Evidence from Assistant Commissioner Daley on fire safety training pilots and Dr Sabrina Cohen-Hatton on LFB decision-making models, incident command training, and research into how commanders actually make decisions under pressure.
00:00:32 yes would you ask mr daley to come back in please
00:00:44 all right mr daily are you ready to carry on yes absolutely thank you very much yes mr miller thank you mr chairman uh mr daley as your last topic i want to ask you about something you raised last week which was the
00:00:56 week which was the fire safety training to operational personnel pilots you told us that there was a pilot developed and run at ilford and at holloway fire stations before the
00:01:07 holloway fire stations before the grenfell tower fire now i want to show you a document and please help me whether i'm right in what it is lfb3036223
00:01:23 now it's called fire safety training for station personnel 11 april 2017 uh is is this familiar to you
00:01:33 not particularly because i wouldn't have looked at necessarily the contents of the training but it looks like the training i've been talking about yes right
00:01:40 right do you think these were the slides for the pilot
00:01:43 the pilot uh i couldn't tell you because i wouldn't have delivered that but right the title would suggest so i see okay let's see how we go um if we look at the notes on the bottom of page one you can
00:01:54 notes on the bottom of page one you can see that it says this is the first fire safety training for over 10 years therefore it is aimed at a basic level which can be developed based on the amount of your interaction you don't have to remember all the detail a copy
00:02:05 have to remember all the detail a copy of this training will be left on the station and an aid memoir on all pumping appliances it will not make you fire safety experts if you are asked for advice don't guess contact your borough team for support if urgent call out a
00:02:17 team for support if urgent call out a senior sorry if urgent call out a senior fire safety officer
00:02:24 do you remember who created this training i don't know do you remember who delivered this training to the cruise at ilford and holloway
00:02:36 cruise at ilford and holloway off the top head no there was a few people that were involved in developing the pilots um group manager bailly being one um bailey bailey right
00:02:47 bailey bailey right being one but whether or not he put the package together and delivered the training i couldn't tell you for sure because it was under whose um overall supervision was this pilot run it would have been as part of the
00:02:58 it would have been as part of the service delivery improvement uh work that we were looking to undertake so be one of the dacs but again at this point i couldn't tell you which one would have had that reference in which directorate
00:03:09 which directorate it would be under the fire safety um department okay
00:03:15 right i i mean
00:03:18 i i mean i'm just slightly surprised you can't tell me more about it having raised it um
00:03:23 um only in so much as you know i gave some direction as to what it was looking for the detail of what was required was discussed in broadest terms but the actual package is not
00:03:34 terms but the actual package is not something that um i would have sat and poured over it should be delivering me the ambitions of what the pilot was there to do right do you know how the training was delivered was it a lecture was it cbt was it just i believe i
00:03:46 was it cbt was it just i believe i believe it was a lecture directly to uh those personnel at those stations for the pilots right now you won't be able to tell this from your screen but i can tell you that this document is 139 pages long
00:03:58 long 120 slides in all that's a lot of information do you know how long the trainer spent presenting this pack to the crews at ilford and holloway
00:04:09 pack to the crews at ilford and holloway so in terms of this pack particularly whether it formed part of the same thing there was a half days initial training and then a day's training set aside to go through the issues right now whether that was to deal with the entirety of
00:04:21 that was to deal with the entirety of this pack or this formed one or other aspect of those day and a half input and this went to front liners yes this was for station-based personnel yes now let's just look at the kinds of
00:04:32 let's just look at the kinds of information that this presentation includes can we first turn to page 12. [Music]
00:04:38 [Music] uh it's a slide that says regulatory reform first safety order 2005 aims of order create a single regime uh which can be better understood and administered by both businesses and and
00:04:49 administered by both businesses and and the relevant authorities to be based on risk assessment fire prevention and mitigation measures and it goes on about the need to protect relevant persons uh it's very much the thumbnail sketch um if we look then at page 13
00:05:02 um if we look then at page 13 here's a list of examples and over to page 14 of the kinds of premises to which the order applies and to those which it doesn't apply on page 3 on page 14
00:05:11 14 doesn't apply to a domestic premises as it says there and then if you look at the notes on page 14
00:05:18 page 14 underneath the slide there's a question about whether it applies to sea going vessels
00:05:27 vessels on page 16 if we go to that there's a list of enforcing authorities
00:05:36 and the notes then go on to consider who enforces the order in occupied construction sites page 17 it uh considers the interpretation of relevant terms used in the rro
00:05:47 terms used in the rro including uh domestic premises relevant persons etc and that continues all the way down to page 20 and then on page 21
00:05:58 page 20 and then on page 21 [Music]
00:05:59 [Music] there's
00:06:00 there's a slide which identifies the powers of inspectors ios and in fact i think it sets out by way of direct quotation the text of the order itself the rra itself doesn't it
00:06:12 order itself the rra itself doesn't it yes
00:06:12 yes yes now i mean i've shown you really just a dip toe here but these slides are clearly very rich in information and would have been put together with a great deal of thought but would it be fair to say that a lot
00:06:23 but would it be fair to say that a lot of this is detailed and technical almost legal information probably entirely new to operational firefighters receiving this training for the first time yes absolutely and i think one of the reasons for undertaking
00:06:35 think one of the reasons for undertaking a pilot is to understand to what extent the information is required trying to take the ambitions of the project yes i see so this is really it's experimental yes moving a little further on in the
00:06:46 moving a little further on in the presentation if we can go please to page 28
00:06:49 28 you'll see there that there's information provided about the aspects of the building which um
00:06:56 which um has
00:06:57 has [Music]
00:06:58 [Music] features
00:07:00 features page 28
00:07:01 page 28 there's a reference here to firefighting facilities which under article 38 of the rro have to be maintained in efficient working order go to page 30 there's information about dry and wet rising
00:07:13 information about dry and wet rising mains
00:07:15 mains and 31 st
00:07:17 and 31 st the same
00:07:21 and then 32 and 33 you've got firefighting stairwells high fighting stairs on 32 56
00:07:30 on 32 56 uh lifts on page 34 firefighting lifts and the 35 for the fire fighting lobby again just i've just shown you a a
00:07:41 again just i've just shown you a a selection of what's in this but again would it be fair to say that this presentation is more focused on informing uh fire station crews about what information fire safety personnel
00:07:52 what information fire safety personnel would be looking at rather than educating operational crews about what information they might come across
00:07:58 across on building visits or otherwise by way of it i think it does two things i think it sets the context under which we we operate and have a protection or fire safety role but then also gives a lot of information
00:08:11 but then also gives a lot of information that i should i would expect potentially in the feedback from the crews as part of the pilot may be deemed unnecessary for the purpose for which the pilot was developed right was part of the purpose of this pilot and therefore these slides
00:08:23 of this pilot and therefore these slides to
00:08:23 to uh
00:08:25 uh improve
00:08:26 improve uh the
00:08:28 uh the knowledge base of station-based crew um
00:08:32 um so that they would know what it was that they had to communicate to the fire safety department whenever they went on what is called 72d visits or otherwise
00:08:43 what is called 72d visits or otherwise gathering information for the purposes of compliance i think that's absolutely one of the aspects
00:08:48 aspects i think the other main driver here is as i say we
00:08:51 i say we we carry out a fairly limited number of audits with the fire protection dedicated staff that we have yet we know in london there's an enormous number of buildings to which the iro potentially applies
00:09:01 applies firefighters make up our largest section of the workforce and probably interact with that environment more than we could with a especially a small team of ios so i think the intention is to
00:09:13 think the intention is to allow us to have more eyes and ears if you like on the ground to then inform us of where there are issues and i think we always took the view or certainly i always took the view that there was the potential here for
00:09:24 there was the potential here for issues to be raised with fire safety that needn't have been um but equally outside as a learning opportunity for crews to learn what wasn't necessary but for ios to understand what
00:09:35 what might trouble or concern operational crews
00:09:37 crews um but that you know the more we did the process
00:09:41 process the more there would be a natural leveling and out an understanding of what the mutual issues are for concern but absolutely uh to help with better understand the regulatory environment the role that we have in that regard and to help inform some of the issues they
00:09:53 to help inform some of the issues they may want to include right within 72d information capture
00:09:59 what was the status of these pilots as at the 17th of uh as the 14th of june 2017 i think the training was was ongoing i
00:10:10 i think the training was was ongoing i think the
00:10:11 think the um
00:10:13 um if i remember correctly the idea at the time was that as a watch was trained they would start to undertake some of the checks rather than wait for the entire station to be trained because we were conscious there's a lot of information
00:10:24 information and it was important that you start to practice
00:10:27 practice the use of that information before it has time to to fade are you able to tell us anything about how this presentation was received by station based crews at those two
00:10:39 station based crews at those two stations
00:10:40 stations i don't have detailed feedback i know anecdotally there was some concern about the amounts of information and i think the point you've alluded to really the relevance of some of it for
00:10:52 really the relevance of some of it for the role that we wanted them to undertake
00:10:55 undertake as at the date of the grenfell tower fire did you have a view as to whether this
00:10:59 this training and these pilots had successfully increased the awareness of what the fire safety department did i think it would be very early to to
00:11:10 i think it would be very early to to make that assessment given that the training was rolling out in the earlier part of that year and would take some time to be practiced by firefighters so i don't think it had an opportunity certainly those two stations to embed the intent
00:11:23 those two stations to embed the intent and in fact the process more fully has only recently been rolled out in the last year right was it was there whether before or after the grenfell tower fire a a
00:11:34 the grenfell tower fire a a formal system for adjudicating whether this pilot was successful which got fed back to you uh there was an evaluation process carried out
00:11:46 at some point i think after about a year of operation um i think
00:11:52 i think what was the result of that i think broadly speaking again i couldn't remember the detail i think broadly speaking it was well received in terms of um firefighters
00:12:04 in terms of um firefighters overall
00:12:06 overall appetite for that bit of work and information there was uh definitely feedback in terms of the training provision in terms of content and how much and the amount of time
00:12:18 and how much and the amount of time possibly required to deliver that training and support it ongoing
00:12:24 ongoing was anybody on the nfb's operational side aware that this pilot had taken place
00:12:30 place uh i had the full support of the assistant commissioner for fire stations because ultimately this is that individuals group of staff that we were seeking to work with
00:12:41 were seeking to work with and it was a commitment that we entered into in our london safety plan so it was in full view of the wider corporate team and wider senior management team
00:12:52 management team and it would have been developed alongside the dacs and the borough commanders for those stations as well to understand that this was an ask being asked of their staff yes and did you ever report
00:13:04 their staff yes and did you ever report back to anybody for example the the deputy commissioner or to the odcb about how the pilot had gone no i don't think um in terms of where
00:13:16 no i don't think um in terms of where where we got to it took a bit of a backstep if you like because as events unfolded there clearly became other priorities for the department i think is one of the reasons why the full rollout has only happened in the last year or so
00:13:31 and looking back on it looking back on it now and i know it's a hindsight question but um
00:13:38 do you think this is a pilot that should have been rolled out far earlier than april 2017
00:13:46 i think having come into post only a year before it's quite a seismic shift it involves conversations with the rbs around our intent as well in terms of what we need to do
00:13:55 to do getting corporate support for such a different
00:13:59 different change in the way that we deliver that activity i think is important so there's a lot of stakeholder engagement to do that and developing the pilots so
00:14:07 pilots so actually
00:14:08 actually i think it was a reasonable success story to deliver something that i think i had very clear views on that something i feel that in time when we stopped doing regulatory fire safety
00:14:19 we stopped doing regulatory fire safety in the fire service broadly was a mistake
00:14:23 mistake and so it was something i was seeing and directed by now that had responsibility for that area of work well assistant commissioner you'll be glad to hear that i've come to the end of my prepared questions i'm going to ask the chairman now to
00:14:35 i'm going to ask the chairman now to call for the usual break to see if there are any questions that i have for you which i haven't asked but should have done and to see all say whether there are any any questions from uh
00:14:46 are any any questions from uh from elsewhere so i'll do that now mr chairman yes thank you well as mr militz explains today we have a break at this point
00:14:54 point partly to enable him to ensure that he's not left anything out and partly to enable other people who are following the proceedings but not here
00:15:03 here um can suggest other questions that perhaps we ought to put to you so we'll stop now
00:15:09 stop now we'll resume at half past two please okay and see if then if there are any more questions for you okay all right thank you very much
00:15:28 all right mr willett how fast you then thank you very much
00:28:56 uh right would you ask mr daley to come back in please
00:29:11 right mr daley well we'll see if there are any more questions for you good thank you yes mr miller mr daley you'll be pleased to hear that i have no further questions for you therefore it only remains for me to thank you very much for coming to the inquiry and
00:29:22 much for coming to the inquiry and assisting us with our investigations we're extremely grateful to you so thank you thank you yes well mr daily it i speak on behalf of all three of us when i say that it really has been very helpful to hear from you
00:29:33 helpful to hear from you um you've been here quite a long time and i know you've taken you away from other
00:29:37 other important matters so we're particularly grateful that you've given us so much time to to help us with our investigations thank you very much thank you very much indeed thank you
00:29:48 indeed thank you um right well you're now free to go then and uh
00:29:52 and uh thank you very much for coming thank you thank you again thank you
00:30:03 [Music] well now mr minute we have another witness i think in the wings but we need to rise from the moment just for usual uh we do mr chairman yes that would be helpful so
00:30:15 yes that would be helpful so i'm going to ask you to rise for i think 10 minutes should do it i'm going to suggest you ask the usher to come and get us when you're ready very good thank you very much very much
00:36:53 well mr minute you have another witness for us i think i do mr chairman can i please now call dr sabrina cohen hatton thank you yes
00:37:15 good afternoon dr conehan i gather you're going to make the earth yes right well there should be an old testament there to your right would you take the book in your right hand please and read the words on the screen
00:37:27 please and read the words on the screen i swear by almighty god that the evidence i shall give shall be the truth the whole truth and nothing but the truth thank you very much i'd like to sit down make yourself comfortable please
00:37:42 right there's water there if you wanted to leave it to you to pour it as you wish yes yes mr chairman thank you dr conhack good afternoon good afternoon thank you and thank you for coming to the inquiry and assisting us
00:37:53 coming to the inquiry and assisting us with our investigations we are extremely grateful to you uh as with all witnesses my questions are intended to be short and simple sometimes they're not and i'm happy to repeat them or put the question in a
00:38:04 repeat them or put the question in a different way we'll take scheduled breaks during your evidence we will take a break this afternoon even though we've started a little bit late probably in about 50 minutes or so but other than that if you want a break
00:38:16 but other than that if you want a break in any other time please let us know we can we can do that can i ask you to keep your voice up so that the transcriber who sits to your your right can get down everything you're saying also please don't nod or shake your head a yes or a
00:38:28 don't nod or shake your head a yes or a no it has to be otherwise it doesn't go onto the transcript now you've given a rule 9 witness statement to the inquiry on the 14th of may 2020. i'm going to show that to you that is lfb double 00110660
00:38:42 that is lfb double 00110660 [Music]
00:38:44 [Music] there it is can you confirm that that is its first page that's correct thank you and can we go to page 26 please there's a signature uh under the statement of truth is that your signature yes it is have you read this
00:38:55 signature yes it is have you read this witness statement recently i have can you confirm that the content of your statement is true to the best of your knowledge and belief it is are you happy for that statement to stand as your evidence to the inquiry yes i am and uh
00:39:06 evidence to the inquiry yes i am and uh there are some exhibits to the statement i think some 37 can you confirm for us that you've read those exhibits yes i have and have you discussed your evidence with anybody before coming here today only my legal advisors yes now can
00:39:17 today only my legal advisors yes now can i then ask you um some questions about first your role and your responsibilities uh you've put an awful lot into your statement and therefore what i'm going to ask you is really just by way of confirmation um you began your
00:39:28 by way of confirmation um you began your career i think in in south wales fire and rescue service in 2001 is that right that's correct uh and in south wales i think he occupied initially an operational and
00:39:39 occupied initially an operational and then a management role that's correct and in 2013 is this right you were seconded from the south wales um frs to become a member of the national operational guidance program that's
00:39:50 operational guidance program that's correct
00:39:51 correct uh now i'd i'd like you to help us understand what the function of the remet of that program was first is it right that the national operational guidance program was established in
00:40:02 guidance program was established in 2012. i believe so yes and that was a this is right a joint partnership between the chief fire officers association cfoa and local government association and the
00:40:13 and local government association and the lfb that's correct uh and is this right the purpose of the program was to create a new catalogue as it were of high quality national operational guidance to be used by all
00:40:24 operational guidance to be used by all fire and rescue services nationwide that's correct it was intended to replace extant guidance of which there was a myriad of different pieces right and
00:40:34 and yes
00:40:35 yes and i think at that time the existing suite of operational guidance materials was generally considered to be in a poor state that's correct that's what you say i think and there was a lot of material which came
00:40:46 there was a lot of material which came from different sources as you say piecemeal
00:40:49 piecemeal and inconsistencies abounded yes um now um the national operational guidance program is this right was actually hosted by the london fire brigade that's correct what does that mean hosted the london fire brigade
00:41:03 mean hosted the london fire brigade hosted the team in their building and co-funded the national operational guidance program they co-funded it they co-funded it with the chief fire
00:41:14 they co-funded it with the chief fire officer association right
00:41:17 right does that mean that during your time with the program you were physically based
00:41:24 based at union street i would work out of a number of different places nationally we would come for meetings in union street however as a member of one of the programmes i was formally seconded to
00:41:37 programmes i was formally seconded to london fire brigade as part of the process of being a second e to the national operational guidance program right
00:41:43 right now you say in your statement there's no need to go to it but it's paragraph six uh that you led core elements of the program by drafting elements of the um the new incident command guidance that's
00:41:54 the new incident command guidance that's correct and also acting i think as lead author of the command skills guidance that's correct um now the incident command guidance that you're referring to i think is this right was it eventually published in july 2015 that's correct right and would
00:42:07 july 2015 that's correct right and would it be right to say that parts of the guidance that you were responsible for drafting
00:42:12 drafting were those parts that related to the research that you've described in paragraph 6
00:42:17 very briefly about the decision-making process of incident commanders that was a component of it i led on a section that looked at command skills in its entirety right so non-technical skills
00:42:28 entirety right so non-technical skills and the human factors that would affect the way an incident commander would apply the process of incident command i see um and maybe i'm oversimplifying it but and if i do um let me know but but does that mean
00:42:39 does that mean basically how incident commanders make real decisions at real life events in real time
00:42:45 real time broadly along with elements such as leadership and communication situational awareness etc
00:42:53 now i think you were then seconded to the cfoa to lead a research program into the psychology of incident command weren't you that's correct and did that's the comment take place while you were still working at um incident on
00:43:04 were still working at um incident on incident command nog there was an element of overlap yes because of the publication timelines and what were the dates of the overlap um the dates of the overlap would have been
00:43:15 the dates of the overlap would have been around the end of the of 2014 the last eight months of 2014 i believe so
00:43:26 so some eight months seven months perhaps before publication of the nog approximately yes and eight months before the the future of incident command paper that's august 2015 right now we're going to come on to the detail
00:43:38 now we're going to come on to the detail of your research with the cfoa shortly but just putting it again very simply for the moment would it be right to say that that further research sought to test the efficacy of
00:43:49 sought to test the efficacy of goal-orientated training in improving incident command does decision-making processes and incidents in short yes yes in short
00:43:58 in short so it builds on the research you carried out i think before during your succumb to the nog that's correct the initial research informed the development of the decision control process the second program of research that was sponsored
00:44:09 program of research that was sponsored by cfoa tested it right
00:44:16 yes i see now following that research work you i think moved to the nfb that's correct uh and you then i think we're employed is it was this full time as dac yes i moved to london fire brigade in
00:44:27 yes i moved to london fire brigade in february 2015 as a deputy assistant commissioner yes and following a three-month three-month induction i think you then became head of development in june 2015. yes now
00:44:38 now just on that um i just want to ask you one or two questions about the role and how that fits into the broader structure as we understand it to be of the lfb at the time
00:44:48 the time is head of development the same thing as head of learning development and strategy or lds no i believe there were some differences there wasn't a head of learning development and strategy when i moved
00:44:59 development and strategy when i moved into that position i believe there'd been several restructures so the areas that i was responsible for as the head of development were personal development and also organizational development
00:45:13 right and how did that differ from learning development and strategy i wasn't employed in the london fire brigade when they had that post in place so i'm afraid i'm not best placed to answer how
00:45:24 afraid i'm not best placed to answer how it would have differed precisely does that mean that the role of ls lds had disappeared by the time you joined i believe so are you referring to the role that was previously occupied by
00:45:36 the role that was previously occupied by dac kevin hughes yes yes that was some time prior to my joining london fire brigade there was no head of development when i initially joined it was a new position right so i'm afraid i'm not i'm not able to compare and contrast the
00:45:47 not able to compare and contrast the previous uh position because of the restructures to whom did you report in your role as head of development peter groves peter graves now you say in your statement that your responsibility in that role included leading the personal
00:45:59 that role included leading the personal and operational development directorates which i think within which was a team that acted as a like a conduit between nfb departments the commission training
00:46:10 nfb departments the commission training and the external training provider is that right yes but it was the uh organizational development i think you said operational i think that was a mistake it's organizational development uh it was me misreading my name personal
00:46:22 uh it was me misreading my name personal and organizational development that's correct nah um the external provider was babcock i think yes that's correct there's nobody else now when you refer to the team that acted as the conduit between the lfb and babcock
00:46:33 between the lfb and babcock is that right is it right that that was the team that managed the process under which new training was requested by the lfb that's correct they would provide the conduit between the commissioning department who would request the training and babcock so they would act
00:46:45 training and babcock so they would act as the project managers effectively what was the name of that team that was personal development that was personal development right and to be clear is the process that you just described
00:46:56 process that you just described um that
00:46:58 um that we've seen referred to in various training documents uh known as tcap the training commissioning and alterations process yes that's correct right and would it be right to say that you or your team at least you from february
00:47:11 your team at least you from february um 2015
00:47:13 um 2015 uh oversaw that process from start to finish that's correct right now in march 2016 you say that you were appointed as north west area dac at the lfb
00:47:25 west area dac at the lfb that's correct yes was that a role that you fulfilled alongside your training and development related role or did that role the training and development role stop when you became northwest area dac
00:47:36 stop when you became northwest area dac no that role stopped although i did continue to lead the revalidation program
00:47:43 program or the development of the revalidation program yes and we're going to come to that later on your evidence in june 2017 very shortly before the grenfell tower of fire i think you were
00:47:54 grenfell tower of fire i think you were made dac of the operations review teams that's correct also ought and that included as i understand it governance of the diot system the dynamic intelligence operational
00:48:05 the dynamic intelligence operational training system yes that's correct yes and after the grenfell tower fire november 2017 i think you were then seconded to her majesty's inspectors of constabulary and fire and rescue services yes that's right right
00:48:17 services yes that's right right now since that time you i think have left the nfb completely haven't you that's correct and you are now currently chief fire officer of the west sussex fire and rescue service that's correct
00:48:28 that's correct now i think also standing back from fire brigades is it right that during your career you've also achieved a number of higher educational qualifications including a phd in psychology that's correct
00:48:40 psychology that's correct and i think you've also been awarded a number of honorary research associate ships uh and fellowships at cardiff university yes yes that's correct and
00:48:50 and uh exactly two years ago last week i think on the 29th of september you were a guest on bbc's desert island discs is that right that is correct we can hear some more about your career and your experiences on that
00:49:01 your experiences on that um now um research undertaken during the nog review i just want to ask you about that and first of all decision making models within that um i want to ask you about the research
00:49:12 um i want to ask you about the research you carried out while you were seconded to the nog program which as you've confirmed was from 2013 yes that's correct um if we just look at your statement please
00:49:24 if we just look at your statement please and go to page six lfb double zero double one zero six six zero page six paragraph 25 uh you've got a heading research undertaken during energy review
00:49:36 undertaken during energy review and you uh say there that uh you you propose that research should should be undertaken in conjunction with cardiff university whereby data would be collected from a range of fire and rescue services on how
00:49:48 range of fire and rescue services on how incident commanders made decisions in line with the extant models i led the research team that accompanied incident commanders for 24-hour periods over six consecutive days for a period of six weeks we recorded footage of the entire
00:50:00 weeks we recorded footage of the entire incident from the perspective of the incident commander using helmet cameras we developed a cognitive interview which we performed on incident commanders following their attendance at incidents along with psychometric tests the
00:50:11 along with psychometric tests the research team then analyzed the data and drafted a research paper on the responses of incident commanders
00:50:19 [Music]
00:50:23 now you had actually already i think um done some research on the decision-making model that was the initial research on the decision-making model that was the
00:50:34 decision-making model that was the result the initial research yes and that research on the decision-making model which i think you refer to paragraph 25 was on the is this right was on the effectiveness of normative models of
00:50:45 effectiveness of normative models of decision making yes that's correct of which the decision-making model was effectively a normative uh decision-making model could you just explain to us what a normative
00:50:56 you just explain to us what a normative model of decision making is of course normative decision-making models assume that decision-making is made in a very linear way for example an individual would assess a situation
00:51:07 an individual would assess a situation and gather information that way and then develop a plan and then execute a plan there were many examples of normative decision-making models but it would assume that the decision maker was
00:51:18 assume that the decision maker was effectively evaluating the course of action and choosing the most optional at the most optimal upon me yes so the research on the effectiveness of normative models was a part of the
00:51:29 normative models was a part of the development of the nog uh that was eventually published in july 2015. yes
00:51:34 2015. yes now when that happened when it was published am i right it was issued alongside very shortly before a different report by the cfoa called the future of incident command yes
00:51:45 the future of incident command yes that's correct the uh roy wilshere who was at the time the director of operations for the chief fire officer association wrote to all chief fire
00:51:56 association wrote to all chief fire officers to note and uh and to note the content of the future of instant command report and to say that there was an expectation that the uh national operational guidance for instant command
00:52:08 operational guidance for instant command would be adopted by the first of january 2016. right and um uh we'll we'll come on in some detail to that document but let's just um let's look at it lfb-00118236
00:52:22 [Music]
00:52:28 there's the first page you can see the date august 2015 uh
00:52:32 2015 uh and i think i'm right in saying that it explains some of the background to the revised guidance including some of the issues that had led to your own research that's correct uh can we go to page nine
00:52:44 that's correct uh can we go to page nine please and look at the first paragraph on page nine on page nine there's a heading catalyst for change national operational guidance for incident command literature review
00:52:55 for incident command literature review you see and um that then um refers to a review comprising documents reports and reviews of critical incidents both within the fire and rescue sector and i
00:53:06 within the fire and rescue sector and i think other industries now i think that's the same literature literature reviews this right to which you refer in your statement as having been carried out by group manager philip
00:53:17 been carried out by group manager philip butler of the lfb yes that's correct now any new incident command national operational guidance reflected and took account of the important lessons learned from those
00:53:29 important lessons learned from those incidents yes that's correct yes and i think i'm right in saying that group manager butler or phil butler as the case may be went on to work with you in the research that you then carried out relating to decision making at cardiff
00:53:40 relating to decision making at cardiff yes that's correct now going back to this report looking at the first paragraph can we just pick it up uh about halfway down the text where it
00:53:53 uh about halfway down the text where it says this literature review and it says this this literature review confirmed
00:53:58 confirmed human factor failures human error can impact on all elements of incident command an absolutely critical need was highlighted for the revised guidance to emphasize the importance of command
00:54:09 emphasize the importance of command skills in particular situational awareness and decision making it was important to consider both people and processes to improve incident command in the operational environment
00:54:20 the operational environment um now just to be clear when the report speaks of human factors would it be right to say that that's a term given to human characteristics or skills as
00:54:31 human characteristics or skills as opposed to technical knowledge or technical skills which may influence operational performance on the fire ground yes that's correct yeah now can we go to paragraph 24 of your statement we'll come back to this shortly can we
00:54:43 we'll come back to this shortly can we go to paragraph 24 of your witness statement and you refer to your own research there and you say um uh in the second sentence command skills are non-technical skills
00:54:55 skills are non-technical skills considered necessary to act effectively as an incident commander examples of command skills include situational awareness decision making communication leadership and resilience
00:55:07 leadership and resilience now um
00:55:11 basically that's the same isn't it as human factors yes those are the human factors
00:55:17 factors it would be right to say that decision making is is one aspect of the of human factors
00:55:22 factors uh that plays a central role in how effectively individuals are able to perform in a command role yes that's correct right now um if we go to page 10 of the future of incident command report
00:55:35 incident command report you can see that there's a summary of
00:55:40 of the literature review which i think included in relation to incident command's decision making specifically uh a number of features if you go down the page to the third subheading review
00:55:52 the page to the third subheading review of incident command decision making it says this
00:55:57 says this uh the literature review identified that the area of psychology of incident command and in particular operational decision making needed to be expanded significantly in the refreshed national operational guidance there were a number
00:56:10 operational guidance there were a number of issues identified in relation to decision making the predominant criticism is that it was not prominent enough in incident command manual cfaru 2008 given its critical nature
00:56:22 2008 given its critical nature for incident command now 2008
00:56:26 2008 the incident command manual of that year was was i think is this right was what the new incident command national operation guidance of 2015 was intended to replace yes that's correct and to
00:56:37 to replace yes that's correct and to summarize it is this right what the literature review discovered was that the 2008 manual didn't sufficiently emphasize the importance of decision making as a critical concept in relation to incident command yes that's
00:56:49 relation to incident command yes that's correct amongst other command skills amongst other command skills including the human factor yes that's correct yes i see and was it uh considered important that the new incident command energy
00:57:01 that the new incident command energy should consider the concept of decision making
00:57:04 making in more detail including the human factors yes that's correct the primary issue with the previous national operational guide or the previous incident command system as you were was the fact that it was very focused on
00:57:16 the fact that it was very focused on process and omitted to consider how people might interact with those processes and how they might effectively work in practice yes i see and was that why you carried
00:57:27 yes i see and was that why you carried out your research that you did during your secondment to the nag yes there was very little work on human factors that had been undertaken in the fire and rescue service there was lots in other industries but very little in the fire
00:57:39 industries but very little in the fire and rescue service and although those skills might be common across various industries the context is important so we felt it important to explore those in more depth within the context of the
00:57:50 more depth within the context of the fire and rescue service in which they'd be applied yes i see now can we go back to paragraph 25 of your statement uh on um page six
00:58:01 uh on um page six and you say there that as part of the research we consider the effectiveness of normative models such as the egg stand decision making model dmm and you want to explain as you have just
00:58:13 and you want to explain as you have just now what the normative model is and paragraph 27 if you turn the page what you say there is such models assume
00:58:24 uh
00:58:27 rather a long paragraph but it's the fourth line down such models assume that decisions are made analytically where options are considered evaluated and activity as planned and if we look then at your paper
00:58:39 and if we look then at your paper following your research we'll find that lfb00110667
00:58:45 [Music] let's go to that
00:58:51 um here's the title an investigation of operational decision making in situ incident command of the uk fire and rescue service and you can see the three authors there
00:59:02 and you can see the three authors there of which you are the first we'll come back to the specific findings in your research and and your article um later on but just for the moment in
00:59:13 later on but just for the moment in relation specifically to the normative model of decision making can you go to the bottom of page one if we can scroll down to that and look at the right hand column
00:59:26 and note on the left hand side that the date of this is august 2015 so the same month as the incident of future command cfoa paper
00:59:37 paper and on the right hand side it says reflective models of operational decision making and it says dewey 1933 argued that when people solve problems they do so in an
00:59:48 people solve problems they do so in an analytical and rational way that proceeds according to an orderly sequence of phases these ideas are echoed in normative models of decision making that typically identify three key phases
01:00:00 identify three key phases situation assessment essay plan formulation pf and plan execution pe and to summarize it you then go on to to
01:00:12 and to summarize it you then go on to to say that that normative three-phase model can be detected in the then current
01:00:17 current decision-making model uh adopted in the fire and rescue service incident command system current in in the um in the united kingdom that's correct i mean i'm summarizing it
01:00:29 that's correct i mean i'm summarizing it um that's a third of the way down that column um
01:00:33 column um is that a reference to the 2008 incident command manual we've just referred to yes it is right now if we can look at that manual the 2008 manual in fact you do actually refer to that you say cfra
01:00:45 do actually refer to that you say cfra 2008. let's look at that that's uh at smc
01:00:50 smc 6013
01:00:54 let's just look at the first page to make sure we're talking about the same thing
01:00:58 thing that's the document yes it is and if you go to page 18
01:01:05 um you can see on that page on in the right hand column 1.9 incident management and decision making and what that says in the second paragraph is this
01:01:17 paragraph is this and there's a description of
01:01:21 the processes in the first paragraph and then it says however such a description of the cognitive processes is not a tool in the search for a device to practically assist commanders in the discharge of their responsibilities
01:01:33 discharge of their responsibilities experienced officers have reported the value they have derived from the decision-making model developed by the london fire brigade see figure one overleaf
01:01:41 overleaf and we're going to come to look at the lfb's dmn or decision-making model in more detail shortly but at the moment if we could just look at the figure that's reproduced on the next page of the 2008 manual there it is would it
01:01:55 of the 2008 manual there it is would it be right to say that the three vertical bars
01:01:58 bars in red in red and purple or blue and red reflect the three stages of the normative decision-making model that you've described in your paper in
01:02:09 you've described in your paper in essence yes in essence let's say just to be clear about this to explain it think is in which is in red is that situation assessment yes so you take into account the information outlined on the left
01:02:21 the information outlined on the left side of the diagram in the blue boxes yes yes so resources incident hazards and then you think about it and then you prioritize objectives and then you plan that's the plan formulation is it yes pf
01:02:34 that's the plan formulation is it yes pf yes yes yes and then outcome um is in red is plan execution the communicating control element is the plan execution and the outcome would be the the outcome of that but in essence
01:02:46 the the outcome of that but in essence yes your section's correct i follow i follow
01:02:50 i follow so to to put it into the three-stage language
01:02:53 language uh think is essay plan is pf plan formulation and communicate communicate and control is planned execution precisely right so
01:03:05 is planned execution precisely right so in fact the three stages are actually red
01:03:08 red blue and then the two yellow boxes yes right
01:03:11 right now
01:03:12 now okay uh it looks as if the 2008 incident come on manual was essentially endorsing this normative linear approach to decision making is am i right yes
01:03:23 to decision making is am i right yes i'm sorry
01:03:25 i'm sorry the word normative has been used quite a lot
01:03:28 lot um it used in this context to mean um not quite prescribed but um standardized method or approved method something along those
01:03:39 approved method something along those lines uh commonly assumed yes it was the commonly assumed belief that decision-making would happen in that very rational way but normative suggests
01:03:50 but normative suggests something that's controlling not normal but normative by setting a standard is that right i i think it was more as in a normalized
01:04:01 think it was more as in a normalized approach to it so a more assumed approach would be that it would happen in those three distinct phases in a very rational way yeah
01:04:11 yeah that it would or should uh that it would it was assumed that that described how decision making happened and the literature at the time when it was analyzing the way decisions were were made it was done according to
01:04:24 were were made it was done according to that psychological premise yeah right thank you very much
01:04:29 so yeah your psychological premise is an interesting way perhaps an insight into the
01:04:35 the answer to the question that the german asked
01:04:38 asked norman is it right normative doesn't denote or connote any sort of designed process but
01:04:46 but um a a a collection of the way people are regarded as doing things in terms of a normative model yes this particular model as described by the instant command manual at the time was
01:04:58 instant command manual at the time was the model that people should have been expected to have been using when they were making decisions on the instant ground it was the the extant tool for making a decision
01:05:10 the extant tool for making a decision and as such it was very often the tool that was used to judge the efficacy of someone's decision following the outcome of that event and the underlying assumption in the
01:05:21 and the underlying assumption in the tool is that a normative approach would be taken in other words a linear and rational one yes yes i see um
01:05:29 um your paper points out i think we'll just go back to it please
01:05:34 please zero double one zero six seven six six seven page two left hand column we look at the lower down the page scroll to the bottom
01:05:45 scroll to the bottom left hand column uh last sentence however you see what it says it says however the fact that the normative model which is what we've just been looking at is embedded within training and operational
01:05:57 embedded within training and operational guidance need not mean that it represents how decisions are made in practice
01:06:03 practice so is it right in fact that since the 1990s in fact further research on decision making has been carried out and that more recent research supported alternative models for the way in which
01:06:14 alternative models for the way in which decisions could be made or should be made yes that's correct right specifically is this right the the the research had shown
01:06:23 shown that decisions can also be seen to have been made on a much more reflexive basis drawing on intuitively on past experience and what that incident commander happens
01:06:35 and what that incident commander happens to know
01:06:36 to know rather than acting
01:06:39 on an analytical assessment of possible options before formulating an explicit plan yes that's correct around 80 percent of the time we found that to be the case when people were making decisions on the incident ground
01:06:51 decisions on the incident ground i see so you put it in other ways is it right that your research showed you that the normative model in the 2008 uh cfra
01:07:02 cfra uh was all very well but that's not how people worked in practice yes that's correct but could it could it be suggested that what
01:07:11 what we might in common partners called intuitive decision making is actually just short-circuiting the rather more um
01:07:18 um analytical approach to decision-making in other words you you see something you react to it because of previous experience and the whole the process in a sense
01:07:30 and the whole the process in a sense um
01:07:32 um encapsulates obtaining information processing it and deciding it but all as one part of one intuitive
01:07:40 intuitive decision yes that's one way of describing it there were two ways in which you might predominantly use a very intuitive process one is precisely as you described called recognition primed
01:07:51 described called recognition primed decision making where an incident commander will have previously experienced something similar and will have
01:07:58 have essentially a prototype in their in their mind that they would move to that would mean they would short-circuit that they'd be operating on a bias essentially and taking an action based on what they've previously experienced
01:08:11 on what they've previously experienced in those circumstances we know that instant commanders are choosing an option that is satisfactory as opposed to optimal however the other mechanism that might depend it might the other mechanism that might
01:08:22 it might the other mechanism that might underlie it is something that is more based on associative learning mechanisms so it might be something that is even more reflective where a particular cue in the environment might buy us a response directly to a particular
01:08:34 response directly to a particular outcome or a particular response well presumably you can get bias if we want if we're going to use that word though it's rather loaded in any form of decision making because
01:08:45 in any form of decision making because even your analytical normative process is susceptible to taking a certain view of each
01:08:52 of each previous stage but it strikes me at the moment that the reflexive or intuitive approach is not actually entirely at odds with the normative approach it's just
01:09:04 the normative approach it's just um telescopic and i should say when i refer to bias i'm referring to cognitive bias because of the previous experiences that you might have had um in some respects it might be considered as short-circuiting that but of course
01:09:16 short-circuiting that but of course that's basic that's that's assuming that the plan formulation stage will have happened at some time where actually what the incident commander might be doing is recognizing a situation and recognizing an outcome that was
01:09:28 recognizing an outcome that was previously associated with that so the plan formulation may or may not be implicit in that circumstance and of course it might be the appropriate response for that particular cue in the
01:09:39 response for that particular cue in the environment but given every environment is different and every every incident will be novel it may have unintended consequences for the rest of the situation should that option be selected
01:09:52 situation should that option be selected right
01:09:53 right sorry to interrupt you mr military interesting ground yes uh yes um now um can i then go back to the future of incident command uh august 2015 we looked at earlier
01:10:04 2015 we looked at earlier lfb double zero double one eight two three six page fourteen
01:10:13 uh and um here we here we have uh quite a lot here about intuitive reflexive components of decision making and i i i fear i should read this to you
01:10:24 and i i i fear i should read this to you just so that everyone can see what i'm asking you about it says this whilst the kind of analytical reflective models of decision making represent one way in which decisions can
01:10:35 represent one way in which decisions can be made it has also been argued that they do not capture how decisions are often made in the real world environment klein 1993. instead decisions are often influenced by various biases and involve the use of heuristics including those
01:10:48 the use of heuristics including those based on previous experience for example gigarensa 2007 shafir 1994 tversky economy in 1979 i think it should be 1974 actually
01:10:59 i think it should be 1974 actually [Music]
01:11:01 [Music] also cues in the environment in this case at an incident can prime knowledge structures that include actions goals and expectancies previously related to that or similar environments for example
01:11:12 that or similar environments for example recognition prime decision making decline 1993. in such cases various options are not necessarily evaluated against one another but rather the decision to act might be one that is deemed to be satisfactory rather than
01:11:24 deemed to be satisfactory rather than optimal now this is the point i think you were making to the chairman just now yes that's correct and that's abernathy and ham and klein uh alternatively the basis for an action might be more reflexive as opposed to reflective and
01:11:37 reflexive as opposed to reflective and automatic uh affected by previously established associations that have developed between their situational cues actions and outcomes doyer 2008 these acquired associative influences can
01:11:48 acquired associative influences can easily generalize across situations that affect behavior in a variety of ways for example ballen and ausland 2007 conhatton george hadn't honey 2013 dickinson 1980. these more reflexive
01:12:02 dickinson 1980. these more reflexive influences might or might not be appropriate to the given operational environment nevertheless they could exert a powerful influence over incident command
01:12:13 now just pausing there that passage in this paper the future of incident command is lifted i think uh almost verbatim from your
01:12:25 i think uh almost verbatim from your article of the same month wasn't it yes it's very similar i mean there are one or two transcription errors for example the title of your joint 2013 article is the wrong way around i think
01:12:37 article is the wrong way around i think and uh the date of the tversky and hanuman classic is 1974 or not 1979. but leaving aside those little uh inconsistencies my question i'm afraid is a bit of a
01:12:48 my question i'm afraid is a bit of a blunt one did the cfoa ask to crib your work
01:12:53 work i wrote this report right so you cribbed your work i cripped my words right continuing whilst uh such processes were acknowledged in the psychology of incident command appendix in the
01:13:04 incident command appendix in the incident command manual cfaru 2008 they are not reflected in the dmm which represents an analytical and reflective processes
01:13:15 and reflective processes this would require relatively slow time reflective and conscious deliberation in order in order prioritizing objectives or tactical planning which may not always be feasible in a dynamically
01:13:26 always be feasible in a dynamically changing high pressured and high risk operational environment now is it right therefore that by the time you came to be seconded to the national operational guidance program to work on incident command guidance as
01:13:39 work on incident command guidance as you've explained would it be right to say that there was already a body of thinking out there that recognized that
01:13:47 that the traditional normative decision-making model involving explicit situation assessment plan formulation and plan execution may not in fact reflect uh how decisions are made in reality yes
01:13:59 uh how decisions are made in reality yes that's correct and some of that was reflected in appendix 4 i believe to the
01:14:06 the national incident command manual in the psychology of incident command appendix which outlined a a small piece of material looking at recognition prime
01:14:17 material looking at recognition prime decision making but that had not translated into the decision-making model
01:14:22 model no
01:14:24 no we may come to that indeed but thank you am i right in thinking also just taking it in stages that the more recent research didn't tend to be based on operational decision making in the fire and rescue sector it came from elsewhere
01:14:37 and rescue sector it came from elsewhere the majority of research had come from elsewhere there was some that was based in the fire and rescue service how uh predominantly klein's work gary klein's work however that was based on
01:14:48 work however that was based on retrospective interviews sometimes carried out sometime after the event which obviously relied on people's memory as opposed to collecting data when it was happening and i think also simulations correct yes
01:15:01 simulations correct yes uh
01:15:04 can we go to page 12 i think we see that summarized in fact in this paper a little bit earlier on if we go to page 12 and look at the third and fourth paragraphs on that page
01:15:15 paragraphs on that page uh i i think the point you've just made is is reflected there whilst there is a large body of work looking at general decision making processes there is a relatively limited amount conducted into operational
01:15:26 amount conducted into operational decision making with fire officers although the mental processes may be similar the way in which they are implemented can differ according to the task and the context hence most safety critical industries explore these
01:15:38 critical industries explore these processes in the industry environment you know june 2015 there is comparatively little research conducted within the operational fire and rescue context which leaves a gap in
01:15:49 and rescue context which leaves a gap in our knowledge relating to how these processes might affect us during incident command and then the next paragraph essentially tells us what you've just told us the small amount of research that does
01:16:00 the small amount of research that does exist is limited to either simulations or interviews after an incident client called the word mcgregor these studies can provide only relatively distant clues about decision-making at emergency incidents
01:16:11 decision-making at emergency incidents and you go on it goes on to say critically many of these studies rely on the accuracy of participants memory for events etc did you did you write this part of the document yes i did you did
01:16:22 part of the document yes i did you did now the research that you intended to carry out
01:16:25 carry out sought to plug the gap that we've identified here is that right yes that's correct
01:16:30 correct uh uh and in in the sense that you you were intending to follow fire and rescue incident commanders as they attended real life incidents monitored their decision-making processes in real time as a sort of controlled experiment yes that's correct
01:16:42 controlled experiment yes that's correct i see and would it be right to say that your
01:16:45 your your rationale for for carrying out that research was in order to um
01:16:51 um uh it was well to say that incident command nog which would then be reflected in policy at local level and nationwide training should properly you i say properly
01:17:02 should properly you i say properly realistically reflect
01:17:05 reflect the way operational personnel in fact make decisions on the ground in real time it was partly an intention to do that and partly an attempt to find techniques to support those decision-making processes
01:17:17 decision-making processes to support them yes techniques to support them can you just explain what you mean by that yes in terms of the decision control process the implementation of the decision controls in particular
01:17:28 controls in particular were aimed at helping incident commanders when they were making decisions to help to avoid some of the decision traps or the unintended consequences of those reflexive decisions that we saw was so often used
01:17:40 decisions that we saw was so often used i see we'll come to the decision trap very shortly um before we come to the detail of your research that you carried out as part of the nog program i just want to look at the model
01:17:51 program i just want to look at the model itself
01:17:52 itself that was
01:17:54 that was i think the case at the time of your research and remained the case on the night of the 14th of june 2017. we've you've told us that the decision-making model is an example of a
01:18:05 decision-making model is an example of a normative decision-making model um could you just i think you confirm that that is so yes um let's look at it uh it's at lfb lfb 50238
01:18:19 it's policy number 341
01:18:25 and this is the version viewed as current on the 27th of november 2014. so it was can be taken that this was the this was the um the policy that you were
01:18:36 this was the um the policy that you were examining for the purposes of the national operational guidance program work you were doing yes now um if we go to page two we can see that there's a diagram which
01:18:47 we can see that there's a diagram which sets out the process i think in a single image is that right yes um and if we look at that i won't describe it everyone can see it but if we go to the next page
01:18:59 but if we go to the next page we can see under introduction it says this policy introduces the decision-making model as a tool for dynamic risk assessment dra the model provides a framework for decision making for any task or event as
01:19:11 decision making for any task or event as discussed in policy number 342 dynamic risk assessment every individual requires the skills to apply its principles in order to control the risks associated with an activity the decision making model is therefore applicable to
01:19:23 making model is therefore applicable to all
01:19:24 all bold personnel at all levels and then if we turn to page four [Music]
01:19:32 [Music] we can see paragraph 2.1 under the heading the decision making model the dmm is formed around two main activities deciding and acting each stage identified in the model falls into
01:19:44 stage identified in the model falls into one of these activities and then if you look at the um
01:19:49 um deciding part uh
01:19:52 uh that's got elements of situational awareness i think is that right yes so if you look at the first bullet point under deciding you've got gathering and thinking about all available information
01:20:03 thinking about all available information followed by elements of plan formulation identifying appropriate objectives defining a plan yes yes and then under the acting part you've got
01:20:14 you've got communication communication control and evaluation and and um they all relate to the activity that's being done yes yes
01:20:25 yes yes so
01:20:26 so uh
01:20:28 uh i just want to ask you about the planning stage under this model the dmm now that's on page 9 of the policy over to page 10. can we just go there
01:20:41 the plan [Music]
01:20:45 [Music] now what what once is it right that once you get to this
01:20:50 this stage the decision maker is supposed to have gathered the relevant information and used that information to identify a series of objectives that need to be achieved yes and if you look at paragraph 9 1 it says
01:21:03 and if you look at paragraph 9 1 it says this stage in the process requires that prioritized objectives be developed into plans that are achievable and take into account the need to reduce any risk to acceptable levels would it be fair to say just on what
01:21:14 would it be fair to say just on what i've shown you so far dr cohn hatton that this part of this policy doesn't actually provide any guidance
01:21:22 guidance to how a decision maker might actually go about formulating a plan at all that's correct it simply tells you that the plan should be achievable should reduce risk to an acceptable level and
01:21:34 reduce risk to an acceptable level and if you go to the page you'll see this at 9-4 should be designed to deliver the required outcomes
01:21:42 yes
01:21:45 is that because it's it's just not possible to formulate universal guidance for how an operational plan should be put together i think that it is possible to provide
01:21:58 i think that it is possible to provide more guidance than this and in the decision control process that element of plan formulation was unpacked slightly to reflect operation to reflect objectives so those primary
01:22:10 to reflect objectives so those primary objectives that you would come up with in your incident plan but then also to consider your tactical priorities and then the operational tactics that you would use to enable you to achieve that
01:22:23 would use to enable you to achieve that so there was an attempt to unpack that further to provide more support to decision makers when they were making a decision
01:22:30 decision during incident command right
01:22:34 right [Music]
01:22:36 [Music] my question was slightly different i mean maybe mine was over simple but it is the problem that you can't really formulate on paper universal guidance as
01:22:47 formulate on paper universal guidance as to how a plan an operational plan should be put together because it would depend on what was in front of you the situation yes there are some principles that would be helpful but you're correct that there
01:22:59 be helpful but you're correct that there are so many variations that it would be very difficult to pre-prescribe a plan that would meet the needs of every potential incident that you might come to right but but you also think you're
01:23:11 to right but but you also think you're just trying to make just trying to unpack your answer or perhaps repack your answer was it in fact the problem that it was it was possible to give generic guidance as to how to formulate a plan but the problem was
01:23:23 formulate a plan but the problem was that this policy just didn't do it um i think part of the i think an additional part of the issue was that that wasn't reflecting the reality of how decisions would be made
01:23:34 reality of how decisions would be made therefore it would only reflect a very small subset of the decisions that were being made as well let's look at the related policy that's referred to here before we go further and that's the dynamic risk assessment
01:23:46 and that's the dynamic risk assessment that's at lfb uh five two three eight [Music]
01:23:55 [Music] i'm sorry i i i've already read this to you i don't think we're looking at the policy itself but
01:24:01 but there's a reference back to page one on of that policy in this policy if we go to page two paragraph one point one sorry page
01:24:12 two paragraph one point one sorry page three paragraph one point one i've shown you this it refers to the dynamic risk assessment policy can you just tell us in simple terms
01:24:23 can you just tell us in simple terms what you understand a dynamic risk assessment at least the one captured by the dynamic risk assessment policy 342 to be
01:24:34 risk assessment policy 342 to be certainly a dynamic risk assessment would essentially help you to identify the hazards that you might come across and the risk that they might pose or the likelihood of them posing a risk
01:24:45 likelihood of them posing a risk and then the opportunity to consider how you might be able to control those measures what you might be able to do to reduce that risk of happening to determine whether it was safe to proceed or not in an incident command capacity
01:24:58 or not in an incident command capacity we would use a dynamic risk assessment in particular to ascertain whether it was safe to proceed to put firefighters into the risk area in which case it
01:25:09 into the risk area in which case it would inform your tactical mode as offensive or whether the risks were too great and you weren't able to commit firefighters into that risk area yet which would then make it a defensive tactical mode so the outcome of the
01:25:21 tactical mode so the outcome of the dynamic risk assessment itself would inform your tactical mode specifically i think i see that but would it be right to say that a dynamic risk assessment involves
01:25:30 involves a process whereby the incident commander gathers evidence continuously through the incident in order to devise a plan and revise the plan that takes into account particular circumstances and hazards as they change
01:25:42 circumstances and hazards as they change yes
01:25:43 yes and can you explain then how the decision-making model relates to the dynamic risk assessment as a policy or as a as an idea uh in short terms the dynamic risk
01:25:55 uh in short terms the dynamic risk assessment would be something that you would do alongside the decision-making model as it was outlined here that would help to inform the the action that you would take
01:26:06 action that you would take they are separate in the national operational guidance that we produced the decision control process which replaced the the decision-making model and the dynamic risk assessment elements were separate
01:26:17 risk assessment elements were separate within that all people on the incident ground would be able to make a dynamic risk assessment to ascertain how safe the environment was that you were going into
01:26:28 environment was that you were going into or operating in whereas these decision making model or the decision control process laterally would be a tool that would be used by the incident commander in deciding their that how they would proceed with the incident more more
01:26:41 proceed with the incident more more generally
01:26:45 right [Music]
01:26:48 [Music] let's then look at the dynamic risk assessment policy now which is lfb 650236
01:27:00 and it was the one as issued in august 2016 as current and if we go to page two you can see the key point summary there
01:27:14 and
01:27:17 if uh you then go to page eight you could see the concept of operational discretion at section six operational discretion and paragraph 6.1 says this due to the fast-moving and varied nature of fire
01:27:28 fast-moving and varied nature of fire service operations it is not possible for the authority to provide explicit guidance that will satisfactorily cover all situations on the rare occasion that operational guidance does not meet the needs of the incident ics can adapt or
01:27:40 needs of the incident ics can adapt or move away from an operational policy where this is necessary and justifiable in terms of risk versus benefit now does the reference to operational guidance there include the decision-making model
01:27:57 sorry in which in the third line in paragraph 6.1 of this policy which is the dynamic risk assessment policy oh i see i think the reference in this
01:28:08 i think the reference in this line in particular when it talks about operational guidance they're relating that to
01:28:13 that to standard operating procedure so a policy that might be applicable to a particular incident type as opposed to the national operational guidance for incident command oh i see
01:28:24 oh i see so like grasslands yes so it might be that that applying that particular piece of policy in its entirety might uh inhibit your ability to resolve the incident or
01:28:35 your ability to resolve the incident or the incident itself might be so
01:28:39 so so rare that you don't actually have a standard operating procedure that's appropriate for that right um
01:28:46 um i see um
01:28:47 i see um we saw a reference to discretion more generally um
01:28:52 um would it would an incident commander use the dynamic
01:28:58 use the dmm itself to decide when to depart from it or would he use the dynamic risk assessment uh he he or she would use either one of those
01:29:09 either one of those the dynamic risk assessment would allow you to identify whether it was safe to proceed or not the decision-making model as it is in london would uh should help you to
01:29:20 london would uh should help you to develop your incident plan but actually in reality the situation that you're faced with would enable you to identify whether there is an applicable policy or
01:29:31 whether there is an applicable policy or whether it's it's feasible to apply that policy
01:29:35 policy right
01:29:38 another way does the dmm ever contemplate departure from itself there's nothing in the dmm that would uh support a decision maker in
01:29:49 support a decision maker in that process no and indeed you're right there's nothing in the dmm which averts to the need to consider the possible exercises of operational discretion that's correct yeah does that
01:30:01 discretion that's correct yeah does that mean that an incident commander might get stuck in the dmm because they've got no signposted means of escaping from it that's correct right
01:30:12 if you're going to use operational discretion at what stage in the process is envisioned by the dmm would you expect an incident commander to consider whether it's necessary to exercise his or her discretion
01:30:24 or her discretion to depart from it at what point uh if you were relating it to the decision-making model specifically then one would imagine it would be under the planning section but again from our experience in the
01:30:37 but again from our experience in the research when we were watching decision makers on the incident ground actually there was a much more complex situation unfolding whereby we weren't
01:30:48 situation unfolding whereby we weren't often seeing incident commanders running through that process and developing a plan
01:30:54 plan rather there were particular cues in the environment that might be triggering a response
01:30:59 response so in the situation where operational discretion might be required it would be at the point where the decision maker would recognize that responding to that particular queue with
01:31:11 responding to that particular queue with the outcome that they might that might have been envisaged might not be suitable for the incident itself yes i see yes thank you very much mr chairman we've had about 50 minutes um i
01:31:24 chairman we've had about 50 minutes um i i think this would be an appropriate moment i think we should have a short break yes
01:31:27 break yes um
01:31:29 um dr kenhatten we have a break normally during each session and for everyone's benefit so i think we'll take a break now we'll come back please at quarter four and as with all the other witnesses i
01:31:41 and as with all the other witnesses i have to ask you please not to discuss your evidence or anything relating to it with anyone while you're out of the room all right
01:31:48 all right thank you would you like to give the usher please thank you
01:32:01 thank you for please
01:45:31 would you ask dr cohn hatton to come back in please
01:45:44 all right dr gotten ready to carry on yes thank you good thank you very much yes yes dr cohn hatton um i'm right in thinking as you told us earlier that from june 2017 you were head of the operational review team
01:45:56 operational review team yes and therefore you were responsible for incident command policy yes yes and in the same role you also i think had oversight of the brigade's dynamic and intelligent operational training system or diot
01:46:07 or diot yes yes um and sat on the incident come on project board i think yes as well you didn't tell us that but we know that from your from your statement and that was from 2015 wasn't it uh yes it was now um
01:46:19 2015 wasn't it uh yes it was now um it would it be right to draw from the fact that you were involved in those roles that you had a considerable degree of insight into how incident commanders were being trained by the lfb yes
01:46:32 by the lfb yes and drawing on your pre-lfb experience you were in a good position is this right to compare that training with what happened in other fire and rescue services in the united in the united kingdom broadly and
01:46:43 united in the united kingdom broadly and i could draw it to uh to the national operational guidance and the intent of the national operational guidance also yes can you can you explain how the lfb's incident command training reflected
01:46:55 command training reflected the
01:46:56 the decision-making model the dmm yes and i think that's one of the key differences was that london fire brigade didn't move to the decision control process it maintained its use of the
01:47:07 process it maintained its use of the decision-making model which was used as uh
01:47:11 uh effectively to assist decision-makers to make decisions during training so incident commanders in london would have been trained on the decision-making model they would have received some information about it and how to use it
01:47:25 information about it and how to use it the training in london had uh changed from the old style training of which i wasn't privy to because that was prior to my commencement in the london fire brigade but there was a move
01:47:36 brigade but there was a move particularly at level 1 and level 2 incident command training to try to focus more on the decision-making process so they moved to smaller cohorts
01:47:49 process so they moved to smaller cohorts that would be involved in being coached through decisions
01:47:55 at particular scenarios to look at how they might deal with that at an incident right were you involved in the
01:48:11 um only in as much as i sat on the instant command project board but initially that was um
01:48:18 was um more from the perspective of the providing that conduit between the commissioning departments which was the ort team
01:48:26 ort team and operational assurance and babcock so i was able to advise on where national guidance
01:48:34 guidance uh departed from the activity in london fire brigade but i wasn't responsible for
01:48:40 for i wasn't able to influence directly the content of training if that answers your question yes it does how embedded was the dmm in incident command training um it was as embedded as it might have been
01:48:52 it was as embedded as it might have been in other fire and rescue services i think it's fair to say people would have received some input on it but i think it would be fair to say that the training of the dmm in london pretty much reflected the training of the dmm
01:49:05 much reflected the training of the dmm in other fire and rescue services prior to the national operational guidance being published right that's my question but let me try a different way from what you saw was the dmm so embedded
01:49:18 saw was the dmm so embedded in the minds of incident commanders from their training so is to be second nature to most incident commanders or was it just another piece of paper that most incident commanders disregarded once they were actively
01:49:29 disregarded once they were actively engaged at an incident i saw nothing that would suggest to me that the decision-making model was more embedded in london than in the minds of incident commanders elsewhere
01:49:40 commanders elsewhere maybe but um how do most of them look at it
01:49:43 it second nature or just a bit of paper uh i think that it would i hadn't seen evidence of it being used during decision-making incidents so more so the latter more so the latter
01:49:55 more so the latter more so the latter where it was used and what effect in your view did it have on the development of those individuals decision-making skills at an incident in other fire and rescue services or in
01:50:06 in other fire and rescue services or in london
01:50:07 london in london um i think that it was used more so during handovers and briefings to articulate the uh
01:50:15 uh the the asset the situation as it had been assessed so the bits of information around resource information hazard information for example and the overarching plan as it were as opposed
01:50:27 overarching plan as it were as opposed to
01:50:28 to recognizing its use to in the formulation of those plans and planning around the particular decisions that have been taken now if we were to think about
01:50:39 now if we were to think about the lfb's training in the light of the three phases of the normative decision-making model we've discussed already so situation assessment plan formulation and then plan execution
01:50:51 and then plan execution did you consider that there was an emphasis
01:50:53 emphasis in the brigade's operational training on the plan execution part of incident command
01:50:58 command in other words that part which corresponds to acting in the dmm we saw i think that in the training that you would see in many fire and rescue services the overarching emphasis is
01:51:09 services the overarching emphasis is often in the plan execution because those are the elements that you can more conceivably observe there's less emphasis on the plan formulation itself
01:51:20 formulation itself but what you what you would also see would be the questioning to gather information around the situational assessment piece so what sources of information you would be seeking to actively inform that but i
01:51:33 be seeking to actively inform that but i think it's true to say the elements that are easier to judge would be the execution of those plans and is that because that is what the trainer sees
01:51:45 because that is what the trainer sees that's the observable element more so yes now thinking again about those three phases of situation assessment plan formulation and plan execution to what extent did you consider that plan formulation was part
01:51:56 consider that plan formulation was part of the brigade's training of its incident commanders um i think that it would be it would be considered
01:52:06 but it would be considered in the context of the overarching incident as opposed to every decision that's made and it should be every decision that's made in which you'd be
01:52:17 decision that's made in which you'd be regularly applying the decision-making tool that you would be using and the reason i say that is when you come to assess an incident commander for example the assessment criteria would
01:52:29 example the assessment criteria would reflect the the national occupational standards for an incident commander and so it would be very focused on the outcomes of those decisions as it were as opposed to the way that each decision
01:52:41 as opposed to the way that each decision might be made and the what the uh bits of information that might be considered against each decision that's been made in the overarching incident itself right let's see if i can understand
01:52:52 right let's see if i can understand that see are you saying that the lfb's training
01:52:55 training when it came to planned formulation was to look at the outcomes and then work back from that more broadly yes yeah it's a broad unscientific i suppose we're putting it but i see so you don't actually get to
01:53:07 but i see so you don't actually get to see the machinery of the incident commander's brain working through the decision you just look at the outcome and
01:53:12 and infer from that the a decision making process must have been a good one uh more so
01:53:18 more so yes more so particularly during assessment now the one deviation to that that i should point out is the refreshed nation the refreshed instinct command training both in terms of the development training and
01:53:31 in terms of the development training and the maintenance training was focused on a a scenario where you'd have a decision maker an instant commander that would be going through a scenario and at various points the trainer would pause and unpack the decisions that they were
01:53:43 unpack the decisions that they were going to be making and they'd be doing that in a group so that others who were also present could learn from that so there was an element of trying to draw in some of the machinery if you like
01:53:54 in some of the machinery if you like that would sit behind the decisions but that was uh mainly from 2016 onwards i believe when the new incident come on training started to go live
01:54:04 live [Music]
01:54:05 [Music] yes i see now just building on that were um
01:54:12 um did training on plan formulation include the need to be able to modify an operational plan when a building or a fire behaves in a way that's unexpected there was a there was an element of
01:54:25 there was a there was an element of operational discretion that was introduced into london fire brigade that had an associated training package with it and operational discretion was also one of the elements that the
01:54:36 one of the elements that the commissioning department had specified should be included in the incident command training itself so there was an element of that there were injects that were included in some of the
01:54:49 were included in some of the cdes the command decision exercises that may look at an unexpected event but i couldn't speak to the number of those or the extent to
01:55:00 to the number of those or the extent to which they were tested in every scenario right
01:55:05 right uh
01:55:06 uh we may be able to be able to identify some from the evidence we've already seen but is your evidence that those were designed those injects were designed to teach uh incident commanders how to
01:55:20 to teach uh incident commanders how to use a discretion to modify an existing plan
01:55:23 plan in order to deal with an unexpected development there were some the greater emphasis was on the application of existing policy yes i see
01:55:35 yes i see um had you yourself observed in your own experience at the lfb a tendency on the part of incident commanders to experience difficulty in formulating operational plans that were adapted to
01:55:46 operational plans that were adapted to particular circumstances of the fire in front of them i had very few occasions when i had observed people uh deviating from those those plans and in particular standard operating procedure procedures
01:55:59 operating procedure procedures i think up to 2018 i believe operational discretion was only used around six times uh according to her majesty's inspectorate of constabulary and fire and rescue services um the overarching emphasis in london
01:56:11 um the overarching emphasis in london fire brigade was the adherence to policy and so most of the emphasis that i saw at incidents in london fire brigade was focused on the application of policy and the evidence and evidence to show that
01:56:27 um just in that last answer uh you you say that most of the emphasis you saw at incidents in in lfb were focused on the application of policy
01:56:39 focused on the application of policy um were those incidents life incidents yes so here's what you're telling us that when you went along and observed an incident and observed the incident commander
01:56:48 commander you observed that incident commander simply following policy or at least trying to rather than using discretion and decision making to adapt
01:57:00 and decision making to adapt at incidents and at performance reviews of command i think it's fair to say london fire brigade is a very conservative fire brigade and there is great comfort in following the procedures that are set
01:57:12 in following the procedures that are set out and i certainly saw evidence of that both at incidents and in post-incident debriefs there was a great focus on following the policy and was that at the expense of being
01:57:23 and was that at the expense of being able to engage with new or unexpected um developments in the incident i think that culturally there was more emphasis on following the policy than deviating from it yes but did you ever
01:57:34 deviating from it yes but did you ever observe that that came on occasion at the expense of the ability to engage with a new development or unexpected direction that the incident was taking not directly not
01:57:45 the incident was taking not directly not directly but slightly differently had you observed the lf in the fb a tendency for incident commanders to have difficulty using the dmm at incidents
01:57:56 at incidents as opposed to relying on their instincts and experience and common sense perhaps what i saw were the majority of decisions being taken relating
01:58:07 decisions being taken relating less to the dmm and more if you were to refer to those particular those normative models it was more situational assessment plan execution rather than observing the plan
01:58:18 rather than observing the plan formulation element which was not unlike the research that we conducted nationally it was a very similar pattern was there in your experience a tendency
01:58:29 was there in your experience a tendency to focus on adherence to policy and procedure
01:58:32 procedure uh
01:58:34 uh where that policy and procedure didn't actually
01:58:37 actually provide that middle element that you're that missing element you've just identified uh in what respect of
01:58:45 of the plan formulation the
01:58:49 the procedures were prescriptive so it would set out a set of actions that the incident commander should take and consider
01:58:57 consider so from that regard the direct application of the policy would somewhat negate the plan formulation element because those pieces that you refer to are pre-prescribed i see
01:59:09 are pre-prescribed i see so the
01:59:10 so the plan formulation was already pre-prescribed in the policy follow the policy and you'll have the connecting element between situational assessment and execution essentially yes right
01:59:21 right um
01:59:22 um now can i ask you to go to smc 6011
01:59:28 this is the um hmicfrs report inspection of the lfb done postgrenfell 2018 to 19 as you can see now you say in your statement uh and we
01:59:40 now you say in your statement uh and we don't need to go to it but it's paragraph 11 on page three that you were an inspection stroke development lead at the hmic frs from november 2017. were you involved in producing this report uh no
01:59:53 involved in producing this report uh no in her majesty's inspectorate for consulting and fire and rescue services if you are seconded to the inspectorate you are not permitted to be involved in the inspection process for your home service
02:00:05 inspection process for your home service in any way shape or form so no i was not all right but but can i take it that once it came out you became familiar with it i i read the publication when it was when it was published yes right you
02:00:16 was when it was published yes right you didn't get to see an advance draft no no in fact i'd left the inspectorate by the time this was uh this was produced i see can we go to page 22
02:00:29 now it's under the heading command which starts at the top of the screen but it's the penultimate paragraph in that section of which i think needs to be scrolled down a bit so you can see it that's just
02:00:40 down a bit so you can see it that's just about a quarter of the way down your screen it's the paragraph that starts we were told
02:00:44 were told we were told that organizational culture inhibits commanders from using operational discretion incident commanders aren't confident that the brigade would support them in using operational discretion moreover
02:00:56 using operational discretion moreover not all staff feel that the tone of the brigade's post-incident debrief meetings which review such decisions supports a learning environment
02:01:06 first you know who told the authors of this report that uh no do you know who it was within the nfb who assisted the
02:01:17 who assisted the um constabulary in compiling this report no they would interview a number of people and they would only include something in a report that was triangulated from at least three sources
02:01:28 triangulated from at least three sources of evidence so when they were when they would carry out an inspection they would hold focus groups they would have anonymous surveys that people could uh could write into and when i say
02:01:40 uh could write into and when i say anonymous it's anonymous and they don't publish the results of who said what within that um so it could have been a multitude of places but i would suggest if it was if there was
02:01:51 there was sufficient evidence for them to have cause to write it in a report that they would have heard it from a multitude of places
02:01:57 places [Music]
02:01:59 [Music] and is this conclusion in this paragraph i've just read to you consistent with your experience of the attitude to operational discretion during your time at the lfb uh yes and there are two points that i
02:02:10 uh yes and there are two points that i would make in relation to that i think the first one is to point out that this the organizational culture and its impact on how you would make a decision in particular operational discretion isn't an issue that's exclusive to
02:02:22 isn't an issue that's exclusive to london fire brigade it's something that we've noted nationally it's something that was included in a in the future of instant command report itself and it's something that's been discussed at national working groups since it it is a
02:02:35 national working groups since it it is a it is an issue that is broader than london fire brigade um in relation to london fire brigade itself specifically um i did a piece of work that looked at the pdp process in particular but also
02:02:49 the pdp process in particular but also the application of what you will have seen as inp points incident management points essentially where commanders are under performance is identified and
02:03:02 under performance is identified and reported in the database i had asked for a review of that to be to be undertaken and we identified some
02:03:13 to be undertaken and we identified some issues with incident commanders seeing the use of those development points as very punitive and also the prc process itself
02:03:22 itself was perceived by some to be quite a punitive environment which meant they were more focused on providing a narrative that would prevent them from receiving an imp point rather than being
02:03:33 receiving an imp point rather than being very open and honest about the potential learning points that they might have yes thank you we'll come to look at that in a bit more detail probably tomorrow possibly not but later on um
02:03:44 but later on um but you i think agree that the conclusion we see set out here was consistent with your own experience of the attitude of of the lfb to operational discretion during during your time uh did you see
02:03:57 during during your time uh did you see that have any having any impact on incident commander's performance at incidents
02:04:02 incidents i saw incident commanders that were very focused on adhering to policy because it felt more comforting to be able to use a
02:04:13 felt more comforting to be able to use a pre-prescribed policy i also saw a very subjective view of how appropriate a particular action may or may not have been i think it's fair to say particularly in the prc
02:04:27 it's fair to say particularly in the prc processes
02:04:28 processes um
02:04:29 um so i would say whilst not exclusively because there were some examples i think of very
02:04:36 of very positive uh prcs in particular um i think overwhelmingly that would reflect the experience that i saw which concerned me enough to commission the review of the pdp process
02:04:50 when you say you saw a very subjective view of how appropriate a particular action may or may not have been was that a subjective view of the of the interviewer conducting the prc or the interviewee uh it i think it was a
02:05:02 interviewee uh it i think it was a subjective view of those who were judging the efficacy of the command performance and again this isn't a an issue that would be exclusive to london fire
02:05:13 would be exclusive to london fire brigade i think the number of incidents that we go to has reduced over time thereby the experience that incident commanders have have has also reduced over time as well
02:05:24 over time as well and i think that because of the reduced experience it can lead people to uh to feel quite insecure sometimes about their performance so when you challenge
02:05:35 performance so when you challenge someone on their command performance it can be quite emotive and i think that certainly came through in the prc process where it was quite difficult to gain a really positive
02:05:47 difficult to gain a really positive learning environment on paper it's a fun it it's a good process on paper you should be able to use that process to gather learning to understand any areas of underperformance
02:05:58 understand any areas of underperformance and to generate organizational learning the trouble with any process is it's applied by people and i think that this was the challenge that we had uh culturally within the organization
02:06:10 organization just
02:06:11 just the last two can you just explain that the trouble with the process is supplied by people so do you mean that it's applied by people who were perhaps not as culturally imaginative as you
02:06:23 not as culturally imaginative as you would have liked i think it's a culture that's been developed without the human factors in mind i think is more the point that i'm trying to make so the
02:06:31 the the consideration of how the process might be applied by people in reality under the same pressures that they might be experiencing i think is is what i was trying to
02:06:42 trying to trying to outline sorry well let's look at the human factors um because i think you mentioned earlier that um you carried out research in conjunction with uh the university of cardiff during your common to the energy programme yes um
02:06:55 common to the energy programme yes um if we go to your statement i've already shown this i think to you uh you said that paragraph 26 that you led the the team 24-hour periods over to six consecutive days i've shown you paragraph 26 there
02:07:07 days i've shown you paragraph 26 there it is
02:07:10 i think it's right that building on what you say there you your published paper says that you you followed 23 incident commanders in total yes yes
02:07:21 commanders in total yes yes from six frs uh frses across across the country from east sussex to town and where yes that's correct and i think 33 separate incidents in all yes that's correct now
02:07:33 incidents in all yes that's correct now in terms of the analysis of the data that your team collected i think you sought
02:07:37 sought to apply specific um code components to the commander's decision making yeah you called situational awareness essay plan formulation pf
02:07:48 plan formulation pf and plan execution pe is that right that's correct right and that was that was that achieved by a process of cued recall whereby the commanders would be asked to review their own footage
02:08:00 their own footage within the within 24 hours of the incident having taken place and then provide a commentary for the rationale of their decisions in each case yes that's right that meant that we were able to review the data directly from
02:08:11 able to review the data directly from their point of view with the helmet camera that captured all of the information but we were also then able to use the footage to assist their recall of their thought processes at the particular point in time
02:08:23 particular point in time and
02:08:23 and as you've referred to already i think the findings of that research were published in the journal human factors in august 2015. yes that's correct uh let's go to that lfb double zero one one
02:08:35 let's go to that lfb double zero one one zero six six seven
02:08:48 [Music]
02:08:51 and we looked at this before um
02:08:54 um in the publication with human factors as as
02:08:57 as that's the title of the of the publication isn't it yes that's the journal that's the journal uh and um your can we summarize your findings
02:09:08 can we summarize your findings uh as follows and tell me if any of this any of this is wrong commanders were more likely to make decisions that involved transitions from situational awareness to plan execution stage rather than transition from
02:09:21 stage rather than transition from situational awareness to plan formulation as is expected by the normative model yes
02:09:28 yes and uh plan formulation was the least commonly occurring stage of the decision-making per incident yes i think your figures were a mean of 5.51 occurrences as against 45.45 occurrences
02:09:41 occurrences as against 45.45 occurrences of situational awareness yes and 17.06 occurrences of plan execution yes we get all this out of your report so it's not just um a brilliant act of memory um across the 33 incidents 19 began with i
02:09:53 across the 33 incidents 19 began with i think with situational awareness and 13 with with plan execution but only one with planned formulation uh yes that would be correct and and in all of those cases i think
02:10:04 and and in all of those cases i think you conclude page eight that there's little indication that plan formulation was followed any more often with plan execution than further situational awareness yes that's correct right
02:10:15 this sample
02:10:18 what gave you confidence that the sample size was gave you statistical certainty or statistical reliability we ran statistical tests as you'll see in the paper itself and it
02:10:30 you'll see in the paper itself and it was those statistical tests that met the criteria that that are set throughout research
02:10:36 research to uh to tell you whether the correlations that you're seeing whether those things that you're seeing happen as a result of chance or whether there's an actual underlying relationship between those things and i should say that in the publication
02:10:48 should say that in the publication process the data that you've collected and the manuscript that you produce goes out to other researchers for peer review so they also review not just the things that you say but also your methodology
02:11:00 that you say but also your methodology your methodology and your application of statistical tests to ensure that it's a sufficient enough quality to make a contribution to science and hence meet the criteria to be published in the journal so these were to use the
02:11:11 journal so these were to use the language statistically significant findings they were uh is it right to say as you go on i think to observe in the discussion section
02:11:19 section um
02:11:20 um from page 10 of this document um the those findings are or were inconsistent with the normative three-stage model of situational awareness followed by plan for
02:11:31 awareness followed by plan for formulation followed followed by plan execution yes that's right uh now uh
02:11:37 uh now uh you also say in your statement that in fact most decisions and i think you accord about 80 percent to it appear to rely on intuitive process yes does it follow from that that only
02:11:49 yes does it follow from that that only it may be obvious that only 20 of decisions are actually made after an explicit
02:11:54 explicit plan has been formulated yes can you explain why these findings are significant in relation to the way in which incident commanders are trained to make decisions
02:12:05 commanders are trained to make decisions under pressure yes because with such a small amount involving some critical thinking if you like in relation to the decision that you're about to make and i should say
02:12:16 you're about to make and i should say actually the other point that's relevant to the explanation that i'm about to give is that we also found relatively low levels of situational awareness and incident commanders so if i could describe that for the inquiry we saw
02:12:27 describe that for the inquiry we saw incident commanders essentially making decisions based on the here and now rather than thinking about what might happen next and basing their decision on on the future state in mind or with a
02:12:39 on the future state in mind or with a consideration of the implications of the decisions that they're making now when someone is making an intuitive decision a reflexive decision whether the mechanism is more recognition prime
02:12:50 mechanism is more recognition prime based or whether it's more associative based
02:12:53 based actually the the commonality is they're making that decision based on a cue or a series of cues that they might be experiencing so if if i can liken it to a piece in a jigsaw they're making a decision based
02:13:06 jigsaw they're making a decision based on that one particular piece rather than slotting the piece back in the overarching picture and making the decision based on that and when you couple that with relatively low levels of situational awareness there is a
02:13:17 of situational awareness there is a danger that it might be absolutely the right decision based on that cue alone but if you don't consider that within the broader picture of the incident then there might be unintended consequences you may fall into a decision trap you
02:13:29 you may fall into a decision trap you may suffer from confirmation bias because you're only attending to the bits of the situation that relate to the pattern matching exp uh the pattern matching process that you're going to
02:13:40 matching process that you're going to that would trigger that particular outcome because it's that cue or that pattern of cues so that was the issue with only 20 percent of the decisions effectively involving the plan formulation element
02:13:51 involving the plan formulation element there are some benefits to using very reflective decision making it's very quick it can be very helpful in a very dynamically changing situation and it also uses less processing power it
02:14:03 also uses less processing power it requires less processing power so you have more cognitive capacity available to do other things so i'm i'm certainly not suggesting that uh intuitive decision-making is a bad
02:14:14 uh intuitive decision-making is a bad thing but what you need are some some controls effectively that would help to stop you falling into one of those decision traps if the process that you're relying on is an intuitive one
02:14:28 yes i see and
02:14:32 you've given us an insight into the into the effect of the figures eighty percent that's against twenty percent what would be the dangers can you illustrate the dangers
02:14:45 illustrate the dangers of training incident commanders in a way that reflects the normative model the the dmm
02:14:51 the dmm yes i think the danger with just solely relying on that normative model is it ignores the intuitive processes that you might use and thereby doesn't enable you
02:15:04 might use and thereby doesn't enable you to teach
02:15:06 to teach what the uh what what those potential pitfalls are the reality of those decision traps and how you might stop yourself from falling into it because you're assuming that every decision that
02:15:17 you're assuming that every decision that you make will be based on situation assessment and plan formulation and then plan execution at which point you return on the loop and you evaluate
02:15:29 [Music] now if we go to page 10 of this document
02:15:38 which is your your paper and look in the right hand column on that page at the first sentence after the reference decline 1989 you say this the observation that sa is
02:15:50 you say this the observation that sa is most often immediately followed by p e suggests that particular situational cues might directly prime specific decisions that do not involve explicit pf
02:16:00 pf and evaluation but remain directed towards the objective at hand i.e recognition prime decisions klein 1993
02:16:08 1993 um
02:16:09 um i just emphasized specific decisions sorry um yes situational cues that might directly prime specific decisions emphasizing that does that mean in
02:16:21 emphasizing that does that mean in in simple terms that most of the time incident commander's actions are a reaction to what they're seeing that was what we found in that uh in the initial research yes that's the 80 percent yes
02:16:32 research yes that's the 80 percent yes right and
02:16:34 right and you're saying that reactions can be instinctive or they can be learnt behavior yes can you explain how situational cues um
02:16:43 um might prime specific decisions without involving explicit plan formulation yes if there if you have experienced a particular cue in the environment so something when i'm talking about a cue
02:16:56 something when i'm talking about a cue you could encompass that in situational assessment you're assessing a situation and you're experiencing things which would provide you with information which would help you to understand the situation now if one of those pieces of
02:17:08 situation now if one of those pieces of information that you're seeing primes a particular response because it might be associated with a previous experience that you've had it might be a particular incident that's been similar it might be a particular smoke pattern
02:17:20 it might be a particular smoke pattern for example that you've experienced previously it would prime a knowledge structure that you would have that contains if you like those those memories the um the prototype of that particular
02:17:32 the prototype of that particular incident or the prototype of a particular action that was associated with that previously or it might be a more conditioned response so you might have experienced something several times and the the
02:17:43 something several times and the the reaction to that becomes more of a conditioned response like a habitual response if you like so in those circumstances you're not explicitly activating plan formulation you're not considering
02:17:55 you're not considering what the implications of that particular decision might be you're not necessarily weighing up that option against another option and selecting the optimal one as we saw from the line about
02:18:07 as we saw from the line about recognition prime decision making previously the incident commander is selecting an option that is satisfactory because it meets the criteria that are triggered by that particular exposure to
02:18:19 triggered by that particular exposure to that particular queue as opposed to thinking about the uh the decision itself in comparison to the experience that you're having the situation as you're assessing it and then choosing
02:18:30 you're assessing it and then choosing the optimal response
02:18:35 is that a case then of commanders really just drawing on their previous experiences and familiarity with certain types of events and then having that trigger an intuitive response yes
02:18:46 intuitive response yes well would it be right to think that the the
02:18:49 the intuitive response will come to you whether you like it or not but the question is whether you should question it that is absolutely correct yes
02:19:02 would it be right to say that these kinds of intuitive decisions aren't necessarily the what i might call the correct decisions yes and i think is that what you mean in your statement perhaps i'll show it to
02:19:13 your statement perhaps i'll show it to you
02:19:14 you page 7 paragraph 27.
02:19:19 [Music] uh where you say paragraph 27 just 10 lines down you say
02:19:26 you say uh
02:19:27 uh it's right in the middle of the paragraph these more intuitive influences are they triggered by a specific queue in the environment might or might not be appropriate to the entirety of the given operational environment when considered in line with
02:19:39 environment when considered in line with all other factors now and you go on to say the influence of these
02:19:44 of these associations can be very powerful a commander may fall into a decision trap what is a decision track there are a number of decision traps um we outline
02:19:55 number of decision traps um we outline them in the national operational guidance for incident command as well as the foundation document where we provided some more information and if i can provide the inquiry with a few examples confirmation bias is a decision trap whereby
02:20:07 trap whereby you will have a situation um and you will
02:20:11 will essentially have an idea of what that situation might be and so then you only attend to information that reinforces your view of what or your understanding of the situation and that would be
02:20:22 of the situation and that would be confirmation bias another decision track might be decision inertia for example whereby the incident commander in this case would have a um uh would be faced with a situation where
02:20:34 uh would be faced with a situation where they feel paralyzed to make a decision they don't make a decision they either defer the decision to another point in time they look for additional information erroneously or they might defer it to a different decision maker
02:20:45 defer it to a different decision maker it might be choice deferral for example so their tunnel vision would be another example where you're focusing on a narrow aspect of the situation rather than looking at the situation in its
02:20:57 than looking at the situation in its entirety
02:20:58 entirety so there are a range of of decision traps that an incident commander might fall into
02:21:05 and is it right to say that as a decision trap is either a thought process or the absence of a thought process that can lead to a bad outcome yes that would be a fair summation i mean it's a very
02:21:16 a fair summation i mean it's a very probably over simplistic most people would just call that an error what's the mistake what's the difference between a decision trap and an error
02:21:23 an error you could describe it as either we termed them as decision traps within the national operational guidance really because we wanted to introduce a concept that people would be able to understand and to be able to relate to
02:21:36 understand and to be able to relate to in some of the descriptions that we were putting in there so we used decision traps to try to uh tell incident commanders that these are uh these are issues that you might they're issues you might fall into
02:21:47 might they're issues you might fall into it's a trap that you might fall into but an error would still be a perfectly adequate way of describing it right
02:21:56 and a decision trap might be some an error which is made by an incident commander without them knowing that it's an error yes on the contrary being persuaded that because they're thinking they're making a decision they're making the right one
02:22:09 decision they're making the right one yes that's right is what you're saying that um the intuitive decisions that are more usually made by incident commanders on the incident ground can lead to
02:22:20 ground can lead to unintended consequences yes uh
02:22:24 yes uh precisely because those consequences have not been examined yes precisely and is that because the intuitive process doesn't tend to involve a clear stage of plan formulation that moves
02:22:36 formulation that moves or tends to move directly to plan execution yes it's very often done without rational thought sometimes potentially below the level of consciousness as well right and and again i apologize for for reducing it
02:22:48 again i apologize for for reducing it but does this mean that the intuitive decisions
02:22:51 decisions are typically made without the decision-maker thinking through the potential consequences of their chosen cause of action yes uh or weighing up the pros and cons of alternatives yes hence they've fallen into the decision
02:23:02 hence they've fallen into the decision trap they falling into one kind of a decision yes and is is that what the decision-making model was designed to avoid uh the decision-making model or the decision control process decision making model uh the decision-making
02:23:15 making model uh the decision-making model was my understanding is it was developed some time ago based on the best understanding of the people at the time i'm not aware and there's nothing that i
02:23:26 i'm not aware and there's nothing that i have read that has led me to understand that it was designed with any of the psychology of incident command in mind
02:23:34 mind uh
02:23:35 uh right let me ask it differently given what you told us just now about think that about the thinking does the decision-making model whatever it was designed to do
02:23:47 it was designed to do work
02:23:48 work in
02:23:49 in helping incident commanders avoid a decision trap or does it encourage the making of a decision trap unwittingly through the research and the subsequent
02:24:00 through the research and the subsequent process of developing the national operational guidance we recognized that the decision-making model wasn't sufficient to help incident commanders to avoid falling into a decision trap
02:24:15 uh and is that because the dmm
02:24:18 the dmm is in its way flawed or because most internet commanders can't get their heads around it and so therefore can't use it i think the decision-making model itself doesn't
02:24:29 the decision-making model itself doesn't provide any inbuilt techniques or support to help a decision maker to uh to avoid those things [Music]
02:24:40 [Music] right so
02:24:42 right so in a case where an incident commander simply doesn't use it doesn't think about it as an incident he's he or she is exposed to a decision trap they could be yes but they're exposed to the risk of falling into one yes
02:24:54 the risk of falling into one yes similarly are you saying that where the incident commander thinks about the decision-making model and tries to use it
02:25:01 it they're still at risk of falling into a decision trap because the decision trap is not sufficient to assist them from avoiding
02:25:12 avoid a decision trap yes the the chairman made the point earlier on that you cannot uh quite accurately that you cannot essentially decide whether you're going to use an intuitive process or an analytical process
02:25:24 analytical process so there very much is the point that you may make an intuitive decision and you don't have the opportunity to stop yourself making that intuitive decision right so do we end up at this
02:25:35 decision right so do we end up at this point
02:25:36 point if an incident commander doesn't use the decision-making model at all they're at risk of falling into a decision trap but even if they do they're still at risk of falling into a decision trap because the decision-making model
02:25:47 because the decision-making model doesn't help them avoid it that reflects our summation when we were developing the national operational guidance yes and that is because they're moving straight from sa to pe and not passing pf uh yes that's correct yes i see
02:26:00 pf uh yes that's correct yes i see and mr chairman it's it is uh two minutes before 4 30. um well it's just time for me to ask one more question and i think you have time for one more question yes um it sounds
02:26:13 for one more question yes um it sounds to me from what you've just been describing that the the pictorial representation of the decision-making model perhaps ought to
02:26:24 perhaps ought to include within it or perhaps that ought to be added to it the stage just before pf
02:26:31 pf which is think i mean it could be put in a rather helpful way than that but is that really what you're saying that if you've got to the stage of making a plan you just want to check
02:26:43 plan you just want to check the basis upon which you're doing it yes and in fact the decision control process which followed on from the decision-making model uh introduced a stage by which we recognized that you would either make a decision analytically or reflexively and but the
02:26:57 analytically or reflexively and but the opportunity for intervention is once you've made a decision by either one of those pathways but before you apply the outcome of that treat it as a provisional decision precisely and then review it precisely
02:27:09 precisely and then review it precisely and it's at that point that we introduced the decision controls which are your essentially your check to ensure that the decision that you're making and i'm happy to outline the decision controls now or if that's at a later point
02:27:21 later point but essentially they were introduced as a check
02:27:23 a check to help incident commanders not to fall into those decision traps but also to raise their levels of situational awareness as well directly yes thank you thank you very much well you've still got time to follow that up
02:27:34 you've still got time to follow that up if you want no because we are just about to embark on an examination of the decision control process in some detail so that's a convenient tomorrow morning yes thank you well um as you had uh dr kane happened that's um
02:27:47 kane happened that's um the point of which mr militz reached the sensible
02:27:50 sensible stage at which we should have a break for the afternoon so we'll stop there um i'm gonna have to ask you to come back for some more evidence tomorrow but i think you were expecting that wouldn't you absolutely
02:28:01 you absolutely right so we'll resume at 10 o'clock tomorrow please and again while you are away from the hearing please don't talk to anyone about your evidence or anything related to it all right thank you very much we'd like to go to the usher thank you
02:28:17 [Music]
02:28:26 all right thank you mr ten o'clock tomorrow thank you