reflection of that is i think we often
02:58:43 often look to
02:58:45 look to areas of development follow an incident to prompt learning rather than also looking at where good practice has been employed as an exemplar to demonstrate and reinforce learning
02:58:56 and reinforce learning now
02:58:57 now just in the minute or two before the break if i can just ask you to go back please
02:59:01 please to the same paragraph on the screen in front of you and i've read this to you you said well shepherd's court revealed some external fire spread it was not hugely dramatic or spectacular it did make the news because it was
02:59:12 it did make the news because it was unusual but fortunately no one died whilst this should not be a metric for learning and incidents where that happens it can drive or focus people's attention
02:59:23 people's attention in your experience was that
02:59:27 was that something you encountered in relation to fire safety issues specifically or was that a more generic attitude across the brigade
02:59:35 brigade i think it was probably my reflection on some of the previous work and campaigns undertaken by the brigade i've mentioned it a few times but i will use it as an example so the white goods issue
02:59:45 issue i think there was growing concern about the number of white goods involved in domestic fires from
02:59:55 from uh a period probably going back to just after um
02:59:59 after um the year 2000 2004 2005 there were there abouts
03:00:02 abouts um what really drove and gave impetus that campaign was the tragic loss of life in a couple of fires in particular one in northwest london where six members of a family died in the same fire that started in
03:00:13 died in the same fire that started in the white good and that is what gave real impetus to the sector and the work that we undertook it shouldn't like my point being that should never be the metric but unfortunately for the wider community that has interest and
03:00:24 community that has interest and investment in these things it is what brings people's attention um and it's a shame but i think it's just a it is one of those facts that's uh
03:00:34 uh it's just a fact in my experience well is that a convenient moment yes i think it is thank you well mr daily i think it's time we had a break everyone can get some lunch so
03:00:46 break everyone can get some lunch so we'll stop there we'll resume please at two o'clock and again please don't talk to anyone about your evidence thank you thank you very much
03:01:07 thank you two o'clock please