Testimony from Scott Hayward, former Principal Operations Manager of London Fire Brigade control room (2009-2019), about training failures, lack of oversight, and inadequate quality assurance systems.
00:00:29 good morning everybody welcome to today's hearing today we're going to hear evidence from another former senior officer of the london fire brigade yes mr millet good morning mr chairman
00:00:41 yes mr millet good morning mr chairman good morning members of the panel i now call mr scott heywood please
00:00:53 good morning mr hayward good morning sir i understand you're going to make the affirmation yes the words are on the screen would you please read them out yes sir i do something sincerely and truly declare and affirm that the evidence i shall give should be the
00:01:05 evidence i shall give should be the truth the whole truth and nothing but the truth thank you very much now please sit down and make yourself comfortable
00:01:15 right yes thank you yes yes thank you mr chairman mr hayward good morning can i start by thanking you very much for coming to the inquiry and assisting us with our investigations we're extremely
00:01:26 with our investigations we're extremely grateful to you thank you my questions are intended to be short and simple sometimes they don't quite work out that way so if you would like me to ask the question again or to rephrase it i'm happy to do that can i ask you also please to keep your
00:01:38 can i ask you also please to keep your voice up so that the person who sits immediately to your right can get down everything you are saying also not pleased to nod or shake your head a simple yes or no will do
00:01:49 your head a simple yes or no will do because a nod or shake of head does not go onto the transcript okay we will be taking scheduled breaks during the course of the morning and the afternoon during your evidence but if you feel you need a break at any other time then
00:02:01 need a break at any other time then please just say and we can take a break okay now you've provided three witness statements to the inquiry i just want to show them to you first if i may the first is dated the 30th of april 2019
00:02:12 first is dated the 30th of april 2019 which you signed on the 1st of may 2019 and that is at lfb3055191
00:02:20 is that your first statement it is can we look at page 43 please is that your signature above the date yes it is thank you the second is lfb00086213
00:02:40 is that your second statement to the inquiry yes it is thank you and if you go to page 22 you can see a signature above the date there is that your signature yes it is 9th of january 2020. third
00:02:51 third is your statement of the 16th of june 2021 at lfb double zero one two one one seven six
00:03:02 is actual third statement of the inquiry yes it is uh and it's dated the 16th of june if you go to page 20 you'll see a signature there is that your signature yes it is thank you very much have you read each of these witness statements
00:03:13 read each of these witness statements recently yes i have can you confirm that the contents of each of these statements are true to the best of your knowledge and belief yes i do are you happy for those statements to be taken as your evidence to the inquiry yes and have you
00:03:25 evidence to the inquiry yes and have you discussed your evidence today with anybody before coming here today no now i'm going to ask you first about your professional background and your role at the lfb
00:03:36 role at the lfb in your first statement of paragraph eight at page two if we can go to that you say that before you joined the lfb you served in the royal navy where you would you had been a chief petty officer in the warfare department is that right
00:03:47 in the warfare department is that right that's correct and in the same paragraph you say that the role you applied for at the nfb was as operations room manager which had been your title on sea going ships is that correct that's correct now
00:03:58 ships is that correct that's correct now looking at your role at the lfb um you say that you joined as principal controller uh in august 2006. is that right that's correct and then in may 2009 your title changed
00:04:10 and then in may 2009 your title changed to principal operations manager or pom or perhaps pom is that correct that's correct yes uh and that was your title i think until you left the lfb in july 2019 is that right that's correct and
00:04:23 2019 is that right that's correct and what were your main responsibilities as principal operations manager i was responsible for the day-to-day running of the control room and for the efficient service delivery of that
00:04:34 efficient service delivery of that uh if we go to paragraph 10 of your first witness statement you say this
00:04:39 if we just scroll down to page three you say although my titles have changed over time my role in control has remained broadly the same to manage the day-to-day control room functions and to ensure an efficient and effective
00:04:52 and to ensure an efficient and effective 24 7 emergency response service and when you say a day-to-day management of control what do you mean by that um to ensure to ensure that the control room runs
00:05:04 room runs efficiently 24 7.
00:05:08 and does that include things like staff rostering
00:05:12 rostering um
00:05:14 um yeah
00:05:15 yeah i mean the staff wrote is our are pre-planned but of course changing rows and and the like will be part of that role yes right what did you consider were your primary functions um
00:05:26 um what service delivery to ensure to ensure that we could respond to any incident uh in london 24 hours a day seven days a week now you were in charge of the lfb control room from may 2009 to
00:05:37 of the lfb control room from may 2009 to july 2019 that's ten years isn't it it is indeed now paragraph nine of your statement if we can go um back to that and look at the second bullet point though on page two you say that your
00:05:48 though on page two you say that your role
00:05:49 role uh
00:05:50 uh involved you could say you could see there you your your role involved line management responsibilities i'm summarizing but that's right isn't it it is in danger now i think uline managed a
00:06:02 danger now i think uline managed a number of people including lindsey turner correct joanne smith yes victor is it danielle or bagman bagnall
00:06:11 bagnall and keith diamond correct now those people were i think senior operations managers they were they were indeed yes were there any other members of the control staff that reported directly to you during that 10-year
00:06:23 directly to you during that 10-year period
00:06:25 period um adam krinion who is another senior operations manager and he came in i think in 2017. he did indeed yeah anybody
00:06:32 anybody else um
00:06:38 not that i recall directly no what did your line management responsibilities involve
00:06:43 involve um
00:06:45 um prds so performance development of staff
00:06:50 delegating responsibilities to the senior operations managers
00:06:58 sharing an on-call rotor with those senior operations managers
00:07:05 and allocating tasks day-to-day tasks or project work today with senior appraisers managers and when you say delegation of responsibilities to the senior operations managers who decided which responsibilities should be
00:07:17 which responsibilities should be delegated and to whom was that just you i i did but in in discussion with the senior operations majors and identified the strengths to who were best to do those particular tasks
00:07:28 those particular tasks in general did you ever discuss delegation and what should be delegated and to whom with it with um the person who was your line manager um i don't recall exactly but i'm i'm
00:07:40 um i don't recall exactly but i'm i'm sure i'm sure i did certainly with um mr george i will talk about who would be best place to do training for example now um i want to look at the
00:07:51 now um i want to look at the control room and particularly other people who may have had some involvement with the control room during that period first is it right summarizing your evidence that you reported directly to
00:08:03 evidence that you reported directly to assistant commissioner dave brown between may 2009 and may 2012 yes that's correct and then may 2012 ac brown was promoted to third officer
00:08:16 ac brown was promoted to third officer from which point on you i think then reported to assistant commissioner chandler richard chandler that's correct and it was he who then reported up to ac brown that's correct
00:08:27 brown that's correct and uh
00:08:29 and uh ac brown says in his first witness statement to paragraph seven we don't need to turn it up but for reference purposes it is lfb3032166 page three he says that ac
00:08:41 lfb3032166 page three he says that ac chandler took overall responsibility for control and mobilizing between may 2012 and october 2013. that's what he says does that accord with your recollection
00:08:52 does that accord with your recollection do you think no he for me he he was in charge of control from may when he joined in may 2012 and he left in october 14 i believe
00:09:04 he left in october 14 i believe but he did have a period of sickness over that time which may which may have why ac brown put that information down right i see and i think in fact ac chandler was absent between late 2012
00:09:16 chandler was absent between late 2012 and april 2013. okay during that period late 2012 and april 2013 while ac chandler was off did who did you report to whom did you
00:09:28 did who did you report to whom did you report during that period oh you see brown right and after ac chandler left you then i think again reported to ac brand that's correct right
00:09:39 correct right and then from april 2016 when ac tom george was appointed as head of operational response i think you reported to him and he reported to ac brown that's correct right
00:09:51 brown that's correct right what processes were in place to ensure that your direct line manager from time to time was fully informed of any problems arising in control or relating to control so we'd normally have a
00:10:03 to control so we'd normally have a fortnightly meeting um certainly ac chandler and mr george would spend time in the control room so i would be aware of any issues that were arising because
00:10:14 of any issues that were arising because they would go and speak to other members of staff in a control room um but if there were issues or they'd had issues they would raise it at those two weekly meetings you say ac chandler and mr george would
00:10:26 you say ac chandler and mr george would spend time in the control room how often would they spend time in the control room um when they first joined it was more frequent but as time went on it it sort of
00:10:35 sort of maybe once a week once a fortnight how long did they spend in the control in a few hours a few hours
00:10:42 hours were they during the day shift or the night shift or day shift generally right and where did they sit in the control room
00:10:48 room uh they had an office within merton so they weren't actually in the controller but they would go in and speak to staff in the control room during that period was there any time when they would habitually observe the control room in
00:11:00 habitually observe the control room in action
00:11:01 action not to my knowledge what was uh ac chandler's role in relation to the control room between may 2012 and october 2013 or the date you say he left the lfb he was he was the
00:11:12 say he left the lfb he was he was the head of mobilizing control and how much day-to-day involvement did he have in the management of the control room
00:11:19 room as i said when he first started there he probably spent more time in the control room he
00:11:25 room he led on a project to change um resource management into control so so project wise he probably put a lot of effort in actually day to day
00:11:36 effort in actually day to day um
00:11:36 um some
00:11:38 some and would you consult with him on problems which arose yes indeed you did are there any particular problems that you recall that stick in the mind today uh staffing possibly when we when he was
00:11:51 uh staffing possibly when we when he was doing the project for uh resource management they wanted to remove
00:11:56 remove an assistant operations major off the watches which would have impact on staffing so i discussed that with him in the fact that it would be an impact at the union meetings when ac george was appointed head of
00:12:08 when ac george was appointed head of operational response in march 2016 do you remember how much day-to-day involvement he had in the overall management of the control room uh when he first arrived quite a lot
00:12:20 uh when he first arrived quite a lot because of vision and there was still a lot of issues with with staff um getting to grips with vision but again they had he had other tasks as well so he would spend some time in the
00:12:32 well so he would spend some time in the control and the rest of it in in headquarters and would you consult with him on issues relating to control yeah yeah definitely uh so certainly when he first went to control he was in there
00:12:44 first went to control he was in there more often than not and we would discuss it there and then did you have regular meetings with him you said i think you had fortnightly yeah for it was fortnightly but because if if he was in the control room then obviously i would
00:12:56 the control room then obviously i would be i'll be there anyway so we would we would talk and these fortnightly meetings you told us about with this with ac chandler and ac george they continued today after ac george had been appointed to head of
00:13:08 george had been appointed to head of operations they did and um
00:13:11 and um were they minuted they weren't where's that
00:13:15 that um
00:13:16 um they were catch-up meetings i think so you know i'd be over at headquarters and he would put aside some time and hit you know just talk about any issues that he from his side and any issues from my side but they
00:13:28 and any issues from my side but they weren't minuted as such there weren't official meetings right and what was ac brown's role in relation to the control room
00:13:35 room uh during the during the outside of um outside of mr george and mr chandler's role he he would have been the same be responsible for the control room at that point
00:13:47 room at that point you say outside george and chandler's role yeah so i mean he was he was a director of operations so control come under operations so he would have been overall responsible
00:13:59 overall responsible right how much day-to-day involvement did he have in the management of the control room not not to my knowledge not very much i knew only when mr george mr china reported to him
00:14:11 reported to him and do you know what the frequency of reporting or the form of reporting was from ac chandler and ac georgia i don't i do ac brown i do not you do not now can we go to ac brown's statement
00:14:24 now can we go to ac brown's statement please at lfb triple zero eight four zero two zero page 12 foot of page 12 paragraph 28. he says this i held monthly management meetings with
00:14:36 i held monthly management meetings with scott hayward during the periods that i was his direct line manager see paragraph 28 of my statement dated 29th january 2019 those meetings were not minuted and there were no agendas for the meetings
00:14:47 there were no agendas for the meetings they would be dictated by key lines of current work and published brigade control specific key performance indicators all of which were relevant to the successful operation of brigade
00:14:58 the successful operation of brigade control
00:14:59 control and he goes on to say he would sometimes email you in advance of those meetings do you agree with him that you did have monthly management meetings when he was your direct line manager um we we'd diarise meetings however
00:15:13 um we we'd diarise meetings however because of his role um sometimes they would be cancelled at short notice or they would be cut short because he had other meetings to go to but we did we did have meetings and it's right is it that they weren't minuted they weren't
00:15:25 that they weren't minuted they weren't me that's correct they weren't minuted why why was that i don't know
00:15:31 how closely did you work with assistant commissioner brown in relation to control issues outside those meetings um union meetings if we were negotiating an issue with the unions uh he would be
00:15:44 an issue with the unions uh he would be more involved um and also project work for vision uh and discussing how vision would work he would be at those meetings too now he refers there to key performance
00:15:57 now he refers there to key performance indicators as you can see what were they control specific or control rooms specific key performance indicators um to answer 95 percent of all the 999
00:16:08 um to answer 95 percent of all the 999 emergency calls in 90 to 92 percent of the time is the one i recall which is the one we worked predominantly so 99 because the transcript hasn't quite got that right i think 99 of all
00:16:21 quite got that right i think 99 of all 999 92 sorry it's 92 right
00:16:26 right within
00:16:28 within uh seven seconds i believe
00:16:34 any other key performance indicator not i can recall i think there are one or two others but that was the reportable um kpi that i recall right
00:16:45 right and and where were those used in the overall monitoring uh and quality assurance of the control room yeah i believe they were published at cm
00:16:56 yeah i believe they were published at cm at cnb um the management board meetings uh and were made public i take it that there were no other key performance indicators in relation to
00:17:07 performance indicators in relation to any other aspect of the control room is that that's correct so there was nothing in relation for example to training no what's not why is that i don't i don't know who was responsible for formulating
00:17:18 for formulating uh or deciding what key performance indicator should be applied to control room
00:17:24 room um
00:17:28 i would say it will be between the ac in seeing charge myself
00:17:33 was there any discussion that you were involved in or you knew about about what other key performance indicators should be formulated and applied to the control room other than
00:17:45 applied to the control room other than answering calls within a certain time no it was not it was not discussed the meetings that you had with ac brown were those an opportunity to inform him of any difficulties that control were
00:17:56 of any difficulties that control were facing in any aspect of its operation yes it was it was not a gendered so any anything could be discussed and what from your best of your recollection sitting there now does anything stick in
00:18:07 sitting there now does anything stick in your mind about things you did discuss with him at those meetings
00:18:11 meetings um
00:18:12 um around well i mean around that time uh two p uh for staff when there was we were looking at outsourcing um
00:18:19 um outsourcing uh sorry um the new training contract with babcock uh whether control would be part of that was was a discussion now he goes on to say
00:18:31 now he goes on to say it's sticking with the paragraph we've got
00:18:34 got in his statement he says my management style this is about four lines down my management style was to set targets and manage performance against those targets this is a particularly useful approach with scott
00:18:46 particularly useful approach with scott because it encouraged him to be more proactive and better communicate with line managers in terms of progress against objectives at the meetings therefore i would require scott to report back to me with up-to-date
00:18:57 report back to me with up-to-date statistics on the delivery of those targets
00:19:00 targets what kind of targets did assistant commissioner brown set you in relation to control
00:19:07 except for the except for the target of answering emergency calls that's the only one i recall right
00:19:15 and how is the performance of the control room managed against those targets
00:19:19 targets we can monitor we can monitor information management could provide us with a with a a weekly or monthly statistic of those calls how those calls are taken and how fast
00:19:31 are taken and how fast so this was am i right about this this was simply a target relating to speed of answering calls speed and and and
00:19:43 speed and and and the speed speed of taking the call and and the call itself and the call itself and those were quantitative analyses they were so no qualitative kpi
00:19:55 they were so no qualitative kpi no there was none set um was any thought ever given to uh including a kpi about the performance of fsg calls and their
00:20:06 performance of fsg calls and their handling
00:20:07 handling not not during the time i was i was tenure
00:20:11 tenure um
00:20:12 um that time of course includes in fact i think it exclusively includes uh the time after the latin house fire is there any reason you can think of why
00:20:23 is there any reason you can think of why there was no kpi applied to the handling of fsg calls notwithstanding what had happened at lachnal no i can't i can't was there any discussion ever about whether there should be a kpi not to my
00:20:35 whether there should be a kpi not to my knowledge right did you ever have to produce any written reports for ac brown um yes on occasion what kind of occasion um i've done a britain report for the la
00:20:48 um i've done a britain report for the la canal uh incident um
00:20:54 i i i have but i can't recall that long that that far at that time ago what i've done but i have written reports from before
00:21:03 before now
00:21:03 now where he says as i've shown you this was a particularly useful approach with scott because it encouraged him to be more proactive and better communicate with line managers in terms of progress
00:21:14 line managers in terms of progress against objectives did assistant commissioner brown ever communicate to you that he was concerned in some way that you were not proactive enough
00:21:25 you were not proactive enough um
00:21:26 um no i i suppose the only uh i think one of my prds was i didn't communicate with him enough but then
00:21:34 but then i was at merton and he was in headquarters and contacting ac brown was sometimes
00:21:40 sometimes difficult
00:21:41 difficult prds just helped me performance right sorry pawns review yeah so our performance uh annual performance um review i can't remember the acronym right you can't remember it no no all
00:21:53 right you can't remember it no no all right uh
00:21:55 right uh did he ever tell you that you were not communicating well enough with your line managers about progress against objectives no i only only he wanted me to talk to him more but when i did try
00:22:06 to talk to him more but when i did try and talk to him i couldn't get through if we go
00:22:09 if we go back a few pages in this statement of page five
00:22:12 page five assistant commissioner brown says this at paragraph 13
00:22:18 i'm so sorry different statement lfb3032166
00:22:23 paragraph 13 page five nfb triple zero three two one six six uh and he says uh at paragraph 13 halfway down i made
00:22:34 uh at paragraph 13 halfway down i made an effort to be fully informed of any issues concerning control arising at the meetings i did not attend i did this through my monthly one-to-one managerial meetings that i had with scott the lfb's appraisal system and the monthly
00:22:46 appraisal system and the monthly departmental management board meetings that scott and the area deputy assistant commissioners dax attended what was the nfb's appraisal system that he's referring to there
00:22:58 system that he's referring to there that would be the the prds but i can't recall what the acronym stands for and um
00:23:06 what were the monthly departmental management board meetings uh so these were the um uh deputy assistant commissioner meetings they were predominantly an operational meeting where
00:23:17 operational meeting where mr brown would meet with his area dacs to discuss issues around what's happening in the brigade operationally predominantly it was predominantly an operation but i was invited onto the board
00:23:31 as control i didn't have a great input into the into the meetings because i didn't really understand all of it it was it was very much operational type stuff right i see it is the
00:23:42 right i see it is the expression departmental management board another name for principal management board uh no it is it's a department with just the operation side of it i think the principle is more or all areas of of
00:23:56 the principle is more or all areas of of the brigade right was it another name for operational directorate management board no that's a same similar sort of attendance but i think there was more departments in that right in that
00:24:08 departments in that right in that and headed by the commissioner i believe right now these departmental management board meetings which are not principal management board meetings or operational directorate management board meetings but something else did you attend them
00:24:20 but something else did you attend them i did attend most of them yeah you did what was the purpose of those meetings as i said they were to discuss um they were to discuss you know what's happening in brigade predominantly operational what's
00:24:32 predominantly operational what's happening around the boroughs any initiatives that are going on they invited
00:24:37 invited people to come and uh talk about fire safety or or something similar but they were just just to get an update on what's happening around around the areas were
00:24:48 happening around around the areas were they minuted yes they were they were and what control issues were discussed at those meetings do you recall um
00:24:55 um predominantly around um vision we talked a lot about vision with the team that there wasn't there wasn't a great deal to discuss with regards to control if i'm totally honest i don't
00:25:06 control if i'm totally honest i don't remember discussing too much but i did try it and have an input when we were starting to move forward with vision right
00:25:13 right and um how frequent were these meetings he says monthly is that correct i believe they were monthly yet so there should be a set of monthly minutes of these departmental management boards
00:25:24 these departmental management boards meetings i think there are did you ever get to see the minutes after the meetings
00:25:28 meetings um they were correct i i don't recall but i think i did right um
00:25:34 um have you seen any such minutes during the course of your preparations to give evidence no um moving on then to the day-to-day workings of control is it right that the day-to-day staff in the control room
00:25:45 day-to-day staff in the control room consists or consisted of operations managers
00:25:49 managers oms assistant operations managers or aoms and control room operators that's correct or officers cras and the oms and aoms i'm sorry to use
00:26:00 and the oms and aoms i'm sorry to use the acronym but it's it's quicker they manage the control room they do and the om has overall responsibility for the watch on duty or shoes
00:26:09 or shoes yes what did that involve briefly um so they would be responsible for um
00:26:16 um incidents that are running at the time they'll be responsible for allocation of work to the supervisors the aoms allocation of of training slots if there
00:26:27 allocation of of training slots if there were any
00:26:30 and just being in charge just being in charge and allocation during during an instant
00:26:38 you say responsible for the allocation of work to the supervisors the aons that's correct i see so this was a um as it were starting down yes i follow
00:26:50 and the members of staff that we've just looked at it's oms aoms and cras they were all part of what we what you call a watch that's correct and there was one operations manager in
00:27:01 and there was one operations manager in a watch
00:27:03 a watch is that right that's correct how many aoms were in a typical watch four i believe and how many control room operators were there in a typical watch
00:27:14 there in a typical watch well there was 16 in total but we would we would staff down as a minimum of 11 i believe
00:27:23 did that 16 in total um change between 2009 and 2019 yes sorry i was talking about the new shift pattern so in 2009 there was four
00:27:36 shift pattern so in 2009 there was four watches of 24 maximum on watch those four watches there was a watch change a shift change in 2011
00:27:46 in 2011 which went to 16 per shift and six watches
00:27:50 watches why were the why were they reduced in number from 24 to 16 um because the fire control project which was running from 2006 when i joined until it took its demise in 2010
00:28:02 demise in 2010 were looking at different shift patterns and they were looking at risk-based mobilizing over the coiled spring effect where you're waiting for something to happen
00:28:12 happen and they proposed this shift pattern and when it when it went away london fire still wanted to to pursue and make changes uh in the
00:28:23 to pursue and make changes uh in the control room so we pursued that that shift pattern with a few a few variations but i don't recall exactly what it was but obviously it was a negotiation and it was accepted by the
00:28:34 negotiation and it was accepted by the unions
00:28:36 unions we refer to risk-based mobilizing over the coiled spring effect it's not an expression i'm familiar with okay so it's a risk-based mobilizing so
00:28:47 okay so it's a risk-based mobilizing so so
00:28:49 so when there was 24 in a room so overnight for example when there were very few calls
00:28:54 calls a lot of people there was it was non-productive there was nothing happening um so
00:29:00 so rather so
00:29:02 rather so rather than have that many people in the room at that time the busiest part of the day was sort of between 1400 in the afternoon and 2200 at night so that's when people go home for their tea for
00:29:13 when people go home for their tea for example and start cooking and and the like and that's where we saw most of the instance so that's where we wanted to move
00:29:19 move the staff to to have more staff at that point
00:29:25 that's risk-based yes i see when the decision to reduce from 24 to 16 as part of a typical watch was made in 2011 was any consideration given
00:29:37 was any consideration given to what might be called spate conditions uh yes again it was i think there was a um
00:29:46 um uh
00:29:47 uh historical data was done over the previous three years over that i think they worked off a 12 pump fire what a 12 pump how many 12 pump fires had taken place between 2 300 no 500 in the
00:30:00 place between 2 300 no 500 in the morning and i think over that three year period there was three and i think one of those
00:30:05 of those and i don't recall exactly but i think one of those was a recycling plant so it was just a container and let burn and the other two uh required more attendances but but not
00:30:16 uh required more attendances but but not overly
00:30:17 overly um so
00:30:18 um so that was what the risk was based on the fact that there wasn't that what the risk had significantly dropped and was there a risk assessment conduct a formal risk assessment
00:30:29 conduct a formal risk assessment conducted
00:30:30 conducted uh over the reduction from 24 to 16. not but not by me by anybody i i don't know you don't know no following on from that do you know
00:30:41 following on from that do you know whether
00:30:41 whether the brigade ever gave any thought at the time they decided to reduce the watch from 24 to 16 uh what might what might happen if there were what were called multiple fsg calls
00:30:53 multiple fsg calls no not not that i recall now
00:30:57 now if we go to your
00:31:01 your uh witness statement number two please lfb3086213 page eight um a paragraph 39 there you say i delegated responsibility for this
00:31:13 delegated responsibility for this training
00:31:15 training and that's that's some control room training to sao som lindsay turner 2009 to 2012 2012
00:31:26 turner 2009 to 2012 2012 uh som or acting som vic bagnall 2015 and som joanne smith 2015-2019 did that same som
00:31:37 did that same som have line management responsibilities for the operations support team ost yes they did yes and what did that involve
00:31:45 involve um
00:31:47 um performance and appraisal of those staff allocation of work to those to those staff
00:31:54 staff a welfare of those staff
00:31:59 we've mentioned soms um can you explain what the role of a senior operations manager or som was um yeah so that so they were responsible
00:32:10 um yeah so that so they were responsible again for you know they deputised for me they
00:32:14 they they run their particular so one of the one of the sums would be responsible for the training or op support the other one be responsible for the on watch um business so it was a it was a um very
00:32:28 um business so it was a it was a um very similar in role to mind but deputising and reported to me and is it right that some turner was in charge of training control room training until 2012 and
00:32:39 control room training until 2012 and then deployed out of control completely that's correct now i'm going to ask you about um brigade control management meetings uh which we've seen something of what was the purpose of those meetings uh it
00:32:51 was the purpose of those meetings uh it was an opportunity for the oms to discuss any issues in the control but it also gave us the opportunity to update the management the management the watch management on any changes in in
00:33:04 watch management on any changes in in the business who attended those meetings um
00:33:09 um myself the somms and the six oms
00:33:14 oms how often did that group meet um i believe it was monthly and who ran them um
00:33:21 um i chaired initially but then to give development opportunity the oms i allowed them to chair they used to rotate it
00:33:32 thank you now i want to examine training now and start with a little bit of background if i may can we go please to your first witness statement nfb triple zero five five one nine one
00:33:45 zero five five one nine one page seventeen let's look together please at paragraph thirty forty seven under the heading training
00:33:51 training you say
00:33:52 you say there in the first sentence training is organized and delivered by the ost and then if you go back please to page 7
00:34:04 back please to page 7 paragraph 20 you explain who the ost is let's just look at that by reference to your your statement if you look under action nine you can see that six lines down you say this
00:34:15 this the operations support team ost are a group of assistant operations managers who carry out a number of training and system related functions they create and deliver all training
00:34:26 they create and deliver all training documentation for control new entrants and provide training packages that can be delivered by on watch staff they develop familiarization and training packages for the updates to the mobilizing system and or changes to
00:34:39 mobilizing system and or changes to mobilizing attendances as well as deliver that training did the members of the ost receive formal training for creating and delivering the training packages for
00:34:50 delivering the training packages for staff
00:34:51 staff um
00:34:54 they did they did but not until not until um
00:34:58 until um 2017 i believe or 2016. it could have been a bit late than that but the existing con the existing trainers
00:35:07 trainers some of them did most didn't
00:35:11 and in 2016 or maybe 17 what who is it who delivered the training uh we asked babcock to come in and do a trainer trainers course for them and they got a level three
00:35:23 them and they got a level three right are you sure that that was before the grenfell tower fire i i'm not sure um
00:35:32 so before the grenfell tower fire to be clear the members of the mst didn't receive formal training for creating and delivering training packages to staff i think one or two of them may have but those long-standing members um but
00:35:44 those long-standing members um but certainly not in my tenure there did they attend courses that i was aware of did anybody ever give any thought to in instituting formal training for members of the mst so that they could create and
00:35:56 of the mst so that they could create and deliver training packages for watch room staff well i mean they were they were delivering the training and that that was the there was no you know it was never raised that they that the training packages were
00:36:08 that the training packages were you know didn't provide what the staff needed well uh that may be um the because uh that nobody knew what to look for so but in short is it is it a fact uh that
00:36:19 but in short is it is it a fact uh that the trainers were not trained to train that is a fact yeah now can we go please to page 17 of this statement and look at paragraph 49 again you say there
00:36:32 in the first sentence since january 2012 training is generally taking place at merton where there is a training room just off the main control room trainer-led training is carried out by
00:36:43 trainer-led training is carried out by the ost
00:36:46 the ost uh between 2009 and 2011 the ost comprised of two groups the brigade control training or bct team and the technical support group tsg the bct which developed and delivered
00:36:58 the bct which developed and delivered training comprised of one operations manager and three assistant operations managers the technical support group tsg provided a system with system changes
00:37:09 provided a system with system changes assistance with system changes and testing
00:37:19 and and you can see what said now the bct there was responsible is this right for creating training packages that's correct
00:37:28 correct uh
00:37:29 uh you go on to say uh on page 18 uh in 2011 with the introduction of the new shift arrangements the two groups merged into the new ost comprising of five assistant operations
00:37:41 comprising of five assistant operations managers from 2011 to 2014 the ost contingent remained at five aoms before reducing to four in april 2014 with the introduction of vision and the
00:37:52 with the introduction of vision and the resulting training requirements in april 2014 the ost was increased to six although the formal establishment figure remains at four um when in 2011 did that merger take place
00:38:04 place uh with the new shift pattern so april 2011 i believe right i see and after merger did the ost continue to carry out training and system related functions
00:38:15 training and system related functions that the tsg had previously carried out yes
00:38:20 yes now at paragraph 50 you say ost are led by one of the soms who have responsibility for the team and workload from 2009 to 2012 this was lindsey turner from 2012 to the end of 2014 it
00:38:33 turner from 2012 to the end of 2014 it was vic bagnol and from 2015 to date it has been joanne smith and as you say i don't think we need to go there but as you say paragraph 38 of your second statement you delegated is
00:38:45 your second statement you delegated is this right you delegated the management of training to your various soms over that decade 2009 to 2019. that's correct what did that delegation mean in practice
00:38:57 practice um
00:38:58 um i'm i wasn't trained as a control officer uh and the the three um soms who were um had controlled background um were better suited to
00:39:10 um were better suited to um
00:39:11 um organize and get that training delivered
00:39:17 so they may have been better organized and trained to get it delivered but did your delegation involve any retention on your part of any form of monitoring supervision
00:39:29 any form of monitoring supervision quality assurance yeah so so um yeah i'd oversight so and it was report by exception if there was anything wrong or needed to be
00:39:40 or needed to be discussed then because i worked in the same building predominantly then it could be discussed there and then
00:39:47 then did you regularly monitor their work um
00:39:52 i wouldn't go in and stand over them no you know i would we would have regular conversations about any issues
00:40:01 how did you know whether they were doing their job properly uh because i had no negative feedback so at the bcmm for example you know there'll be a training section on there we'd ask the uh oms if there's any
00:40:13 we'd ask the uh oms if there's any training issues or what training issues are coming up and nothing negative was brought up at those meetings to indicate that that work wasn't being done
00:40:25 um and how often did those meetings the bc mm meetings i believe they were monthly monthly meetings and they were they minuted they were yeah and uh would you regularly speak
00:40:37 would you regularly speak to the soms about controlled training i'd speak about a number of things but training would be part of that yeah and was that frequent uh certainly during the
00:40:48 uh certainly during the you know from 2009 to 2012 because i attended the la canal boards then significantly amount of amount of discussion on training uh it probably dropped off after that because of course
00:40:59 dropped off after that because of course we're moving on to other stuff and my focus was elsewhere right um and of course i'd expect the songs to report to me any any issues yes and we'll come to that in detail into your course
00:41:10 that in detail into your course uh what responsibles did the somms or soms have in relation to training in general uh to to um you know identify what training was
00:41:21 you know identify what training was required
00:41:22 required uh to liaise with the ost about what that training would comprise on comprised of and ensure that training was
00:41:32 delivered were they responsibility for did they have responsibility for signing off the training yes they did
00:41:41 did they have to consult you when signing off any of the training packages that were developed no but then i'd you know if they were going to deliver something i would i would go in and observe and and look at the training
00:41:52 observe and and look at the training you know and again during the lack an hour period that a lot of that did go on there was a lot of discussion about the training content of training you say you would go in and observe and look at the training but you had no expertise in
00:42:03 training but you had no expertise in being a controller no but as a as a i didn't have an expertise but i don't i don't i could see uh you know from a from a different perspective um what what could be missing you know
00:42:14 um what what could be missing you know the delivery of the training for example did you ever make any decisions yourself in relation to the control room training no
00:42:22 no did you ever consult your own line manager brown or chandler or george from time to time about any decisions that you felt you might need to make in relation to control room training only about outsourcing of training
00:42:33 about outsourcing of training not about content no
00:42:37 can we go to your second statement again please and look at paragraph 37 on page seven
00:42:42 seven lfb 308
00:42:47 uh and uh you say paragraph 37 there uh
00:42:53 uh in the uh second sentence after i assumed head of service in 2016 i was accountable for ensuring that training was delivered prior to this an assistant commissioner would have had responsibility for ensuring training was
00:43:05 responsibility for ensuring training was delivered this would have sat with ac chandler and thereafter ac tom george prior to
00:43:10 prior to 2016. are you saying here that before 2016 you didn't have any responsibility at all for ensuring that training was delivered i did have responsibility for
00:43:21 delivered i did have responsibility for right yes of course uh you say yes of course it's not crystal clear from a paragraph but that's that you've clarified that but what about the period between may 2009 and may 2012 before
00:43:33 and may 2012 before uh assistant commissioner chandler was appointed
00:43:36 appointed again
00:43:37 again did you have any responsibility at all for ensuring training was delivered at that time yes you did and what about between october 2013 and march 2016 in the period between
00:43:48 in the period between uh chandler and george's appointment yes yes
00:43:54 yes yes um
00:43:56 um you
00:43:56 you you why do you say that
00:43:59 that it was only in 2016 that you were accountable given that throughout that period you were line managing the soms responsible for the training so i can say that again please
00:44:10 so i can say that again please well you see you say in this paragraph i've shown you you say after i assumed head of service in 2016 i was accountable for ensuring that training was delivered why are you limiting yourself only to the period after you
00:44:22 yourself only to the period after you assumed head of service in 2016 uh given your
00:44:26 your your
00:44:27 your uh acceptance that you had responsibility for ensuring training was delivered i had yes sorry i had responsibility for training but accountability would have sat with my life manager
00:44:38 life manager oh i see so by the word accountable you don't mean responsible do you ultimately respond yes i see
00:44:45 and who had ultimate responsibility for the decisions made about control room training
00:44:50 training was that um the person occupying either ac chandra or ac george or ac brown's position
00:44:58 position in my opinion yes in your opinion but what about in fact well you know i'm responsible for but i've got a manager above me who's accountable for control right so i would
00:45:10 accountable for control right so i would say that they would be responsible they will be accountable for it right and how much day-to-day oversight uh
00:45:17 uh did ac brown have in relation to training
00:45:22 uh not a great deal to my to my knowledge
00:45:25 knowledge what about ac chandler um he was in the control room more and more uncles he he didn't understand control as much so he spent more time um but again
00:45:37 um but again probably not a great deal and what about ac george
00:45:40 ac george uh again
00:45:42 uh again not a great deal so the people ultimately responsible for ensuring that training was appropriate and suitable
00:45:51 didn't actually exercise very much oversight no so would i be right in understanding that
00:45:58 that in practical terms it was the senior operations managers who decided what training ought to be given and of what kind yes sir yes thank
00:46:10 given and of what kind yes sir yes thank you very much and then they were responsible for delivering it through the ost which was a group of uh operation managers and assistant operations it was assistant operation
00:46:21 operations it was assistant operation managers yes that's correct now turning to the question of identification of training in your first witness statement if we can go back to that please lfb triple zero five five one nine one
00:46:33 lfb triple zero five five one nine one page seventeen paragraph forty eight you say this
00:46:38 control senior management reviews the training need for staff on an ongoing basis to identify new themes and ensure that lst creates training packages for these i.e jezip
00:46:49 these i.e jezip mtfa
00:46:51 mtfa and deliver these to all staff again training on these packages is recorded by ost and uploaded onto step step uh
00:47:00 uh just help me what's mtfa mobile terminal something marauding terrorist firearm right i was wrong right marauding terrorist firearms uh and step
00:47:12 uh and step it's it's an expression we see and we'll come to later but could you just tell us what that stands for yeah it's an automated it's an automated system which allocates staff to training courses and
00:47:24 allocates staff to training courses and records training now in the first part of the first sentence there you refer to control senior management who review the training need for staff who are you referring to there the um
00:47:36 referring to there the um senior operations major that's the som yes right
00:47:39 yes right and did they identify the topics on which training they thought was needed um
00:47:44 um yes through through what was required operationally so so for example mtfa the marauding terrorist firearms um
00:47:55 um that would have been identified after
00:47:59 after the incidents we had so a training package would have been created and delivered to support that i see so the topics were identified really as a part of a reactive process to
00:48:10 as a part of a reactive process to events
00:48:11 events yes uh the only difference i suppose i know even even jessica which is a joint emergency services which was a which was a country-wide initiative which was obviously fed down to brigades that we
00:48:23 obviously fed down to brigades that we needed to train on and you say on an ongoing basis control senior management reviews the training need for staff on an ongoing basis how regular were those reviews
00:48:34 basis how regular were those reviews uh carried out quite regular uh you know because if it wasn't external training like the jessep or mtfa then internally there would be changes to the mobilizing system which required a tweak to how
00:48:47 system which required a tweak to how something's mobilized or delivered or even the local london fire brigade may change a
00:48:53 change a um the attendance to an incident which would require a change to the system which would require some sort of familiarization or training right and were those reviews documented
00:49:04 were those reviews documented not that i'm aware of right was it only the ost who developed training for control staff um
00:49:16 yes if if we if we got a training package in we the training staff may have to change it to to make it work for a delivery of our trainer to our staff
00:49:28 our trainer to our staff right so so for the best of my knowledge yes we did uh but we may have taken presentations from elsewhere and made our own package up when you say if we
00:49:39 our own package up when you say if we got a training package in who would send well for example um jessip had a training package i believe um and
00:49:49 um and we would have had a presentation for that but we may have changed it a bit to to make it make it more for us make it more local right well jessica is a as you say an example of a
00:49:59 of a nationwide initiative yes uh which we know about but but a training package which came from within the brigade through the tcap process would you include that as something that you might
00:50:10 include that as something that you might have to change when it got to the doors of the control room if it was uh if it was to do with with system changes then yes why would you have to do that can you be more in what relation
00:50:23 can you be more in what relation whether when you say that there may have to be changes in training packages whether you're including those training packages devised and developed by the brigade itself well we didn't we weren't involved in the in the bigger
00:50:34 weren't involved in the in the bigger bigger
00:50:35 bigger brigade training uh anyway because we were
00:50:39 were you know we did our own local training we weren't part of the brigade-wide training
00:50:44 training so no
00:50:47 do you remember whether any particular problems were picked up by ost you know in training uh
00:50:56 uh all the topics that were being suggested
00:51:00 um the time it would take to create them and deliver them would probably be one of those right now turning to that question of delivery if we stay with this statement please and go to the next page page 18
00:51:12 and go to the next page page 18 paragraph 52 you say that due to the need to ensure con the controller is able to continue to carrying out its day-to-day functions most training by necessity is delivered
00:51:23 most training by necessity is delivered to staff
00:51:24 to staff who are on watch this means that if there is a significant incident or a sudden increase in calls the staff including the ost might be recalled to their positions in the control room to answer
00:51:36 positions in the control room to answer and handle 999 emergency calls now was that always how training was arranged for control staff during that decade
00:51:45 decade um 9 2019 the only time i've saw it differently is when we had a not long after i joined we had a major uh update to pro cad the mobilizing
00:51:56 uh update to pro cad the mobilizing system
00:51:57 system where
00:51:58 where we took staff off the watch and trained them that way so yes except for the pro cap experience yeah
00:52:08 why not arrange training for staff not on watch in order to avoid the risk of interruption of which you speak here uh
00:52:15 uh because
00:52:18 because the pro the problem is with it is because we don't have we don't have spares to come in and cover those positions so we don't have ridership
00:52:29 positions so we don't have ridership uh that the number we've got is the number we've got so to maintain service delivery
00:52:35 delivery uh we felt the training we better done or the training has been done on watch that way
00:52:40 that way i mean
00:52:41 i mean in a nutshell does that just mean that you don't have enough people to cover a watch well i mean i mean the the frequency of having to take staff off training to to deal with an incident was was not very
00:52:53 was was not very not very often so it it didn't actually happen hence why why it worked right
00:53:01 right but but coming back to my question why not arrange training for staff not on watch in order to avoid the risk of interruption
00:53:09 is one answer or the answer to that that this was a resourcing issue well i mean during that period we did we were reduced and resourcing because of course we were
00:53:17 we were going out to other projects and and i couldn't i couldn't backfill those positions but i'm not saying that we didn't have enough staff we had enough staff to deliver a day-to-day service and deliver
00:53:28 a day-to-day service and deliver training can you just help me understand how this worked in practice you would have
00:53:34 have 16 people in for uh well in 2009 now it's been a minimum of 16 yeah right so you've got 16 people present at the controller that's correct
00:53:46 controller that's correct all potentially ready to answer calls correct would you take some of them off and leave some of them on yeah you know we could take two or two or three or four off at a time if the room was quiet
00:53:57 four off at a time if the room was quiet and still maintain the service and the the training room both at um island dogs and at
00:54:04 and at uh merton were off to the side of the control room so they were they were literally you know five feet away maybe um and that's how they would that's how they would train right and then the watch would run for a period of how many
00:54:16 watch would run for a period of how many hours
00:54:18 hours um
00:54:19 um well ten and a half hours before the watch change right so and any idea roughly
00:54:25 roughly what a training session would take um a couple of hours depending on what the subject matter was if it was a system if it was a system update it could be 20 minutes half an
00:54:37 update it could be 20 minutes half an hour just to run through that run through that you know to to something more like uh i don't know mtfa i'm not sure a two-hour presentation all right and then at the end of the watch they
00:54:49 and then at the end of the watch they will go home no they'll go they'll finish their watch yeah i'm saying yes so the only alternative to training them in the way that you describe by taking them a small number
00:55:01 describe by taking them a small number off the watch presumably in in turn
00:55:06 in turn is to have them in when they would otherwise be at home yes
00:55:10 yes well you i mean you could you could bring them i mean they do external training does exist for staff and when you when they do go out and do a leadership course for example they
00:55:21 a leadership course for example they they'll have time off before time off after and that time so they'll probably lose an entire shift on that and we could do that in ones or twos
00:55:29 twos but doing it for a whole you know for a number of staff is is very very difficult to resource because i don't have other people to bring in to cover those positions thank you that's very helpful
00:55:40 thank you that's very helpful now we're talking about refresher training obviously yes new entrance training
00:55:45 training uh
00:55:46 uh and we're talking about numbers of 16 or perhaps latterly towards 2017-11
00:55:52 2017-11 because there was a further reduction wasn't there there was yes uh just just help me on that why was there a further reduction from 16 to 11. no sorry no it was still 16 but we use an
00:56:03 it was still 16 but we use an abstraction rate in the in the room so so you know we take into account sickness holidays uh and just general abstinence so so whilst our session will be 16 our actual strategy will be
00:56:15 be 16 our actual strategy will be 11 people as a minimum in the room and um
00:56:21 and um the question is why not just pay your staff over time to make sure that they were properly trained off the watch without interruption um
00:56:32 um because i can't make people come in on overtime for one um
00:56:38 um we use over time we used over time excessively to to maintain our what our watches because of we'd obviously
00:56:49 allocated staff to other other roles um and of course between between 2000 and um 12 and 13. um sorry 2011 and 12 we were being
00:57:01 um sorry 2011 and 12 we were being outsourced so i couldn't recruit against that so i was always i always had less staff than i needed that i could like i have right
00:57:10 in relation to the scale of this problem though uh and we'll come to this in detail later on in your evidence but the refresher training was only annual wasn't it that's correct was only supposed to be
00:57:21 that's correct was only supposed to be annual yes and therefore if you're taking people uh
00:57:26 uh if you're training no more than 16 people
00:57:29 people it's not particularly resource intensive is it to train them off the watch 16 people once a year
00:57:38 at that time it was yes and it wasn't just it wasn't just that training which is important in itself it was the other training and what was going on at that that time and the priorities uh you know
00:57:51 that time and the priorities uh you know the priority was was vision training at that time
00:57:55 that time that was 2015 wasn't it well yeah but it started it started in 20 in 2012 2013. we'll come back to this topic in due course when we look at some contemporaneous documents um but
00:58:06 um but if we um look at uh paragraph 54 please in this statement on the next page page 19 you can see that at line four there
00:58:18 you can see that at line four there paragraph 54 you say the watch supervisor nominates a proportion of staff on the watch to attend the sessions depending on the work led within the control room at the time and the number of staff available on each shift again taking into account sickness
00:58:30 shift again taking into account sickness and other leave those allocated staff are then taken out of the control room and moved into the training room next door
00:58:37 door so
00:58:38 so do we understand from that that the training room where all the control training took place was immediately next to the control room that's correct does that say that the control staff could swiftly return to their duties if they need a if they need a raise
00:58:51 they need a if they need a raise that wasn't the primary it was just the fact that it was a it was next to the control room because we could there was additional pods there that they could set the system up with right but but it was just the nature of it is they could
00:59:02 was just the nature of it is they could walk back into the control room and what would happen to the training which was interrupted in the event that the control staff did have to be recalled to their duties it would be held at that point and then resumed either after or another time did that did that happen
00:59:14 another time did that did that happen frequently not to my knowledge no and would it be finished at some point later it would be finished yes right and how would that be arranged the ost would rearrange with those staff
00:59:26 the ost would rearrange with those staff that didn't finish to redo it would the training be recorded
00:59:30 recorded it should be recorded yes how would it be recorded on a manual spreadsheet uh and were there any problems with staff not being able to complete the training um due to them having to return
00:59:41 training um due to them having to return to the control room were there any problems yes not not to my knowledge were there any instances of of incomplete training sessions because of an interruption not to my knowledge
00:59:53 of an interruption not to my knowledge but it's right i think that the training sessions held in the way they were with the on watch staff in the room next to the control room we're always at risk of imminent interruption and non-completion
01:00:04 imminent interruption and non-completion yes that's true that's true yeah can i ask you then about monitoring of training did you monitor the training to make sure that the training being given by the ost was
01:00:15 training being given by the ost was actually happening no but i would expect my som training to report to me by exception if it wasn't
01:00:23 right why didn't you monitor to make sure positively that the training being delivered by the ost was actually happening because i i i didn't want to micromanage staff i i wasn't in control
01:00:35 micromanage staff i i wasn't in control all the time i had a number of competing projects and and things that need to be done i couldn't i couldn't spread myself that thinly hence why i had two senior operations
01:00:47 hence why i had two senior operations managers to be able to do that did you monitor to ensure whether the training that was being delivered was achieving what it was supposed to yeah and well i mean again feedback from brigade control
01:00:59 again feedback from brigade control management meetings and feedback from psalms would would have given me an indication if that wasn't the case so you say i think you described it as uh
01:01:08 uh as
01:01:10 as negative
01:01:12 negative uh
01:01:14 uh does this tell us that your approach to monitoring the training both in
01:01:20 in in terms of actually being delivered and in terms of its quality what was to rely on
01:01:26 on instances of negative feedback from the soms and if they didn't feedback negatively you assumed that everything was running smoothly uh
01:01:38 no because at the beach at the bcmm if if there was an issue with training there was a line for training if there was any issues with training if staff weren't happy with the quality of training it would have been raised at the brigade control
01:01:50 have been raised at the brigade control management meeting if at my some meetings or my some discussions there was any concerns with training they would have been raised there to my knowledge that there was there was none yes i mean to put my question in a
01:02:01 yes i mean to put my question in a slightly different way your is it right that you're you regarded your monitoring role as one of waiting to hear negative things from soms and if they didn't feedback negatively you assumed that everything
01:02:13 negatively you assumed that everything was running or perhaps negative wasn't though it wasn't a a report by exception yeah so if there was a problem with training or problem training wasn't being delivered i would have expected to
01:02:24 being delivered i would have expected to be told yes but you never took it on yourself to make any spot checks surprise checks to see that the training was being carried out and that it was being carried out to uh the training required objective the
01:02:35 uh the training required objective the training room was was opposite my office that walked straight into the control room so i would walk through that door and see training taking place so i knew training was taking place yes you knew it was taking place but you
01:02:46 yes you knew it was taking place but you didn't know whether it was taking place and had been completed and you weren't able to monitor its quality is that is that right i i didn't look into it in that detail no
01:02:58 into it in that detail no now i'd like to ask you about two processes that were in place during your time as pom which may have given some indication as to performance of the control room and those two processes are
01:03:09 control room and those two processes are call coach remember something called call code and fsg review yes yes um now um i just wanted to show you first on call coach what som smith
01:03:22 you first on call coach what som smith joanne smith says about this in her witness statement um can we go to lfb double zero one two one two one nine page seven
01:03:36 paragraph seventeen and she says this under the heading call coach 2010 to 2012 one technical function that i was responsible for delivering during this period was call coach
01:03:48 during this period was call coach when i was head of the technical team from 2010 to 2012 control was using the procad mobilizing system and i was responsible for procuring a new quality assurance system in 2010 which was call
01:03:59 assurance system in 2010 which was call coach we use this program to monitor and review lfb's call handling standard i exhibit a note which sets out in detail this process as js2
01:04:10 supervisors have a responsibility for three or four cras and so they listened to three calls a month for each of these individuals and graded them against the control call handling standards which he exhibits as js3
01:04:23 standards which he exhibits as js3 cros received a monthly appraisal of their call handling techniques from their supervisors on this basis supervisors and or line managers would then identify additional learning or training points for cros through this
01:04:35 training points for cros through this process
01:04:36 process now i've read you quite a bit of that mr um mr hayward were you aware first of call coach yes i was you were do you know why it was introduced um it was it was something to assess
01:04:49 um it was it was something to assess um
01:04:51 um the core handling um
01:04:53 um of control staff and do you know when it was introduced uh i think we purchased it around 2009 but it wasn't introduced until about 2011 because there were some issues with
01:05:04 2011 because there were some issues with the union
01:05:06 the union are you able to say how often fsg calls were included in call coach reviews it was it was a random dip so because it was a standalone system rst would need to lift calls out and we couldn't
01:05:17 to lift calls out and we couldn't identify what those calls were so they were randomly lifted and given to aom so so no i can't um but what i can say is if they're you know um we would listen to fsg calls and
01:05:30 know um we would listen to fsg calls and any call of uh if there was any issues and take out that core coach process and deal with it that way were you involved in monitoring the results the call coach yes uh yeah we would see
01:05:42 the call coach yes uh yeah we would see we'll see some of the some of the feedback from from ioms of what staff had done
01:05:47 had done did you discuss those um results all that feedback with the sons with joe yeah with joe joe smith yeah joe smith and do you know oh can you remember how often those reviews were carried out
01:05:59 often those reviews were carried out um
01:06:00 um i can't
01:06:01 i can't it wasn't it wasn't regular but it did occur right well any reports written reports provided to you no because they come on a sheet so the the call handling standard was a a tick
01:06:13 the call handling standard was a a tick sheet
01:06:14 sheet if i remember rightly and then there would be comments on those tick sheets whether they were kept um
01:06:20 um if there was no if there was nothing to report then i wouldn't have thought they were kept but i imagine they'll be kept on the watch right and did you report the results to your seniors ac chandler ac brown
01:06:33 to your seniors ac chandler ac brown lucy george not that i recall um let's go to lfb double zero one zero nine zero eight two
01:06:44 uh this is a draft of an audit of quality management systems prepared by station manager steve kelly i think also went by the supra k of ned
01:06:57 i think also went by the supra k of ned kelly didn't he he did indeed yes um dated the third of august 2010 uh which was an audit of the brigade control training department and specifically fsg wasn't it yes
01:07:09 wasn't it yes you remember this document i don't you do and now this draft the one we're looking at on the screen is one which carries um some smith's comments which she inserted on the 11th of august 2010 so a week or so after the date that
01:07:22 2010 so a week or so after the date that you can see on the screen can we go to page 9 in this document paragraph 67 there under the heading quality management and assurance that you can see just at the top of your
01:07:33 you can see just at the top of your screen paragraph 67 says this
01:07:37 says this control officers and team leaders are subject to a monthly review by line managers using the call coach system a confidential assessment of performance is conducted against set criteria on a one-to-one basis using the imported
01:07:48 one-to-one basis using the imported audio files to support discussion and feedback this provides for a very effective workplace assessment of staff now there's a comment you can see in the
01:07:59 now there's a comment you can see in the comments box on the right of the screen by joanne smith which he is inserted and
01:08:08 that says um not according to our data and the opinions of our om you see that yes um
01:08:17 um were you aware of some smith's poor opinion of call coach at the time yes you were she brought that to your attention did she she did yeah what did she say well she said that
01:08:28 said that it was a clunky system because it was standalone and
01:08:33 and the the way it was picked it was just very very um very clunky trying to get staff to uh trying to get it to staff so staff could do a good job of doing a
01:08:46 could do a good job of doing a an assessment of the call so it was it was more about it was a fact that the system was put in um
01:08:55 transferring those calls over to over to the aom's to listen with their cross it was just a clunky system but as time went on um it did get it did get better or not
01:09:08 um it did get it did get better or not it didn't get better but staff worked around it
01:09:10 around it right so would it follow from what you've just said that call coach was considered certainly by some smith at least
01:09:18 least not to be an effective way of identifying new training or learning points for control room officers yeah i wouldn't say that's an unfair assessment what would they but but it did say but
01:09:29 what would they but but it did say but what it did do it highlighted it highlighted some um callers
01:09:36 callers um
01:09:38 um processes when take when when answering a call so they're they're greeting and what they're looking for so it did it did help i think some control officers on the whole though it wasn't considered a great system when
01:09:50 wasn't considered a great system when you say callers i think you mean call handling sorry yes of course uh and uh did you think at the time of
01:09:59 of looking at adopting a different method for assessing call handling uh no because we we'd not long purchases it took us nearly two years to get it into into the
01:10:10 into into the system going through the unions so i wanted to give it a after the money was spent on it to use it right and it did what it said on the tin it was able to break down calls for
01:10:22 tin it was able to break down calls for them it was just the way it was done
01:10:26 so you stuck with it yeah because at that time i mean i don't know what but you know we were looking at new systems after that anyway we should have bought a new a new process along anyway
01:10:37 along anyway so there was nothing else to there was nothing else to that was the only any system we had well that may be the only electronic system but did you think about adopting a different method um perhaps using human beings to assess
01:10:49 um perhaps using human beings to assess uh call handling well human being human beings were used because of course you listen to the call and it's it's discussed with with the aom and the cro so that that was this was just a a way
01:11:00 so that that was this was just a a way of breaking down that call into chunks um now can we go to your first witness statement again please at page 39 and look at paragraphs 96 and 97
01:11:13 look at paragraphs 96 and 97 and i i summarize i think there but in in summary you say that in november 2015 cool coach was replaced with a system called nice nice
01:11:25 nice nice and the discussions about using nice were still ongoing in 2019 which was the time you wrote your statement and control was not conducting random reviews of calls have i summarized your evidence i think that yes i believe that
01:11:36 evidence i think that yes i believe that that was the case yes nice what does nice stand for i i don't remember i'm sorry
01:11:41 sorry uh is it right that no reviews of calls were taking place from at least november 2015.
01:11:47 2015. yes correct right were you aware of that at the time yes did you not do anything to try to rectify that not in 2015 why is that because i had so much dealing with vision i didn't have the
01:11:58 dealing with vision i didn't have the opportunity to look at anything else at that point did you see the value in regularly assessing calls through cool coach clunky though it may have been as a system uh we couldn't use call coach with with this the new system it was a
01:12:10 with with this the new system it was a standalone system and it wouldn't you couldn't interface it with vision so it become obsolete right um mr chairman i'm coming to a slightly different topic
01:12:21 slightly different topic right still on the main um topic itself is that a convenient point it's a convenient effective yes all right that's right well it's a little earlier to take a break than we did normally but as you know we have a break
01:12:32 normally but as you know we have a break every morning and we'll take it now we'll come back please at half past 11 okay and i have to ask you please not to talk about your evidence or anything relating to to anyone else okay so thank
01:12:43 relating to to anyone else okay so thank you
01:12:44 you all right thank you thank you very much would you go with the usher then please
01:12:56 thank you i'll fast 11 please
01:30:42 would you ask mr haywood to come back in please
01:30:56 all right mr hayward ready to carry on i'm indeed thank you sir yes thank you yes mr miller thank you mr chairman um mr haywood we looked at call coach uh now we want to look please with you at the fsg review
01:31:07 at the fsg review conducted by s.o.m smith can i ask you please to look at her witness statement at
01:31:15 two one lfb001212
01:31:16 one nine page eight
01:31:21 and she says this at paragraph 18 under the heading review of fsg calls she says in addition to my role before i was seconded to the cfoa i reviewed all
01:31:32 was seconded to the cfoa i reviewed all fsg calls after the latin house fire i recall i asked the tsg to collate every fsg call and high rise call which was entered onto the system i listened to all these calls to ensure that the correct advice was given in accordance
01:31:44 correct advice was given in accordance with pn539 and our general call standard was achieved exhibited above the js3 this fsg call review process was not a formal requirement following the fire at
01:31:55 formal requirement following the fire at latino house but it was one i undertook of my own initiative having informed the pom scott hayward of this uh and then she goes on any fsg calls
01:32:06 uh and then she goes on any fsg calls stroke high-rise calls that were dealt with well by cras may have generated such positive feedback to the call handler and i exhibit an example of such feedback at js4
01:32:17 feedback at js4 first do you agree that you discussed the commencement of that fsg review with some smith as she says yes can you remember why she decided to undertake that review
01:32:28 that review um
01:32:30 um i don't recall exactly why uh i think i think fsg calls were um
01:32:37 um you know they were an important call and it was right that we should listen to all the calls and and she come and said that she would do it i don't recall the exact reason reason why post post um black now and the types of
01:32:50 post post um black now and the types of calls that were made and the fact we've introduced some new some changes to the training
01:32:54 training it was just to see to make sure that training had taken hold right
01:32:58 right do you remember whether she was the only one to undertake that review
01:33:05 she listened to all the fsg calls but you know we all did um i know that um uh mr krinion did uh and because it was all in the same office we'd listen to it
01:33:16 all in the same office we'd listen to it all at the same time but it was predominantly um um mr barza did it sorry smith it was steve austin's her major yes
01:33:24 major yes correct was the review that she carried out
01:33:27 out carried out using call coach i don't recall no i i don't believe it was i believe just listen to the calls right do you know why it wasn't simply subsumed into the regular call coach
01:33:39 subsumed into the regular call coach assessments that all supervisors were asked to undertake because the fact that um
01:33:45 um that she was listening to all fsg calls anyway and the fact is they were randomized we can't we couldn't choose the system wasn't intelligent enough to choose a particular call from the system
01:33:56 choose a particular call from the system to drop into call coach i see what oversight did you have of that review
01:34:01 review she would talk to me about about those calls and we would listen to calls that were
01:34:06 were that didn't have anything or or added something in that call and we'd ensure that the om in charge of the watch was supposed was told so they could they could speak to their cro about it were
01:34:18 could speak to their cro about it were her findings as a result of this review recorded anywhere not that i recall why is that
01:34:24 is that i don't i don't know did that review continue when or rather once some smith was seconded to the cofa in 2012. uh it was some diamond and sombagno at that
01:34:37 it was some diamond and sombagno at that point i believe when when she went to see fowa
01:34:41 see fowa and fsg calls were listened to yes so so did they continue the review process that they would listen to all fsg calls that come in that coming to come in right and that review was that a
01:34:54 come in right and that review was that a review looking back at all of those historically or a review on a call by call basically call by call basis i see
01:35:03 so what would what how would this this work there'd be an incident at which there'd be an fsg call or maybe more than one fsg call at what point would the call be reviewed by
01:35:14 by either uh
01:35:16 either uh um some smith or som diamond or bagnal if the if the call was downloaded it could be listened to the following day that afternoon there was no specific time frame given to when that call should be should be
01:35:28 to when that call should be should be listened to right but it would have been it would have been listened to um
01:35:33 um any issues identified would be fed back to the om of the watch where the call taker who made the call right and any action taken you know going through that call maybe through
01:35:45 going through that call maybe through call coach before we lost its capability um and to go through that corn break it down and see what was missing right and when did you lose cool coach's capability
01:35:56 capability uh as
01:35:57 uh as when vision come in so 2015 2015 um and was there any um
01:36:04 um record of the issue being identified and then fed back to the om of the watch and taken further not i'm aware of it was done locally was there a system in place whereby the
01:36:15 was there a system in place whereby the problem identified from a particular call by that review process was
01:36:20 was um set up for training so that it could be trained um
01:36:26 um not that i'm aware of but then these were these were omissions of um you know potential emissions of a question being asked for example it was already in the training it was just omitted by the call
01:36:37 training it was just omitted by the call the call taker was this a system in place whereby these calls were reviewed and trends identified so that trends could be reversed through training not that i'm aware not i'm aware of where's that
01:36:50 because each call is is different so it's a and it's not it's not scripted like uh like a um you know they are free to ask they are giving guidance on what sort of questions to ask so each call
01:37:02 sort of questions to ask so each call could be different or every call taker will say something slightly differently so i don't i don't and i i don't recall there ever being trends of saying or not saying something
01:37:13 of saying or not saying something now um if you go to paragraph 19 s.o.m smith says this joanne smith says this i do not know if this review of all fsg stroke high-rise calls continued
01:37:24 fsg stroke high-rise calls continued when i was seconded to cf cfoa in 2012 but when i returned in 2015 i once again requested and reviewed all fsg calls it was no longer possible to monitor all high-rise calls due to the volume of
01:37:36 high-rise calls due to the volume of calls the lfb now receives in relation to high-rise incidents now did those reviews in fact continue after some smith left for the cfoa and
01:37:47 after some smith left for the cfoa and then came back i'm not quite here i understand the paragraph it's uh it was no longer possible to monitor the harass course due to the volume of calls the lfb now receives in relation to high roads
01:37:58 receives in relation to high roads incidents
01:37:59 incidents so we'll talk about fsg calls not not not calls to high-rise incidents which don't always generate fsg so i'm not quite sure the question uh well
01:38:11 uh well let's break it down first when som smith returned from the cfoa which was in january 2015. yes
01:38:20 yes did she discuss with you continuing her fsg reviews that she had been doing before she left in september 2012. not that i recall but she could well are done right
01:38:32 she says uh as you can see that she requested and reviewed all fsg calls do i take it that she if she did that she didn't raise that with you no she would have just
01:38:43 that with you no she would have just gone and got the calls again uh
01:38:46 uh did she raise with you do you remember any concern that her reviews hadn't continued in her absence no
01:38:53 no did she discuss with you what discussions she had had with som diamond or som bagnol about their reviews in her absence no not lyra core
01:39:04 uh you mention or you pick up on the fact that she identifies both fsg and high-rise calls almost as one of the same
01:39:16 was that to your knowledge um the subject of her fsg calls in other words she was looking at fsg calls only from high-rises or all fsg calls and all
01:39:27 from high-rises or all fsg calls and all high-rise calls i i believe she's looking at all fsg calls regardless of whether it's high-rise or not can you can you tell me me from your own knowledge what the relevance
01:39:37 relevance of high-rise is in a fsg review
01:39:47 well because we we deal with a high-rise uh instant differently do we do to other buildings
01:39:55 buildings because of course we have a stay put
01:40:02 now can i ask you about how control training was planned different topic can we go please to your second witness statement lfb triple zero eight six two one three page seven and let's look to
01:40:13 one three page seven and let's look to together at paragraph thirty seven you say there that the ost was responsible for establishing and maintaining the recurring training plan as directed by the som
01:40:24 the som who in sost who in ost did you expect to establish and maintain the recurring training plan there are four standing iom assistant operations managers in
01:40:37 assistant operations managers in uh in ost
01:40:39 uh in ost and the expectation is is those four that would maintain uh maintaining the reoccurring training plan right was that plan ever recorded in a formal written document not that i recall
01:40:51 not that i recall again why is that do you know uh no it just it hadn't been done in the past so
01:40:57 past so it just hadn't been considered so did the how did the aoms know what the recurring training plan at any time being maintained was if they didn't have a document to refer because
01:41:08 didn't have a document to refer because the psalms had meetings with them and would tell them so it was kept in people's heads was it um i i believe it was recorded on a on a
01:41:19 um i i believe it was recorded on a on a training planner um i know at one point it was you it was put on a smart ball behind behind them that would that would establish what
01:41:30 that would that would establish what dates and dates of what training would be
01:41:33 be right
01:41:34 right but it wouldn't establish or wouldn't identify what the content of that training plan was to be or the desired outcomes would it
01:41:43 it no the type of training and what was being trained would be recorded right
01:41:49 did ac brown ever ask you to produce a a recurring training plan uh not to my knowledge what about ac chandra or ac george not
01:42:00 what about ac chandra or ac george not to my knowledge did you ever discuss the recurring training plan with the relevant som whether it was uh
01:42:08 uh whether it was joe smith or whether it was soms diamond or bagnal
01:42:15 outcomes reports we talked about reoccurring training you say after the latino outcomes report is that the the latino control report of november 2012 yes right
01:42:26 november 2012 yes right did you monitor the creation and development of those returning recurring training plans yourself yes to start to start with yes what did you do
01:42:35 you do well because we agreed we agreed when knows when that training was to take place from what the content of the training so it was an annual a bi-annual full day and then uh the other year would be a cbt oh this is
01:42:46 the other year would be a cbt oh this is the this is the process was it yes i think you're describing one of the actions or some of the actions comprising the 34 actions post lacanal but pre-inquest yes yes and we'll come
01:42:58 but pre-inquest yes yes and we'll come to those in detail okay in your evidence later on
01:43:01 later on was there any other formalized structure or any formalized structure under which the control room training needs were identified and managed uh the only uh training needs we did at the time was
01:43:13 training needs we did at the time was for the aom supervisor um pro course
01:43:17 course um the the issue with the training of of control staff uh was the was the fact that they do a cro training course and then there was nothing else after it
01:43:29 nothing else after it so
01:43:30 so all the training was was reactive predominantly um and it was it was done on a needs basis as opposed to a regular to start with and then your last answer where you
01:43:41 and then your last answer where you where you refer to a cro training course is that's the new entrance training is it yes no entrance training course yep do you agree that control
01:43:52 do you agree that control should have a structured training plan in place yes
01:43:59 um
01:44:01 can i just ask you to look please at inq three zeros four
01:44:09 now this is the first page of a document called fire service manual volume one fire service technology equipment and media
01:44:20 equipment and media communications and mobilizing published by hm fire service inspectorate and the date of publication uh although it's not on your screen is 1998.
01:44:32 it's not on your screen is 1998. are you familiar with this document i'm aware of the document i'm not familiar with it
01:44:36 with it right can i can i then show you something in it and see if this triggers a
01:44:41 a uh a recollection can you please go to page one two nine this is appendix one which is um headed control staff training competence and promotion
01:44:52 training competence and promotion and at the very foot of the screen in the left-hand column you can see that it says this through training of personnel the brigade will respond to the needs of those it serves by defining training needs and providing
01:45:03 by defining training needs and providing the most effective means of fulfilling those needs thereby providing a quality service
01:45:08 service training for control personnel has always been hindered by the small numbers of staff available and the need to maintain cover in the control center training is usually watch related and carried out at the normal place of work
01:45:19 carried out at the normal place of work this ensures the maximum number of personnel available for these reasons brigade should consider the provision of a training officer and or watch training days away from control
01:45:30 days away from control were you familiar uh with any of those statements or principles i was aware that in the past um staff did detach and go to the fire
01:45:41 detach and go to the fire training school and do control training certainly for managers but it didn't exist when i arrived at control i've seen i've seen this
01:45:53 control i've seen i've seen this document in when i was doing on the la canal investigation yes so we we did we did have a look at this document well exactly i was going to ask you this document i think is is uh referred to extensively and i
01:46:06 is uh referred to extensively and i think in part verbatim in the latino control report of november yes 2012 but but it wasn't it wasn't used as part of the um gap analysis that's a different exercise which
01:46:18 that's a different exercise which happened in 2010 isn't it yes yes and we'll come to that as well but just just in general terms to your knowledge uh were the principles that i've just read to you from this page of the manual
01:46:29 read to you from this page of the manual from 1998 to 1998 ever used as a benchmark or a standard for control room training after after 2009. and the only as i say the only time we detached
01:46:41 as i say the only time we detached staff to do training that i recall was when there was a major update to the program the pro cad mobilizing system um where we took what took staff away to go and train that
01:46:54 go and train that the rest of the time it was done on watch
01:46:56 watch right
01:46:57 right was there ever any discussion to your knowledge within the brigade about diluting or abandoning these principles during the period 2009 lachnal and
01:47:10 can we go then please uh to the
01:47:15 the a different document which is the 1993 uh home office circular this is at lfb403617
01:47:25 i'll show you the first page of this document
01:47:29 which the inquiry has seen before
01:47:34 in phase one and it's a letter from the home office to the chief executive county councils and the clerk to the fire and civil defense authority and the the chief fire officer it's sometimes
01:47:45 the chief fire officer it's sometimes known as the dear chief fire officer uh letter of the 12th of october 1993 dear sarah madden fire service circular 10
01:47:55 10 1993 training of fire control staff and if you go to page three of this document and look at paragraph 11
01:48:06 document and look at paragraph 11 in respect of watch refresher training it says this it is recommended that on watch refresher training should be given to all fire control staff on a systematic basis i.e it should be both
01:48:18 systematic basis i.e it should be both scheduled and monitored the subject matter will depend on local circumstances but emphasis should be given to little used procedures or areas of weakness it is recommended that brigade training officers should be
01:48:29 brigade training officers should be encouraged to participate in the training to augment the efforts of fire control officers um were you aware first of this letter yes were you aware of paragraph 11 as
01:48:41 yes were you aware of paragraph 11 as i've just read yes do you accept that that document indeed this document and the manual that i've read to you from 1998 made it clear
01:48:52 read to you from 1998 made it clear that training for control room staff needed to be defined planned and structured yes
01:49:02 and again was there any discussion to your knowledge leaving aside the gap analysis detail will come to about diluting or abandoning the standard set out in paragraph 11. no not that i'm of always
01:49:14 paragraph 11. no not that i'm of always now let's go back to the ned kelly audit if i can call it that of the third of august 2010 lfb double zero one zero nine zero nine two
01:49:29 uh and this time i want to show you a different draft of the one we were looking at before this one carries comments from assistant commissioners brown well as assistant commissioner brown and som turner
01:49:43 commissioner brown and som turner which were provided in august 2010 um if we go to page seven paragraphs 47-49 they're under systems for performance management you see that
01:49:55 for performance management you see that it says under 47 it appears that adequate long-term planning of the regularly delivered elements of the bct's curriculum is not being carried out
01:50:06 being carried out and there's a comment and i'll come back to this may account for the fact that the delivery of fire survival continuation training to observed candidates fell outside the parameters of recommendations found in the
01:50:17 of recommendations found in the emergency call handling techniques and fire survival guidance training document ie12 monthly however brigade the grade control principle management have stated that once the current tranche of fast
01:50:29 once the current tranche of fast survival training is completed it is planned for all staff to receive a full course every 24 months with 12 month
01:50:37 month 12 monthly interim training being delivered via a computer-based training solution
01:50:42 solution notwithstanding the above it is vitally important that adequate training planning systems are implemented for all courses including appropriate training records that support the cyclical
01:50:54 records that support the cyclical training planning process recommendations of paragraph 50 in bold
01:51:00 in bold implement adequate training planning and recording
01:51:04 recording systems um now first um do you recall that recommendation in the text of the draft yes you do do you recall discussing it with assistant commissioner brown no
01:51:15 with assistant commissioner brown no do you discuss do you remember discussing it with anybody um
01:51:20 um yes i'll discuss it with the song is that some turner tom turner yep yes and in the review comment corresponding with the recommendation uh som turner
01:51:34 uh som turner says this is in the blue box i think once we start using step which is imminent we will be doing this you see that yes
01:51:45 you see that yes and i asked you about step before what was the relevance of step in this context okay so so training is recorded and was recorded up to that point
01:51:58 and was recorded up to that point manually so a spreadsheet within the training on the training drive um
01:52:06 um london fire brigade i've got a system called step and i'm i'm not sure of what the acronym stands for but it's an autism it's automated system so it'll allocate a um firefighter to a
01:52:18 it'll allocate a um firefighter to a course it will send them pre-course notes
01:52:22 notes tell them where they need to be what time and at the end of the course it'll send them a feedback form and then six months later it sent him a follow-up feedback
01:52:31 feedback because we weren't part of the lfb training uh setup we didn't get any of that so
01:52:38 that so none of our training was was recorded electronically brigade-wide it was kept locally so
01:52:46 so what we've done what happened is we asked that we be put onto that system so that we could better record our training however
01:52:56 however it relies on a system called stars which is our staff um training and i can't remember the acronym on story but it's about all this all the staff that are in uh on watches and that
01:53:09 are in uh on watches and that it will take the name from stars it we weren't set up for stars because it's a predominantly operational was then predominately an operational um piece of equipment
01:53:20 piece of equipment which we didn't we weren't on at that time so all we could do at this point was to transfer our spreadsheet on a monthly basis to information management in uh
01:53:31 to information management in uh headquarters and they would upload that information onto step and that's what we've done until around 2015 i believe right so in fact some turner was wrong but in that
01:53:42 but in that being put on step would not ensure adequate training and planning and recording
01:53:47 recording because it was reliant on the star system yeah but at the time when she when she wrote that i expect we did we expected to go on to step but as it was technologically wise we couldn't do it
01:53:59 couldn't do it i see you didn't know that at the time no
01:54:05 uh now um can we then go to lfb triple zero five eight zero seven seven
01:54:14 this is an email from the spring of the next year 2011 and if you go to the uh to page two in this email string please and look at the bottom email
01:54:25 bottom email um you could see that um you uh email
01:54:31 email lindsay turner at som turner yes yes fsg refresher is the subject lindsay can you let me know how we are training staff in fsg i'm not sure we're quite there yet aren't we did you want page two
01:54:43 did you want page two uh uh yes i do yes page two it's come up for some reason it hasn't come no it hasn't come up that's why i've interrupted you yes it's quite right okay there it is
01:54:54 yes it's quite right okay there it is yes
01:54:55 yes on the screen now from you to lindsay turner fsg refresher lindsey can you let me know how we are training staff in fsg this year please and a timeline you see that yes
01:55:06 you see that yes now it looks as if this is the 12th of may 2011.
01:55:09 may 2011. so this is some seven or eight months after the um discussions in august the previous year you
01:55:17 you were inquiring is this right for the first time in may 2011 what the fsg training was for that year yeah i believe this this was referenced to whether we were using cbt package or
01:55:28 to whether we were using cbt package or we were going to have to use our own powerpoint presentation because the cbt wasn't ready
01:55:37 but my question was slightly different was this the the first time may 2011 that you asked what the fsg training was to be for that forthcoming year
01:55:48 year within that year no i i think the reference is that i was asking i was asking whether it was a cbt package
01:55:57 package or because i was waiting to get to get feedback from um lfb training about the cbt packages that were created to deliver the training into intervening years of the full day
01:56:09 years of the full day and in 2011 we were still having problems of them putting it together so it would it would look like we'd have to use our existing powerpoint presentation oh i see what i was asking there is
01:56:22 oh i see what i was asking there is how are we going to train the staff if we're not using the cbt right so implicit in your question is there was a there was a background to the cbt not yet having been done yes i followed that
01:56:33 followed that does that explain why it is so long after the third of august 2010 draft or perhaps the mid-august comments on the draft uh that you asked
01:56:44 comments on the draft uh that you asked this question uh well we'd already trained the first transfer because obviously training because there's over 100 staff the training rolls into the year so we don't
01:56:55 training rolls into the year so we don't do it all in sort of a four-week block it rolls on so i think i think i was asking at this point the first we'd done the first one in 2010 and i was asking what how we were going
01:57:07 and i was asking what how we were going to do it this year for running 20 2011 2012.
01:57:11 2012. and is it right looking at this email that there was no training plan in place at that point at least for fsg um
01:57:19 um like i can't i can't answer that question i don't know i i mean the the email is the email is if we were waiting for cbt perhaps we were waiting for the timeline because the cbt if we were told that the cbt
01:57:31 the cbt if we were told that the cbt weren't going to be ready we'd have to look at alternative but then but then i don't know whether there was a timeline at that point or not i don't recall given station manager kelly's recommendation of paragraph 50 of the draft that i showed you
01:57:43 draft that i showed you uh the previous summer august 2010 uh can you explain why um
01:57:50 um there was still no training plan in place
01:57:54 place what from this sheet from this email this time i i'm i don't know that there was a training plan in place or not because i'm this email doesn't reference it's not i don't think it references that from my understanding it looks to
01:58:06 that from my understanding it looks to me like i'm just asking what we're doing instead of can we go to lfb double zero double one three two three seven
01:58:20 is a brigade control management meeting or i think as you refer to it a bcmm yes and this one is a minute of the meeting dated the 18th of july 2012 at merton
01:58:33 dated the 18th of july 2012 at merton and we can see who was present you see there yes and operations manager bagel was in the chair
01:58:45 uh did you did you always attend those meetings
01:58:49 meetings if i was available yes and we could see that ac chandler was there and some steve ads yes but you weren't i don't think no so i was obviously out another business and given
01:59:01 obviously out another business and given that you couldn't attend would you have read the minutes afterwards yes you did and um if you look at page one um you can see uh that i think you were on leave at the time um
01:59:13 leave at the time um it's page eight would that sound about right given the time of the year it bear it varied you can't see it from the screen no um but yeah but can we take it that you would have caught up
01:59:24 would have caught up with what had transpired at this meeting uh i would say so yes now if we go to page seven at the bottom let's look at item five
01:59:33 item five we can see there there's a heading training ac chandler and it says ac chandler began by saying that he had attended a meeting recently which spoke about the training commissioning and alteration process
01:59:45 alteration process he stated that in the document there was nothing showing that controller carried out any form of training he went on to say that he spoke to control training to see if there was anything in place to show what form of training had been
01:59:56 show what form of training had been received by staff the ac asked if there was a training matrix which control worked to the response was no ac chandra asked the ops managers to see what training would be needed for their
02:00:07 what training would be needed for their watch
02:00:08 watch all ops managers to present this information in the form of a spreadsheet so that he is able to see what controls need our needs are for the year ac chandler will then speak to nick to see what can be done this information can be
02:00:20 what can be done this information can be used by ops managers as guidance and also at the end of the financial year for easy audit ost have been tasked to produce a training matrix ac chandler went on to say that ost's
02:00:31 ac chandler went on to say that ost's line management situation would be addressed when pom hayward was back from leave the line management will now come under the remit of the soms there will only be a single line of management o.m vic van bagnell reminded us that
02:00:43 vic van bagnell reminded us that training at that time had set up a system that all staff training was fed into which would then be transferred into the authority's step system ac chandler said the recording of information was good but it needed to
02:00:54 information was good but it needed to show where control are heading it was suggested that a bigger training team would be required to carry out this function but the difficulty lies with releasing staff to attend training office managers to pick this up at the at their next local level meeting omni
02:01:07 at their next local level meeting omni natalie bagnol agreed to collate all training information together
02:01:13 now were you aware that
02:01:16 that ac chandler was asking for all ops managers to present this information in the form of a spreadsheet so that he could see what controls needs were for the uh i'm going to say i don't recall but i would excite i would have done
02:01:28 but i would excite i would have done this is it right therefore that there was no training plan in place at that point
02:01:33 point not the way he's saying he's stating it there
02:01:36 there because i think oh yes no not the way it stated there no can you explain why that was still the case almost two years after station manager kelly's ned kelly's recommendation we've seen a paragraph 50
02:01:47 recommendation we've seen a paragraph 50 of the august or dude
02:01:51 or dude i can't like do you know did you know that ost had been tasked to create a training matrix uh well i don't recall but if they see
02:02:03 uh well i don't recall but if they see china's asked them to do that and yes they would have done do you know whether one was ever created i i don't know i don't recall were you aware that ac chandler had said that recording the information was needed to show where control was heading
02:02:15 control was heading uh no i don't record i don't recall that i i do know that we were feeding on to step but as i explained him previously it was a manual it was a manual setup
02:02:26 it was a manual it was a manual setup did you yourself do anything to progress the training plan or matrix after you came back from leaving i can't recall right and if you go to page eight of the same document or lower down um i've read to you that there's a
02:02:38 um i've read to you that there's a reference to a bigger training team in that last paragraph or penultimate paragraph in the box that i've read to you were you aware at the time of any difficulties with releasing staff for attending training
02:02:51 releasing staff for attending training yes
02:02:52 yes and what were the what were those difficulties do you remember um
02:02:57 um what date was this could it just remind me what day yes this is july 2012 18th july 2012. so july 2012 which has taken over the um fire rescue service national coordination center so i detached the
02:03:10 coordination center so i detached the further six staff to be able to train on that because we were getting ready for the olympics in 20 in 2012 and also as this time we were being outsourced so i couldn't recruit against
02:03:21 outsourced so i couldn't recruit against it that was so i was 11 staff down and um
02:03:26 and um and we like to provide the service
02:03:39 did you at that stage give any consideration to what i've read to you from the 1998 uh document the fire service manual volume one and remember the words there
02:03:51 volume one and remember the words there about
02:03:52 about training for control personnel always being hindered by the small number of staff available and therefore brigade should consider the provision of a training officer or watch training days away from control did you consider
02:04:05 days away from control did you consider that at that time yes but it was as i explained i couldn't i couldn't spare any more staff at that point to be detached out of the control room because i was already 11 staff down i
02:04:17 because i was already 11 staff down i had the olympics to deliver and the frs ncc to deliver and of course the staff were
02:04:24 were due to the outsourcing issue although i think it had changed by then but there were still the ramifications of the outsourcing and i had no no pipeline for training at that time right did anybody do some kind of risk
02:04:37 right did anybody do some kind of risk assessment of the implications to control of the circumstances you've just described to us such as the outsourcing
02:04:48 described to us such as the outsourcing and the
02:04:49 and the the
02:04:49 the imminent olympic games not our record um
02:04:54 um do you know or couldn't remember whether um om
02:04:58 um om natalie bagnol collated the training information as this minute said she would i i don't i don't recall but knowing um i went back noise i suspect she would have done
02:05:10 and there just to be clear there are two bagels there yes this is natalie bagnall is that his wife it is indeed right or partner yeah um lfb double zero sorry
02:05:21 or partner yeah um lfb double zero sorry lfp triple zero four nine nine two seven
02:05:26 if we look at the net uh next at an email chain of the 15th of august 2012 we can see that it's on your screen uh that the top email is from you to om
02:05:37 that the top email is from you to om natalie bagnol dated the 15th of august 2012. so about a month
02:05:42 a month after the
02:05:44 after the bcmm we've just seen of the 18th of july and in the second email down from the top of the chain you can see that she sent a secular email to mer
02:05:56 she sent a secular email to mer operations managers forwarding a training plan and she says following our management meeting last month richard asked for an annual training strategy as we did not
02:06:08 annual training strategy as we did not have a meeting this month to discuss this i approached richard in the first instance with an idea that i had taking into consideration that we cannot just book off status seven we need to have a flexible training plan that fulfills
02:06:20 flexible training plan that fulfills richard's expectations as well as allowing us to manage training alongside our normal work please see my email below and let me know your thoughts obviously it's in a very rough form at the moment but i'm happy to produce a
02:06:31 the moment but i'm happy to produce a more detailed plan if you are all in agreement that this would be a good way to go forward uh and uh
02:06:38 uh and uh richard clearly is richard chandler there isn't it yes it is and she must be referring to the 18th of july 2012 bcmm
02:06:47 2012 bcmm when she refers to the meeting yes yes um
02:06:51 um did you know that ac chandler had asked for an annual training strategy that she refers to here i i don't recall but if it was on the bcmm which i believe it was then yes
02:07:04 and um
02:07:09 she goes on to say as i've shown you
02:07:13 that
02:07:15 well if you look at the email below that you need to go to page two for this it splits between pages one and two but what she's forwarding is her email to richard
02:07:28 forwarding is her email to richard chandler
02:07:31 you see that yes uh hi richard and in the first paragraph she says following our meeting last month you requested
02:07:38 requested that the oms produce a one-year training plan for control at the time i believe that it was also stated that we can't quite follow a rigid plan as we are unable to guarantee the availability of staff and training officers due to the
02:07:50 staff and training officers due to the fluctuations of our business i have therefore been considering a plan that i would like to put forward to the other oms
02:07:58 oms now
02:07:59 now first did you did you agree uh at the time that you couldn't follow a rigid plan because you were unable to guarantee the availability of staff and training
02:08:10 availability of staff and training officers but due to the fluctuations of your business
02:08:17 is that something you agree with um
02:08:22 at that particular time yes i agree
02:08:29 again would it not have been possible at that time to have organized an annual training day where staff were not expected to be on shift um
02:08:38 um no because this is the same this is the same year
02:08:41 same year um that i i was my staffing was was i was eleven short in the control room so
02:08:49 so to let out another uh 16 staff and rely on overtime to cover it was was not was not viable at that time in my opinion did you look into it
02:09:00 did you look into it i don't recall to be honest with you it it's it's always been an issue in control about you know and like like um miss pagner's put there we just can't
02:09:12 miss pagner's put there we just can't just can't book ourselves off and go and do a training course you know it's just not it's not what we do we don't have spare staff
02:09:23 now the email goes on to detail a plan that's been considered by om bagnal and then sent around for discussion doesn't it as you can see yes and and and uh to summarize it
02:09:34 summarize it uh her do you recall her proposal was that there could be a set period for fsg training to be completed and then the rest of the year could require
02:09:43 require um
02:09:44 um each cro and aom to complete a set number of training packages yes yes and then the the benefit of that type of plan was that she thought that the packages could be completed by one
02:09:55 the packages could be completed by one member of staff at a time as a minimum at any time of the day or night and the training could be done during quiet times and less busy periods do you mind scrolling down a bit i've only got i've only got the first part of that okay yes there it is thank you
02:10:07 that okay yes there it is thank you exhibit so yes if you
02:10:12 if you go to the penultimate paragraph on page two i was attempting to summarize it but yes probably better just to look at that um but the thrust of it was that the benefit would be that you could have
02:10:23 benefit would be that you could have this the plan or package completed by one member of staff at the time during the quiet periods yes yes and that would that would be a defined strategy but it would be flexible that was the beauty of it yes
02:10:35 flexible that was the beauty of it yes now you've added some comments to this um and if we go to the top email on page one
02:10:42 one bear with me because they're not immediately obvious um you say uh good morning natalie this is also 15th of august 2012. good morning natalie my comments below
02:10:53 good morning natalie my comments below for consideration in your future planning regards scott hayward now um
02:10:59 now um you need to scroll back down to
02:11:03 to the next email down we've looked at before your
02:11:08 your comments are not immediately obvious um
02:11:12 um from the email itself but they appear to be written after the end of each paragraph
02:11:17 paragraph they're not in color or bold there's nothing that distinguishes your comments from her text if we look at page two
02:11:28 if we look at page two in the third paragraph on page two
02:11:37 you can see in that third paragraph
02:11:42 uh that it says one of the supplementary reasons can you see yes i can one of the supplementary reasons for the introduction of the short shift was to provide quite time for staff to train and develop this is
02:11:53 for staff to train and develop this is not being considered your in your initial rough plan this also provides aoms and the om if required to direct the training now first of all was that a comment that you made yes i believe it is yes
02:12:05 yes i believe it is yes were you disagreeing with o.m about her plan no
02:12:09 plan no it was just it was just for further consideration so the new the new shift pattern allowed a four-hour window in the afternoon to to train staff why did you consider
02:12:21 to to train staff why did you consider that using the training for the short shift was adequate when there were already problems releasing staff to attend training um
02:12:41 because the trait the on watch training meant that staff was still on watch the issue the fact was is the fact that i didn't have enough staff to release staff outside of that
02:12:53 staff outside of that so
02:12:54 so what i'm saying is is that we provide we provide four hours in the short shift which is adequate to deliver training it wasn't being used was it
02:13:05 it wasn't being used was it or not at least adequately for reform no ac chandler's purpose no but it was is there it was there available now yeah yes
02:13:17 i think that's the point though isn't it that even though the short shift meant that there was this extra time to train and develop staff it wasn't being used or at least not being used not at that point no no
02:13:29 not being used not at that point no no um were
02:13:30 um were owen
02:13:31 owen natalie bagnell's ideas in this email taken further than this email discussion do you remember uh i don't recall but i know that owen bagnall did get involved in training
02:13:44 bagnall did get involved in training more significantly right but but you don't know what happened to her proposal i don't know right
02:13:50 right um can we then turn to lfb double zero double one three four zero two please this is the next bcmm meeting and these are the minutes
02:14:02 and these are the minutes 12 september 2012 and this time you are present as you can see from the list on the first page there and if you go to page six you can see section five
02:14:15 which says ac chandler update training ops managers discuss the issues of training for control but did not reach a conclusion on the matter i'm just pausing there why was ac chandler providing an update in relation
02:14:27 chandler providing an update in relation to training uh because he
02:14:33 he he'd not long joined and was was heavily involved in the control right do you know who briefed him um i don't recall was it you i would have discussed it with him yeah right
02:14:44 right um what were the issues for training that he refers to there um
02:14:51 um the issues of training for control what were those
02:14:56 i don't recall at that point um he says did not reach a conclusion on the matter what was that about well i i think i
02:15:07 what was that about well i i think i think this is about this is about the staff don't get the opportunity to go out and and do training because there there is no formal control training
02:15:18 there is no formal control training outside of control but i think it was also other training so not just control specific training but training in general so uh non-controlled like it training or or
02:15:31 uh non-controlled like it training or or which are courses that are available to staff but we were unable to release staff to go and do that sort of training do we take it from that sentence that at this stage
02:15:42 that sentence that at this stage september 2012 there was still no agreement
02:15:46 agreement uh
02:15:47 uh on the training strategy or plan to be adopted by control i i don't recall but looking at that that appears to be the case why was that
02:15:58 why was that now more than two years after the ned kelly audit report the i think the the ned kelly audit report was specific um to do with the fsg training element of which there was
02:16:11 fsg training element of which there was a plan
02:16:12 a plan um the other the other training outside of that um was still being worked on there was no there were training packages but they they would they were developed a while ago
02:16:23 ago and they needed updating but of course the training staff needed to update those packages so i just don't think all everything was ready to be able to deliver it but you're not saying are you that that the fsg element was
02:16:36 the fsg element was the fs the fsg training was being delivered at that time
02:16:42 so are you i'm trying to understand your evidence are you saying that the issues of training for control did not include fsg training oh no i don't yes i do it includes all training
02:16:53 includes all training um continuing with point one it says this ac chandler pointed out that there is no robust defense if anything happens in control he also went on to say training needs assessment for all staff to be built
02:17:05 assessment for all staff to be built into their prds
02:17:09 and then skipping over to uh ops managers will be meeting in october
02:17:17 october we'll discuss further training
02:17:21 do you know what ac chandler meant by there is no robust defense if anything happens in control i don't
02:17:30 i don't do you remember what the discussion was about that
02:17:36 i honestly i honestly don't on the face of it it looks as if ac chandra is recognizing uh that
02:17:46 uh that control is exposed to criticism if anything went wrong during an incident
02:17:53 okay does that
02:17:56 does that way of reading what is recorded there does that trigger a recollection of a discussion on that topic i i'll be honest it doesn't you know it does
02:18:08 it does i can't i can't comment can we can you comment this father can we take it that you at least were aware that at this point there were problems
02:18:17 problems with getting control staff trained properly to such an extent that if there were a serious error in the control room during an incident there was no good explanation that could
02:18:28 there was no good explanation that could be given for it i i think training was going ahead going ahead in control not not not as as robust as as it's as it's saying there
02:18:39 saying there but
02:18:39 but the staff were being trained on the frs ncc at this point as well as as well as uh fs3 training which was taking part taking
02:18:50 which was taking part taking going ahead so i i think this refers to training generally so and it's not all control focused training it's all training
02:19:01 uh were you present for the further meeting in october 2012 i'm not sure the reason i ask is we don't we don't have the minutes for that bcmm if you
02:19:12 have the minutes for that bcmm if you don't remember i i don't i if i was i don't remember so i would have attended all of them if i was there do you know whether uh om natalie bagnol
02:19:23 do you know whether uh om natalie bagnol had yet collated all the training material as suggested at the 18th of july 2012 meeting i don't
02:19:30 i don't we haven't seen it in our in the documents no i don't do you know why she hadn't i don't
02:19:38 i don't were you monitoring her doing that or or not
02:19:42 not um she'd have been no i i don't recall i don't recall right who had um oversight as you might call it over whether uh om natalie bagnall did or
02:19:53 whether uh om natalie bagnall did or didn't um
02:19:54 didn't um carry out the task that had been allocated to her at that meeting so at this time i mean she was reporting to ac chandler she was still an on watch operations manager so she'd have been
02:20:05 operations manager so she'd have been doing this in her own time you know while she was on watch during the the short shift when the um so she had been liaising with ost and the simon charge at that time right
02:20:18 the simon charge at that time right and this is this is uh september 2012 at which point some uh som smith is about to go off yeah cfoa
02:20:26 cfoa and and som bagner would have been taking over uh right so she would have natalie bagnall would have been reporting to vic yes
02:20:35 yes her partner yes and he would have been reporting to you potentially yes so what did you do to make sure that he ensured that
02:20:47 make sure that he ensured that natalie bagnall collated all the training material as had been suggested at the 18th of july bcmm i i don't know because we haven't got the minutes the following minutes but i mean bagna was
02:20:58 following minutes but i mean bagna was reporting to ac chandler at the time not not to me but look at it why would that be uh
02:21:04 uh because this was in 2013 char sorry when was the day sorry this is this is september 2012. so ac china was only in the only in the business since may that year
02:21:15 since may that year so he took a proactive role in control at that point and was just coming in and making changes i suppose i can't comment what he was doing but he did he did have
02:21:26 what he was doing but he did he did have a lot more input at that early stage but the fact that he might be having a lot more impact input at that early stage didn't mean did it that you would have a lot less
02:21:34 lot less no absolutely not no but i i didn't necessarily get access to everything he did
02:21:43 why is that so i i don't i don't know i ac chandler asked owen bagnall directly for that information maybe she sent it directly to ac chandler i don't recall seeing it i may well have done no i mean
02:21:54 seeing it i may well have done no i mean i'm just trying to understand the reporting lines here i mean is there any good reason why you wouldn't have seen it given that uh s.o.m bagnall was your immediate report and that o m bagnall
02:22:05 and that o m bagnall was his immediate report on this topic no i don't know i don't know can we then go to lfb double zero one zero six one four six please
02:22:29 uh this is an email from you to ac brown
02:22:34 ac brown on the 17th of january 2013 uh and you say dave attached is the lack of action sheet with responses as directed
02:22:46 and that document is at lfb double zero one zero six one four seven
02:22:56 and there it is uh we'll look at it in detail in a moment my first question is do you remember whether ac brown had asked you to send him that document
02:23:08 well i don't remember saying it but if he says on the email then obviously he did
02:23:13 did do you remember what prompted that request
02:23:17 uh no and it might be an update of the insurance i don't know uh the assurance was dated november 2012 just to be getting the chronology right
02:23:29 just to be getting the chronology right does that help you i don't recall i don't recall um did you prepare this document that we can see on your screen it looks like that my type of
02:23:40 that my type of work yes uh because of the font yeah
02:23:44 yeah and the layout yep right do you have a recollection of preparing it no
02:23:49 it no um
02:23:51 um did you prepare the task list which you can see in the left hand most column
02:23:57 column uh i didn't perfect it they were action they were control action so i just copied the actions onto the onto the
02:24:04 onto the table
02:24:05 table now this is the only version i should tell you of this action sheet that we've seen
02:24:10 seen and is it right that this was a one-off document
02:24:16 uh yes i i can't i don't recall but if that's the only one we can find yes and we haven't seen any travelling drafts or any drafts with comments on them that
02:24:27 any drafts with comments on them that being the case if we can assume that this was the only document created do you know why it wasn't used to monitor the outstanding or ongoing actions moving forward
02:24:38 i don't i i i assume this was sent to dave brown for him to report
02:24:46 at the cmb or or a principal management meeting
02:24:52 but i don't i can't be sure let's look at one or two of the contents if we go to the foot of page one
02:25:01 one over to the top of page two let's start with page one you can see on your screen training matrix
02:25:08 and then under actions stroke issues it says
02:25:12 says two-year training matrix including all control training fsg refresher and then in the third column matrix being created by the ost and then in the fourth column under
02:25:23 and then in the fourth column under outcomes it says senior managers with ost have revised systems for the release of staff for the for training delivery to be and if we turn the page implemented shortly the two yearly
02:25:36 implemented shortly the two yearly matrix will form the backbone to this plan completion date end of january 2013 but the plan will evolve as a living document projecting training for the future on a rolling basis
02:25:48 future on a rolling basis now this was is this well is this right that this was the resolution proposed in order to address uh station manager kelly's ned kelly's audit recommendation in august 2010 and
02:26:01 audit recommendation in august 2010 and in response to ac chandler's request at the brigade control management meeting in july 2012. is that right i'll i'll have to say yes i don't recall
02:26:12 i'll i'll have to say yes i don't recall but yes
02:26:14 but yes it makes it it makes sense yeah yes can you explain why that exercise was still outstanding as at january 2013.
02:26:25 as at january 2013. i can't
02:26:26 i can't was it completed by the end of january 13 as proposed i don't i don't recall was it ever completed
02:26:33 completed i again i don't recall i mean we're moving into a realm of of vision at this point so things would have changed right
02:26:43 right and we've not seen any evidence
02:26:46 evidence that the
02:26:47 that the the resolution proposed here in this last column was ever carried into effect okay
02:26:52 okay um can you explain if that assumption is correct why
02:26:58 like no i can't explain why i can only reiterate the fact that during
02:27:04 during january 13 and certainly up to 16 um there was competing priorities yeah so so ost
02:27:16 competing priorities yeah so so ost changed into into delivering vision um
02:27:21 um and obviously in 2014 we took on the resource management so
02:27:29 that's what changed
02:27:35 despite by this time the
02:27:40 the lachenal
02:27:41 lachenal control report and january 2013 the uh the ongoing inquest
02:27:51 i mean there was training uh planned in but you know the training was cu training which was a part of the la canal
02:27:59 la canal outcome
02:28:00 outcome so training was planned in whether it was as robust i don't recall now let's look on in the year to may 2013 lfb
02:28:11 2013 lfb 3042081
02:28:16 this is an email you sent to som vic bagnall on the 9th of may 2013
02:28:27 on the 9th of may 2013 subject training plan and database hi vic
02:28:31 vic during my regular meetings with richard yesterday we discussed the training issue
02:28:35 issue and the fact that whilst the database is on the system and has a good layout it is not dynamic and does not provide staff and management with a picture of the state of training for control staff for the next year to 18 months
02:28:48 and then if you look at the very foot of the email we need to scroll down please to the end you can see it says or you say this we can see an improvement to the database sorry i'll start again can we see an
02:29:00 sorry i'll start again can we see an improvement to the database by the end of next week and then we will have periodic updates as the plans for all the training develops now was that database in effect the training matrix that was being developed or was it
02:29:12 that was being developed or was it something else
02:29:15 i i don't recall but i would suggest it would be the training matrix or the outcome of what the training makes it should have been or was it step no because we still didn't have at this
02:29:26 no because we still didn't have at this point we were still manually putting our training database onto step i see is it fair to say that
02:29:36 at this point may 2013 the proposal was not working as intended not least because it wasn't projecting future training
02:29:48 but training was planned the training was planned in as it states there we had um
02:29:54 um we started doing exercises with operational staff so we're actually moving our training outside of control and supporting operational staff as well and also exercises with our buddies uh
02:30:06 and also exercises with our buddies uh fallback buddies to try and improve that as well so training it might not have been as robust as we planned but training was being developed and it was looking better than it had been in the past the training but i'm i'm
02:30:18 past the training but i'm i'm maybe we're at cross purposes with the planning of the training then well in the first paragraph you are telling mr or ac chandler that
02:30:27 that the
02:30:28 the system the database doesn't provide staff and management with a picture of the state of training for control staff for the next year to 18 months so
02:30:39 so my question is why didn't it do that because i don't think it was it was there was enough in it so i think we were
02:30:47 were it wasn't enough of a plan over that period of time so it wasn't a problem with the database or the or the system it was the problem that you hadn't populated it sufficiently i think that's probably the case why was that um
02:31:01 case why was that um i don't know they were obviously working on it but hadn't got that far down the line at that point well did you investigate i don't i don't recall i'd like to think so the fact i've responded to this email
02:31:12 so the fact i've responded to this email yes and indeed you go on and it's just difficult to navigate it on the screen but if you go on up um
02:31:18 um scroll up please you actually give some
02:31:23 some considerations and suggestions to what to populate the database with as you can see yep so at this point we're now at may 2013 can we take from this
02:31:35 can we take from this that even at this point uh the the database was not fully projecting future training yes we can yes
02:31:46 yes we can yes then let's move forward in time more than three years to july 2016. lfb triple zero three two eight two six
02:32:00 uh this is uh a document produced it's a report called the root and branch review i think by uh tom george ac tom george
02:32:11 uh tom george ac tom george uh in july 2016. just for your benefit you'll recall there was in fact a later version of this an update in february 2017. this is the 2016 version now can we go
02:32:23 this is the 2016 version now can we go to page 11 please look at paragraph 47 and paragraph 47 it says this uh and this is under the under the heading development in role
02:32:35 heading development in role power 47 some staff feel that they are not adequately developed in role or received development to progress up to a higher role the review has identified that maintenance of skills training is
02:32:47 that maintenance of skills training is ad hoc
02:32:48 ad hoc not planned in a robust manner and often not recorded on an individual's training records itrs whilst there is a responsibility and owners on individuals to maintain their itrs correctly by
02:33:00 to maintain their itrs correctly by manually entering completed training this is not often done and staff are seldom instructed to do so by their managers
02:33:08 managers and then if you look at the recommendation under paragraph 49
02:33:14 if you turn to page 12 and look at c
02:33:20 at the top of the page it says this each om is to ensure that an appropriate robust annual watch training plan is in place for their watch agreed by their rsom and available to all watch members
02:33:33 rsom and available to all watch members and managers all training must be recorded on an individual's itr individual training record the pom's stroke soms should work with colleagues from the brigade's information
02:33:44 from the brigade's information management team to produce an i.t solution to this similar to training diaries used by station staff do you recall that finding and recommendation yes
02:33:56 recommendation yes did you agree with them at the time yes when you went through this reviews i think you say in your first statement of paragraph 88 that you did in july 2016 did you ask your team why there was no
02:34:08 did you ask your team why there was no quotes appropriate robust annual watch training plan in in place for the watch uh because we didn't have access to the
02:34:19 didn't have access to the individual training records it's via it's like again it's by the lfb system so if you were to go to the lfb system and look at one of our control officers on step it'll have all training that's
02:34:30 on step it'll have all training that's not at this time that was not controlled so
02:34:34 so those other other courses that you can do like um well-being or mental health type training that's recorded all the other training local training we passed that we used we passed over
02:34:45 passed that we used we passed over monthly although i believe at this time we work we did a little bit more access to step
02:34:50 to step um
02:34:51 um but it still wasn't robust enough so when when staff look at their itrs they see big gaps in training where it wasn't it's not been lifted from the um
02:35:04 spreadsheet onto onto the electronic version step so the idea was was to speak to
02:35:10 speak to information management and try and try and get us on the same footing as as a station diary set up so that all training could be done electro put in electronically and and that way there's
02:35:22 electronically and and that way there's less chance of of the manual uh manual system falling by the wayside or people not recording training i see so what's being described here or what you've just described as a mismatch
02:35:34 you've just described as a mismatch is this right between the lfb's general training not non-control which is recorded in in the step system and the and the and the training delivered to control room staff
02:35:45 staff which isn't or or is only done on an ad hoc basis yes so so all control side or control based training it's different now i believe but certainly
02:35:56 different now i believe but certainly and we just started using it around this time i think so all the control training so everything was done in like vision training or mtfa training or or the like would be recorded on a manual database now
02:36:08 recorded on a manual database now uploaded onto step that's how it got onto the itr but what's being said here with which you agreed is that there was no appropriate robust annual watch training
02:36:19 appropriate robust annual watch training in place
02:36:21 in place agreed by the som and available to all watch members not that there was one but it just wasn't on step so i i i
02:36:30 so i i i given that you've agreed with what's in this report my question is why was there no appropriate robust annual watch training plan in place well uh you know 2015 2016 the
02:36:44 well uh you know 2015 2016 the the
02:36:45 the all the training was was vision based training so as you're aware from my uh from my evidence all of 2015 was was focused purely on
02:36:56 all of 2015 was was focused purely on on vision and well into 2016 so again priorities have changed and i needed to get a working mobilizing system so i could i could respond to everywhere in
02:37:08 could i could respond to everywhere in london um and that was the priority at the time so all training was focused on that right i mean is is the reality from what you've just told us this morning so far that
02:37:19 morning so far that by july 2016 six years or so after s m kelly's recommendation in august 2010 and over three years since the latino action document
02:37:30 the latino action document training was still ad hoc and not being planned in an appropriate and robust manner
02:37:36 manner uh i would i'd agree to some of that i still think that that the the competing issues that were going on over that period of time uh hindered that work the fact that we were not part of lfb's
02:37:49 fact that we were not part of lfb's training uh regime uh hindered that we didn't have the technology to be able to have a more robust system in place you know and we're relying on on people
02:38:01 you know and we're relying on on people to release people to do training rather than being directed to by by emails and communications so
02:38:10 so yes to an extent i agree i think i think the impact of what was going on at that time
02:38:18 had an effect on on the outcome
02:38:22 can we look at uh the appendix to this report please at page 31
02:38:31 this is a summary of actions as you can see and if you look at item
02:38:39 item 49
02:38:41 49 you can see this is eight lines down discuss with staff side representatives to implement enhancements to training and development as detailed in the report
02:38:52 report and that action was assigned to js who was joanne smith austin bards yes
02:39:01 and by that point and this is july 16 you were her direct line manager i was what steps did you take to ensure that an appropriate robust watch training
02:39:12 an appropriate robust watch training plan was put in place so at this point we were
02:39:16 we were liaising directly with training and development to enable us to develop
02:39:25 proper development folders for control staff for all levels so from a control to an aom iom to om and right to the top so i believe at
02:39:36 and right to the top so i believe at this point om natalie bagnol was detached to learning and development to help facilitate that and that was the process that we and obviously joanne was talking to the
02:39:48 and obviously joanne was talking to the representatives about how we wanted to do that and of course and and that was still in process when i left the brigade but they had moved forward with it and they were starting with a cro training
02:40:00 they were starting with a cro training or cro development
02:40:04 now can we go please to lfb triple zero eight four zero nine seven
02:40:17 now this takes us to july 2019 13 months
02:40:24 13 months uh
02:40:26 uh well in fact 25 months after the fire and
02:40:31 and after the end of the evidence of phase one of this inquiry this is a july 2019 rebriefing note compiled by ac jonathan smith
02:40:41 smith entitled control overview and control improvement plan and it was a brief for tom george and andy rowe as you can see yep and did you read it at the time no i'd left you'd left by then
02:40:52 left you'd left by then um let's look at page three uh where he concludes this
02:40:59 uh and this is under uh management structure in the middle of your screen the current position with two senior uh operations managers som does not provide lfp with the necessary
02:41:10 provide lfp with the necessary resilience in order to ensure specialist managerial cover in the event of a significant or complex incident whether either when either of the songs are not available cover is provided through the deputy assistant
02:41:21 through the deputy assistant commissioner carter the duty dac this was only intended to be a short-term solution and now requires resolution and then underneath uh that is a proposal
02:41:30 proposal and then underneath that training assurance and professional development you'll need to scroll to the very foot of page three there it is and it says the current provision of training assurance and professional development
02:41:42 assurance and professional development requires a complete and systematic overhaul
02:41:45 overhaul training is ad hoc and lacking in structure there is no system for quality assurance and the recording of training is inconsistent now this is in
02:41:56 in 2019 after you had left are you able to explain why it was that training could be described as it has been here as ad hoc and lacking in structure if the watch training plans were in use
02:42:09 watch training plans were in use uh no i can't um because i i wasn't here then but you know
02:42:17 you know even when uh mr george was in post i asked again about i mean always been aware that that training the trained rst particularly particularly over this period were being used for everything
02:42:30 period were being used for everything including training which impacted on the overall training uh plans uh and again at that point i asked that we outsource a training to a an external provider alongside
02:42:42 provider alongside our lfb operational staff um
02:42:47 um which which was was turned down um but i did make it clear that we didn't have enough staff to to train and particularly you know this is obviously gone on after that and i can't comment
02:42:58 gone on after that and i can't comment on what p what been said but training was being um developed and a training plan was being developed in 2017 2018 before i left
02:43:14 i want to ask you next about the training records for control and i'd like to start if i can please with
02:43:22 with the
02:43:23 the document issued in september 1994. this is an lfb triple zero eight four zero five four
02:43:35 and it's it's a policy an lfb policy entitled training and the issue date is the 29th of september 1994. um if you look at the foot of the page
02:43:47 um if you look at the foot of the page please and we can scroll down to the foot of your screen you can see that the last amended date is the 28th of january 2009
02:43:55 2009 so it was current at that point despite the 1994 date on the top of the policy remaining
02:44:00 remaining um can we go to page three in this document please where you can see that there is a heading continuation training the heading is in fact on the bottom of page two but let's look at paid paragraph 2.5 watch training record and
02:44:14 paragraph 2.5 watch training record and it says this a record of all training and instruction carried out is to be maintained by each watch manager it is to clearly indicate the following there are then five bullet points the subject matter
02:44:25 points the subject matter the date the training was given the name names of personnel receiving the training
02:44:31 training any that the name of the officer carrying out the training any notes or comments relevant to the training the record is to be maintained chronologically and is to be cross-referenced to a further record for
02:44:43 cross-referenced to a further record for each individual on the watch clearly indicating the training stroke instruction he strokes she has received the watch training record will be regularly inspected by the principal controller and or the deputy principal
02:44:54 controller and or the deputy principal controller and or senior controller training and signed by them to the effect that its contents have been seen and if we then scroll down to page six of this document there's a later version
02:45:06 of this document there's a later version of this policy policy number 164 which was reviewed as current on the 6th of may 2015. you see that
02:45:16 and if we go to
02:45:19 to page 8
02:45:20 page 8 again in the same equivalent section continuation training under the heading training records 2.5
02:45:29 2.5 says this
02:45:30 says this a record of all training and instruction carried out is to be maintained on the training database by each operations manager or an assistant operations manager ost this information is then entered by the strategy and performance
02:45:42 entered by the strategy and performance team onto the step at the end of each month and then at 2.6 the training database will be regularly inspected by the principal operations manager and or the senior operations manager and or
02:45:53 the senior operations manager and or assistant operations manager ost now first were you aware of this policy when it was uh reissued i'm familiar with it
02:46:02 with it you're familiar with it were you aware of it at the time familiar with it at the time uh yes i believe it was um that would include with it the specific provisions in respect of the training records yes yes um
02:46:16 what steps did you take did you take any steps to ensure that these provisions were being followed
02:46:23 but the fact the information was being sent to strategy performance to put onto step
02:46:28 step did you regularly inspect the training records i i didn't no why is that because the senior operations manager training would have done or indeed assistance operations transgender
02:46:39 assistance operations transgender so you left it to them to make sure is this right you left it to them to make sure that the training records were being properly carried out or properly reflected the fact that
02:46:50 or properly reflected the fact that training was properly being carried out and recorded i delegated it to them yeah on on the fact that they would come back if there was any discrepancy but we knew there was issues with with step i mean i don't know about at this point i don't
02:47:02 don't know about at this point i don't recall now but we knew there was issues with transferring information on the step so when you say uh you downloaded it to them
02:47:15 um but to come back if there's a discrepancy is that the same thing as exception reports reporting by exception yes
02:47:22 yes in other words is this right that your your method of delegating to the soms was essentially to leave it to them um
02:47:30 um to make sure everything was running smoothly to make sure that the training records
02:47:35 records properly recorded the training being carried out but only report to you if there was a problem uh
02:47:42 uh not not quite like that no you know there's there's only three senior managers in control to do a number of tasks in control so you know i i can't i can't
02:47:54 you know i i can't i can't do everything so i need to delegate some work down to other people and the exception report is an accepted way of doing business
02:48:03 and they didn't is this right didn't ever alert you to any problem with the carrying into effect of either paragraph of this part of this policy
02:48:14 of this part of this policy uh yeah um some smith did raise issues with uh the database but we already knew and we were talking with strategy and performance and the training team and learning and development to try and address those issues
02:48:27 address those issues now you knew i think from the august
02:48:31 august 2010
02:48:33 2010 audit done by sm kelly
02:48:36 sm kelly um that you needed to have training records that supported the cyclical training planning process didn't you yes yes
02:48:43 yes and
02:48:45 and as we've seen his recommendation of paragraph 50 there needed to be adequate training and planning recording training and planning recording systems yes
02:48:55 yes the systems needed to be adequate so you you realized from august 2010 i would suggest you that there was a need for a proper system which adequately recorded the training yes yes
02:49:06 recorded the training yes yes um
02:49:08 um uh
02:49:09 uh now
02:49:10 now given that uh let's look at um lfb triple zero five five two zero eight which is the minutes of the lack of house board meeting held in june 2010 this is a couple of months
02:49:23 in june 2010 this is a couple of months before the kelly reported that yeah and we can see that you're present as one of the attendees of the latino house board yes
02:49:31 board yes and if you go to page two please you can see item eight
02:49:37 uh you provide an update control scott hayward it says that's you yeah uh control uh and then at page three item 8.8 if you just go to that it says this control staff
02:49:49 control staff training records will be aligned to step and individual training records updated and checked annually to ensure completion the training audit authorized by the board has been carried out by sm stephen kelly from the station training
02:50:00 stephen kelly from the station training support and performance team a report is expected by the end of june now although this meeting predated his report which in in the event came in august
02:50:10 august um
02:50:11 um as the audit had been completed were you already aware of the recommendation in respect of having adequate records of training yes you were and is it right that the action to
02:50:22 and is it right that the action to address it was as set out in here in this record to bring control training in line with station training and use the step system yes
02:50:31 yes and was it expected at least at the beginning that the process would be automated so that that would mirror what was happening with station training that's correct yeah and who was going to check the records annually to ensure
02:50:42 check the records annually to ensure completion
02:50:46 i don't know we hadn't got that far down to
02:50:49 to i mean the thing is it'll be a it'll be system so
02:50:52 system so you could do it on a database well maybe but just looking at paragraph 8.8 you're telling uh the latin house board that the individual training records would be updated and checked annually to
02:51:05 would be updated and checked annually to ensure completion yeah who did you have in mind
02:51:08 in mind who would carry out that check some training
02:51:11 training the ost
02:51:12 the ost team
02:51:17 and how would did you think they would go about that
02:51:21 that they could do it via the system they could they could just highlight a person's name and all their itr would come down and tell them what training had been had been done in that year and at that stage did you think that the step system would capture every
02:51:33 that the step system would capture every single instance of training delivered to every single control room officer yes
02:51:41 and as you've told us this morning there came a time when you knew that wasn't happening yes when was that um well i believe we we got the partial access to step 2011 2012
02:51:53 2011 2012 so that we could upload we could upload our manual records onto step
02:51:59 step so we were still relying on a manual database and then we could monthly update
02:52:04 update and send it to information management to put on the step let's see if we can trace this for a bit more a bit more uh granularly can we go to lfb triple zero eight four zero three two
02:52:16 two this is a board meeting of the lack of the latin house board on the eighth of november 2010 uh we can see that you were present as was joanne stibbards as some control uh and if we go to page
02:52:30 as some control uh and if we go to page uh
02:52:31 uh uh one at the foot of the page we'll have to scroll down um 4.6 you can see in the last line there this is about this is about refresher training uh and in the last line it says all
02:52:42 uh and in the last line it says all training records have been transferred onto step were those the manual records those those were the legacy records so there was obviously legacy records so if you check on step there's training
02:52:53 you check on step there's training records there from 1974 so i think the transfer was just to upload
02:52:58 upload all the records that were available at that time right and if we then move on in time to january 2013 uh this is sometime some years after lfb double zero one zero six
02:53:09 double zero one zero six [Music]
02:53:15 this is the email um
02:53:20 um slightly different email but the same day 15th of january 2013 from you to dave brown training audit summary report detailed training audit summary as directed
02:53:29 directed and if we look at the document that you've attached this is at lfb00106102
02:53:39 there's the attached document recommendation summary is this a document that sets out the progress made against station manager kelly's audit recommendations
02:53:52 i was i would yes uh do you know whether ac brown had asked you for an update on the progress of those recommendations or was it something you volunteered to him i don't recall
02:54:03 i don't recall and if we go to page two look at paragraph six
02:54:08 implement adequate training planning and recording systems that's paragraph 50 from the sm kelly august 2010 audit we saw this earlier this morning
02:54:19 this morning and
02:54:20 and it says there in the red text there is a control owned spreadsheet detailing trainer-led or external training courses for all staff this database has been transferred onto the step database
02:54:31 transferred onto the step database however it is still a requirement to manually update step as staff complete courses we are still working with it to enable our training to be automatically updated onto step when the course has
02:54:42 updated onto step when the course has been completed why was it still at that stage necessary to update step manually
02:54:53 because the cogs in london fire brigade turned quite slowly and of course the
02:54:59 the it's not just the it's not just step it's
02:55:01 it's it's stars it's all the it's all the you know the systems that work that work with step to operate it so at this time stars didn't recognize control shift
02:55:13 stars didn't recognize control shift patterns
02:55:14 patterns so you couldn't just add it to the system because it it wouldn't work correctly
02:55:18 correctly um
02:55:19 um it's just it's not quite as simple as just adding a database and switching something on it required recoding needed to speak to the owners of step the owners of stars to try and make changes
02:55:31 owners of stars to try and make changes to the
02:55:32 to the to the system recode it to make it work for our for our shift patterns and for our staff so it's not it's not just us walking and giving it in it needs it needs
02:55:43 giving it in it needs it needs planning and and access and recoding but you say the cogs in london fire brigade move quite slowly some might think that was an understatement given the two dates in
02:55:55 understatement given the two dates in front of us we know that at the latino house board meeting on the 8th of november all the training records had been transferred onto step here we are more than two years later and anything
02:56:06 more than two years later and anything that comes along now has to be manually updated why was it so long why does it take quite that long i i can't answer that i can't answer that question i i you know as i said it it wasn't in within my remit
02:56:17 within my remit or i couldn't influence any more than what i could do there what did the manual process actually involve
02:56:25 involve um taking the person's name down um put it into the spreadsheet and what the course what the course was and when it was conducted right that's not difficult is it doesn't sound difficult no it
02:56:37 is it doesn't sound difficult no it doesn't sound difficult but but you know the the training staff changed quite regularly during that period um
02:56:46 um people leaving people retiring increasing staff to accommodate vision training so um the the the way it was recorded could
02:56:57 the the the way it was recorded could have been recorded differently so um
02:57:00 um and also the fact it might not be recorded at all on some occasions watch-based training wasn't always although it should have been wasn't always given to to the training team the following data put on the
02:57:12 following data put on the um on the spreadsheet so it's not it's not a you know it's not a perfect system what do you know what the nature of the ite difficulty was which which meant that
02:57:24 which which meant that every time a training session had been completed it couldn't be uploaded or didn't appear automatically but had to be inputted manually
02:57:33 manually as far as i'm aware because it because the step takes its information from stars whilst whilst i believe we were on stars it didn't recognize us as as within london fire brigade
02:57:46 as within london fire brigade because it needed recoding to accept the fact that we do these particular shifts and also each training the training package has got a code allocated to it so
02:57:57 so with operational firefighters they're they're i think they're national codes with we've control their local codes of codes at all and and the itr won't the
02:58:08 codes at all and and the itr won't the it won't read it so it needs to be coded in so i believe it was a coding issue and obviously changes to stars and of course styles was being changed operation at the time
02:58:20 was being changed operation at the time it's that's all i can put it down to did anybody to your knowledge bang the table and say
02:58:27 and say this
02:58:28 this it
02:58:29 it um configure reconfiguration has to be done and it has to be done now uh yes it was it was done on a number of occasions about about i.t um
02:58:41 occasions about about i.t um but again there was there was competing priorities stars they were doing a big operational change to stars which took priority over the control element the stars and we did have a manual um
02:58:54 have a manual um as it was a manual way of of recording so it was put down a list of priorities but but there were concerns over over i.t
02:59:04 i.t deliverables certainly for us mr chairman we're a minute or so shy of one o'clock one o'clock uh but i'm in the middle of the topic i'm afraid there's no natural landing
02:59:16 i'm afraid there's no natural landing well that might be a convenient point there might it would mr chairman if that's convenient yes thank you wellness today but i think it's time we all had a break for some lunch so we'll stop now we'll resume please at two o'clock
02:59:27 we'll resume please at two o'clock and again while you're out of the room please don't discuss your evidence or anything
02:59:31 anything relating to it with anyone else okay so thank you we'll see you at two o'clock for you thank you thank you
02:59:45 thank you two o'clock though please thank you
03:00:03 you