Evidence from London Fire Brigade control room staff regarding fire survival guidance (FSG) call handling procedures, quality assurance processes, and policy implementation following the Lakanal House fire.
00:00:25 good morning everyone welcome to today's hearing
00:00:28 hearing today we're going to start hearing evidence from deputy assistant commissioner joanne smith of the london fire brigade yes mr miller yes thank you mr chairman good morning to you good morning members
00:00:39 good morning to you good morning members of the panel i now call miss joanne smith
00:00:43 smith thank you
00:00:53 good morning ms smith i understand you're going to make the affirmation yes thank you well the words are on the screen would you read them out please i do solemnly sincerely and truly declare and affirm that the evidence i
00:01:06 declare and affirm that the evidence i shall give shall be the truth the whole truth and nothing but the truth thank you very much now please sit down make yourself comfortable
00:01:16 [Music] all right thank you yes when you're ready thank you mr chairman good morning miss smith you gave evidence that phase one of this inquiry and i'd like to say thank you to
00:01:28 inquiry and i'd like to say thank you to you for coming back and assisting us yet again with our further investigations at this phase two my questions are intended to be short and simple sometimes they don't work out that way if you would like me to ask the
00:01:40 that way if you would like me to ask the question again or rephrase it i'm very happy to do so can i ask you all say please to keep your voice up so that the person sitting to your right can get down on the transcript everything that you are
00:01:51 transcript everything that you are saying
00:01:52 saying also please don't nod or shake your head because those gestures don't come out on the transcript uh a yes or no must suffice in that situation if you need a break at any time other than our
00:02:03 need a break at any time other than our scheduled breaks which we will take twice
00:02:06 twice during the course of the day plus the lunch break please say and we can take a break okay thank you now you've made one statement for phase two of the inquiry uh pursuant to rule nine and that's date
00:02:18 uh pursuant to rule nine and that's date of the second of july 2021 can we please look at that that is at lfb double zero one two one two one nine
00:02:27 is that your uh your statement or first statement for phase two of this inquiry it is yes and can we go to page 34 please is that your signature above the date second of july
00:02:38 signature above the date second of july 2021 yes it is have you read this witness statement recently i have yes can you confirm that its contents are true yes you've also made a second statement i think to the police that is
00:02:49 statement i think to the police that is at met three zeros eight zero six zero six
00:03:04 and you can see that that is dated the 16th of september 2021 is that your police statement of this year it is and have you read that statement recently i had and can you confirm that it is
00:03:15 had and can you confirm that it is it is true the contents are true yes uh are you happy for those two statements to be taken as your evidence to the inquiry i am yes and have you discussed your evidence with anybody before coming here today no i haven't i
00:03:27 before coming here today no i haven't i want to ask you first if i may about your role at the lfb and i can take this i think in summary a paragraph six of your inquiry statement you say that you joined essex fibrograde
00:03:38 you say that you joined essex fibrograde in 1995
00:03:40 in 1995 as a control officer and then you received several promotions thereafter i did
00:03:46 did and in 2007 you joined the lfb as an assistant principal controller or app con yes ap con ap con and your title in change from ap con to
00:03:58 and your title in change from ap con to senior operational manager or som or som in 2010 was it or 2011. i believe 2010 2010
00:04:07 2010 and you say in paragraph eight of your your witness statement to the inquiry that you were seconded to the chief fire officers association or cfoa in september 2012. is that right yes do you
00:04:19 september 2012. is that right yes do you remember when in september 2012 i think i started with cfo on the 1st of september 1st of september yes 2012. uh and what did you do there so
00:04:30 so my role at sifoa was to um engage with all the fire control rooms um across the country the fire control project had
00:04:42 project had just been cancelled and dtlg
00:04:46 and dtlg had awarded a sum of money to all control rooms to procure new mobilising systems and i was seconded with another
00:04:57 and i was seconded with another member of
00:04:59 member of the control um
00:05:01 um to monitor those projects and feedback to dclg on any improvements they were making
00:05:10 right
00:05:14 uh and we may come back to that and do courts later uh it's right i think that you then returned to the lfb in january 2015. i did yes was that at the beginning of january yes
00:05:25 beginning of january yes and at which point i think you then took on overall responsibility for the operational support team as it had become yes that's the ost and that included line managing the training element of lst did it yes by
00:05:38 training element of lst did it yes by that time it included ost was a group as a group uh on the night of the fire at grenfell tower on the 14th of june 2017 you were the on-call som in
00:05:50 june 2017 you were the on-call som in the control room weren't you i was we've heard that and we've heard also that you attended the control room and managed the control room as som from about one uh about 2 15 a.m yes that's correct now in paragraph six of your statement
00:06:02 now in paragraph six of your statement you say
00:06:04 you say that at the start of 2019 the name of your role changed again from som to senior control commander or scc is that correct it did
00:06:15 correct it did but that was only a change of name am i right not a change of role no it was a change of name and you also say that as of the 1st of january 2021 you became by way of
00:06:26 january 2021 you became by way of promotion a dac deputy assistant commissioner uh for control
00:06:31 control yes that's correct yes and is it right that as at today you occupied the newly created role of deputy assistant commissioner for control and mobilizing i did
00:06:43 control and mobilizing i did and you report i think as at today is this right to ac jonathan smith who is the head of department for operational resilience and control yes that's correct and you're still employed by the lfb i am
00:06:55 lfb i am now can i ask you about reporting lines you say in your your witness statement the inquiry at paragraph 7 that when you joined the lfb as an ap con scott hayward was your line manager was scott
00:07:06 hayward was your line manager was scott hayward always always your line manager from 2007 until he left the nfb in july 2019 yes apart from when i was seconded to seafarer apart from that period yes of course and
00:07:18 apart from that period yes of course and can you explain how in in general terms that line management worked in practice uh so
00:07:26 uh so there were three of us in the senior management group and we i shared an office with the other ap con that became the senior operations manager so i would describe it as
00:07:39 manager so i would describe it as a close working and group
00:07:42 and group and obviously some of the lines we had i was responsible for the technical team when i first joined and lindsey turner was responsible for the training team and but just in the
00:07:53 the training team and but just in the course of making changes and and delivering the service there was a lot of crossover between the two and any technical changes that need to be made need we need to make sure that the training
00:08:05 we need to make sure that the training was aligned to that and vice versa so it was a it was a close working relationship i had with both lindsay and scott
00:08:13 scott right
00:08:15 right and did you work closely with scott hayward yes how often would you meet daily did you have formal meetings whereby you would sit down exchange information
00:08:27 information we had formal meetings um and informal meetings on a daily basis so formal meetings would be regular every two weeks
00:08:37 two weeks possibly and informal meetings daily and would those informal meetings be documented no
00:08:45 no what about the every two weeks meetings the formal meetings no i don't believe so we would just work for a list of topics that we were currently working on and just get some updates on various projects we were lindsay and i were
00:08:57 projects we were lindsay and i were leading on were there any well we know there were brigade command management meetings which were minuted yes were there other meetings which involved you and scott
00:09:10 meetings which involved you and scott hayward which would be minuted only
00:09:13 only meetings with other departments so if we were visiting union street for a meeting those would be minuted more often than not but not internally
00:09:25 but not internally now
00:09:26 now i want to ask you about the technical support group and the brigade control training team before the ost was formed you say in your witness statement of
00:09:37 you say in your witness statement of paragraph seven that as ap con you had line management responsibility for the technical support group or tsg yes uh and two control commanders who included line management responsibility
00:09:49 included line management responsibility for two of the four watches so about 50 staff
00:09:53 staff yes can you explain the technical support group what was that so the technical support group was a team of control staff that worked um daily in a team to
00:10:05 daily in a team to make sure that the mobilising system and all
00:10:08 all systems that we used in control were up to date and were relevant they often worked on changes to the system and they also did some
00:10:19 and they also did some event planning as well so a whole range of stuff but mainly the uh
00:10:26 yeah the monitoring of the mobilizing system right so this was essentially is this right overseeing how the machinery worked yes and i'm recommending changes to its functionality as well and seeing those
00:10:39 functionality as well and seeing those changes through into the control room and did the technical support group itself meet did it meet regularly i believe it did it had a control commander in charge of
00:10:51 it had a control commander in charge of it at the time and i believe they met regularly as a team right now you say that the tsg consisted of steve perry kyra smith terry page graham bonnett and paul pope chrissy smith but
00:11:02 bonnett and paul pope chrissy smith but yeah
00:11:03 yeah chrissy smith what rank were they so steve perry was the control commander in charge and the other team members were senior
00:11:14 the other team members were senior operations managers sorry senior control officers senior control officers is that the same as an som that's the same as an aom the same as an aom
00:11:27 aom and you also say you were in charge until uh that the tsg merged with training to become the ost in 2010. do you remember when in 2010 uh that would have come in with the change of shift
00:11:39 change of shift uh pattern um i think that was it towards the end of 2010 but i can't recall scott hayward told us yesterday i think although he didn't put a precise time on it that the change in shift pattern happened in 2011 but
00:11:50 pattern happened in 2011 but is that is that right that may be true the agreement to change the shift pattern was signed in 2010 but maybe the implementation took some time so before the end of 2010 when the ost
00:12:02 so before the end of 2010 when the ost was created there were two separate teams is this right one the technical support group and one the brigade control training team being bct um why were they separate do you know
00:12:17 i don't really recall i wasn't in london fire brigade when they were two formed originally but i would imagine that just because of the demand for the the technical assurance that was
00:12:29 the the technical assurance that was needed so in 2004 i think or 2004 they'd procured a new mobilising system and so the team was probably established then right and before the merger at the end of 2010 who
00:12:42 before the merger at the end of 2010 who was responsible for the training team
00:12:45 lindsay turner
00:12:50 and she reported to scott hayward she did yes
00:12:53 did yes and did were you involved in that reporting did you know from time to time what it what what was transpiring between lindsey turner and scott hayward on occasion we would discuss workloads
00:13:05 on occasion we would discuss workloads we would discuss um changes that were coming and as i said there was some ongoing projects that we would also talk about all together because
00:13:15 because some things had that i was doing had an impact on lindsay and vice versa right now this may sound obvious but is it right that the brigade controlled training team developed and delivered control training
00:13:26 delivered control training yes yes um and did that mean that the technical support group had no role in the development and delivery of training no i don't believe it did so the technical support group would uh suggest
00:13:37 technical support group would uh suggest a change or there would be a change implemented and they would talk directly to the training team about how the training team would manage that change and deliver that to control staff
00:13:48 change and deliver that to control staff do you know why the two teams merged in late 2010
00:13:52 late 2010 yes so that was part of the change of shift pattern that we went through and just
00:13:59 just as we were planning to go live with the fire control project and what was the basic reason can you tell us for the change in shift pattern at that time so as i understand it um
00:14:12 so as i understand it um the premise of fire control was nine regional flight control rooms that would be able to take each other's calls and support each other as a network and i think dclg at one point were concerned
00:14:24 think dclg at one point were concerned that some fire control rooms would reduce their staffing to below levels and let the rest of the network take
00:14:33 take those calls and and so they proposed a charging system whereas if an over a call overflow to another rcc regional control room that the um other control room would be
00:14:46 that the um other control room would be charged for that and the deputy assistant commissioner in charge of control at the time wanted to avoid that and so we created a shift pattern
00:14:57 shift pattern that had variable staffing so we picked with our staffing levels as the calls increased in the evenings
00:15:08 the calls increased in the evenings i see
00:15:11 and what was the practical effect of the two teams merging to become the ost uh that's a it's an open-ended question i but in in short can you tell us what the practical effect was the knock-on effect to you at
00:15:23 effect was the knock-on effect to you at least was of the two teams merging to become the ost so the practical effect was that i retained responsibility for the two and three members that were in the old technical
00:15:35 members that were in the old technical support group and lindsay retained responsibility or line management responsibility for the two trainers that had gone into that team right and then let's look at the ost um
00:15:46 and then let's look at the ost um you say following the merger into ost it it consisted of paul pope and graham bonnett chris sharp and nicky o'shea yes yes
00:15:54 yes yes um
00:15:55 um where did the ost sit in the overall lfb organization can you give us an idea of that
00:16:04 that so it was just uh it was the only control department that worked at dayshift so it was
00:16:12 it was a support department so it supported the control room and it dealt with any changes that needed to be made it dealt with queries from operational departments as well
00:16:24 operational departments as well and
00:16:25 and so it it just sat below lindsay and i where did it sit in in the directorates which directorate was it in it was in it was with control
00:16:36 was it in it was in it was with control and mobilizing right and that's that where that's set in operations directorate right so ort no
00:16:46 no they're just the operations director under i see dave brown at the time dave brown dave brown's directorate and
00:16:54 and chris sharpe and nikki o'shea what was their
00:16:56 their rank
00:16:59 rank so chris had been a control commander when
00:17:03 when it was a separate team and then when the teams merged um she was
00:17:10 they were both aoms assistant operations managers
00:17:14 managers and you then go on to say that paul pope and graham bonnet retained responsibility for the technical element including mobilizing and they reported to you as the som but
00:17:25 and they reported to you as the som but chris sharp and nikki o'shea reported to lindsey turner they did yes given that the tsg and training team had merged into the ost why did you and lindsey turner take on a
00:17:38 why did you and lindsey turner take on a different area or retain perhaps a different area of responsibility with different lines of reporting i i don't think we saw it as as different lines of reporting like i say we worked together quite closely lindsay
00:17:49 we worked together quite closely lindsay and i shared an office so we would know what each other were working on and the ost was a newly formed group and but the skill base from chris sharp and nikki
00:18:00 and nikki were training and they'd had experience in delivering training and creating training packages as had lindsey because she'd previously come from the training team before her
00:18:11 come from the training team before her promotion
00:18:13 promotion and i was more familiar with the the technical elements that both paul pope and graham bonnet had been working on as between you and lindsey turner was either of you the lead for the ost or
00:18:24 either of you the lead for the ost or was that role shared between you as i understood it that road was shared between both of us now scott hayward said in his in his first witness statement
00:18:35 first witness statement and i'll just show this to you lfb3055191 page 18 paragraph 50.
00:18:44 he says that ost are led by one of the soms
00:18:49 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 was vic bagnell and from 2015 to date it has been joanne smith
00:19:01 date it has been joanne smith do you agree with that statement
00:19:05 so from 2012 to 2014 but i maintained line management responsibility for both graham and paul and from when the ost was created
00:19:18 and from when the ost was created um
00:19:19 um that period is when you were at the cf cfoa
00:19:23 cfoa yes so during that period is it right vic bagnall essentially took your spot uh no i believe he replaced lindsay so i think keith diamond uh when i left
00:19:35 so i think keith diamond uh when i left for seafarer keith diamond took over my roles and responsibilities and when lindsay moved to projects at headquarters vic bagnall took over her work streams
00:19:46 bagnall took over her work streams do you remember when she moved to um projects at headquarters in union street i think at the end of 2012 maybe the beginning of 2013.
00:20:02 now in his second statement and i think i can just read this to you rather than by showing it to you what scott hayward says is paragraph 38 between 2009 and 2019 i delegated training
00:20:14 2019 i delegated training responsibilities to a number of soms all of whom were control staff and so would have held the appropriate knowledge and experience to oversee the training do you agree with that
00:20:25 do you agree with that um i agree yes that we are all we were all control staff that we had the experience and knowledge having all been controlled officers and moved up the ranks yes do you agree that
00:20:37 moved up the ranks yes do you agree that he delegated training responsibilities to soms
00:20:41 to soms yes
00:20:42 yes and what did that mean in practice how did the how did the delegation work in practice
00:20:53 um i think that we would discuss um training as well as other
00:21:00 other items that we had to work through as a team and one of us would take responsibility for that or take responsibility for a couple of tasks to to achieve the goals that we were trying to achieve right
00:21:14 scott haywood gave evidence over the last two and a half days and
00:21:19 and and he described the reporting system as one of uh reporting by exception uh is that something you recognize that is something i recognise with
00:21:31 that is something i recognise with scott yes and how did that work in practice
00:21:34 practice so i think in practice we spoke daily we knew what each other were working on i often attended meetings at headquarters with scott i was often in the same meetings with him and and we often
00:21:47 meetings with him and and we often discussed
00:21:48 discussed our ongoing work on on a daily basis so yes
00:21:53 yes um i would report anything to him i probably reported too much to him right
00:22:00 right the impression he gave from his evidence well
00:22:03 well rather
00:22:04 rather a fair summary of what he told us was that he left it you to get on with it and reported you reported to him only when things weren't working in accordance with the way um
00:22:15 um they were supposed to work i i would have definitely done that you would definitely have done that but would you have done more yes now when the ost was created just make sure you've understood this
00:22:27 just make sure you've understood this speaking for myself um mr hayward certainly gave me the impression that he rather left it to his sons to deal with in particular training
00:22:39 in particular training and didn't get directly involved himself very much is that a fair understanding as far as you're concerned i think that's a fair assumption sir but i wouldn't have
00:22:51 i wouldn't have not
00:22:52 not communicated what i was doing with him right thank you very much when the ost was created did you have regular meetings did you the ost have regular meetings internally
00:23:04 regular meetings internally yes they were opposite my office
00:23:08 office um and
00:23:11 um and directly off the control room so we would have talked every time i was in uh at merton and so those meetings were informal
00:23:22 and so those meetings were informal daily
00:23:23 daily passing meetings yes presumably not minuted no no were there formal ost meetings uh i don't believe sir
00:23:37 did you and lindsay turner meet separately to discuss matters of importance about the ost
00:23:45 the ost in terms of lindsay and i just meeting together yes to talk about rst ost i don't recall that now
00:23:53 did you talk about just training uh delivery of training content of training with lindsey turner uh not specifically and not until
00:24:04 uh not specifically and not until i started work on the lack of investigation
00:24:09 if we go to your witness statement of paragraph seven please on page three your inquiry witness statement you say there
00:24:20 you say there and it's about halfway down
00:24:26 you see on the right hand side of the column of text the word during about halfway down the block of text can you see that
00:24:36 during this time i took a lead role yes you can pick that out read with me it says during this time i took a lead role on a change of shift pattern for control staff implementing a quality assurance system into control a
00:24:49 quality assurance system into control a relocation to a new control building at merton and the adoption of the chief fire officers association cfoa national coordination centre from west yorkshire fire and rescue service to london fire
00:25:00 fire and rescue service to london fire brigade control
00:25:03 this included the establishment of a new team to manage this role and development of new working practices agreeing memorandums of understanding with government departments i was also involved in drafting the control room
00:25:14 involved in drafting the control room response to the latino fire in addition part of my role required me to be on call one week out of three to assist the control room during large or complex incidents
00:25:23 incidents can you explain what your role was in drafting the control room response to the national fire so i was originally asked i think by scott hayward to
00:25:35 scott hayward to look
00:25:36 look and help with a gap analysis and from the control point of view i because i had the technical responsibility for for tsg
00:25:47 for tsg they had already been involved in some work in terms of downloading calls and drafting a timeline so i had been involved just purely for my responsibilities with the technical support team
00:25:58 support team and and then yeah scott asked me to get involved in looking at the gap analysis and undertaking a gap analysis and then that led to me attending meetings and with
00:26:10 led to me attending meetings and with the lack of house board and
00:26:14 and during that time we were asked to put a control report together that detailed all the control actions in the history of fsg um just to be clear can i show you the
00:26:27 just to be clear can i show you the uh control report it said lfb four zeros four seven two four
00:26:36 is that the report that you're referring to
00:26:39 to uh is this the published report yes so
00:26:44 so that was published in november 2012 um and i believe that had some changes to the original report that scott and i worked on to make it more public-facing right
00:26:55 right can i take it though that you were very familiar with the findings recommendations and actions detailed in this document i believe so yes now if we go please to um your
00:27:06 now if we go please to um your uh
00:27:08 uh witness statement of power at page 17
00:27:12 there's a heading
00:27:15 at the at the bottom in relation to action 11 and there's a question based on initial fsg training and you could see the question uh the inquiry understands from the
00:27:27 uh the inquiry understands from the latin assurance review that that's a later document from 2018 that the initial fsg training that was developed as part of action 11 included a suite of training presentations concerning
00:27:38 concerning covering fire behavior building structure fire survival and emergency call handling techniques fsg role play and a presentation on policy 790 in to 2012
00:27:48 to 2012 please explain your involvement in the development and implementation of this initial fsg training that was developed after the latter house fire i will come back to the rest of the question but if you turn the page to page four to page
00:28:00 you turn the page to page four to page 17 to page 18 and look at page 18 paragraph 45 you'll you see you say this um however chris sharpe and nicky o'shea
00:28:11 um however chris sharpe and nicky o'shea were responsible for the creation of training packages in 2011 to 12 my involvement in this training was to review and comment on training packages in my role as a som and due to my involvement in the latino house report
00:28:23 involvement in the latino house report along with scott heywood as a pom lindsey turner was the line manager for training
00:28:29 training and why was um training a part of your role of
00:28:34 of as an som
00:28:36 as an som so it wasn't it was just that we i'd had experience and both scott and i had been to the lacanal house boards had drafted
00:28:45 drafted the control report and knew the actions from the gap analysis so it just made sense that when the training packages were created that we had
00:28:56 had comment on those to make sure that they aligned with what we'd agreed right did you have any prior experience of developing training packages before
00:29:06 before uh assisting in the brigade's response to the latin house fire no so one of my roles in in essex i would have uh delivered some training packages but no formal training now
00:29:18 packages but no formal training now right
00:29:20 right so it sounds very much as if you you your role
00:29:23 your role evolved into oversight of training content and delivery as a result of your initial involvement in the brigade's response to the latter house fire
00:29:34 house fire no i wouldn't have said that it was purely commenting on from our experience that we'd had um through lucknow there was no requirement for me to oversee that lindsay and her team were capable
00:29:46 that lindsay and her team were capable of producing the training packages just as a peer support i commented on those just to make sure they were right because we wanted to learn the lessons from lacanal
00:29:57 learn the lessons from lacanal and make sure those situations didn't occur again when you say you wanted to make sure they were right what were you measuring what she was producing against
00:30:06 against just in terms of what we'd committed to deliver from the lachnal house board
00:30:12 board and the report now i want to ask you about brigade control management meetings a little bit i think you attended those didn't you yes
00:30:20 yes they're known as bcmms they are how often would they take place i think every month and i think there was a period of time and i don't know when
00:30:32 and i don't know when tenure that they moved to every other month and um do you remember when the best of your recollection bcmms started
00:30:43 recollection bcmms started when you when you had when the first meeting you ever attended was yes i think when i first joined london fire brigade they had a management meeting
00:30:54 management meeting but it was split into a management meeting and then a more operationally focused meeting so we'd discuss changes and operational incidents
00:31:06 changes and operational incidents and shortly after that i think it was merged into one meeting and before june 2017 did the brigade control management meetings or bcmms take place every other month
00:31:18 take place every other month until that time i think they may have gone back to monthly right at one point i i can't recall apologies how did the ost's work feed into those meetings
00:31:29 ost's work feed into those meetings uh i think at one point there was a desire for a member of ost to attend and if they didn't attend i think whoever was in charge of ost at the time
00:31:41 whoever was in charge of ost at the time gave an update i think there was a technical meeting minute and there was a training meeting minute um so how it would work prior to when lindsay and i were in post
00:31:54 prior to when lindsay and i were in post lindsey would do the training update and i would do the technical update i but if one of us was absent we'd probably cover for each other now we have three monthly reports
00:32:05 now we have three monthly reports entitled operational support team monthly reports for for june july and september 2011. can we look at the one for june 2011 at lfb double zero
00:32:16 lfb double zero one one one five eight zero
00:32:23 this is entitled ost report june 2011 and you can see training is the first item on the agenda far survival training is the first of those mop-up training for outstanding staff is
00:32:35 mop-up training for outstanding staff is now complete progress is being made in constructing a shorter refresher training package uh just looking at that as an example is it right that that these
00:32:46 it right that that these uh reports would be submitted to bcmm attendees
00:32:52 yes that could have been i don't recall but that could have easily happened right do you know who compiled reports such as these i would imagine that was chris sharp and would you read
00:33:04 and would you read documents such as these before brigade controlled management meetings no that was properly supplied with the papers for for the management meeting and it was probably discussed then
00:33:15 was probably discussed then and what was the purpose of these reports
00:33:20 the one from the ost yes reports such as this this is an example um i i don't know i don't recall um
00:33:29 um ever there being a question about asking ost to provide an update that may have been something that chris did and thought was very helpful to us and would they be discussed at the meetings
00:33:41 meetings if there was any if there was anything the operations managers or wanted to raise yes and they would be
00:33:48 would be and were they created every month or every other month as far as you were aware before you left for secondment uh in september 2012. i'm sorry i don't recall
00:33:57 recall when you came back to control in january 2015
00:34:01 2015 did these continue to be produced by the ost for the brigade control management meetings no so at some point they stopped did they yes do you know why i don't know
00:34:12 yes do you know why i don't know now at these meetings the bc mn meetings is it right the the training being uh discus
00:34:18 discus discussed was the training being developed and delivered by the ost yes yeah it would have been and looking at
00:34:25 at at the meeting for
00:34:30 july lfb double zero one one one five seven nine if we can
00:34:38 i'm sorry june this is the june bc mm meeting as you can see uh
00:34:43 uh you can see that you were in attendance som stebards you see that yes that's you and then at page three if we go to page three bottom of the page we can see a title
00:34:55 title css training fsg som steve ads ops managers to contact andrew mckay directly to arrange for him to deliver familiarization to assistant operations managers and then over the page
00:35:08 managers and then over the page som steve aard spoke to andrew mccain confirmed that control staff should be able to have an access to the training what was css training fsg
00:35:19 what was css training fsg so as part of our um investigations uh and our desire to have better two-way communication with the instant ground following the lack of fire
00:35:30 fire we looked at various methods that the control can contact the instant ground and vice versa one was the cu telephone that we'd put in there and the other was access to the css system
00:35:43 other was access to the css system and the instant messaging on the css system so control staff could send a direct message to the incident and that is just to make sure that all staff have access
00:35:54 staff have access and just some familiarization training on how to access the system and use it so this is not about call handling no this is about using the instant
00:36:05 this is about using the instant messaging service on css to pass information to the command units now the date of this bcmm is the 15th of june 2011. we know from
00:36:16 is the 15th of june 2011. we know from other documents that the very next day 16th of june something called the haygate challenge took place was this
00:36:24 was this part of this minute related to that i don't believe sir you don't believe so
00:36:31 did you oversee the css training fsg referred to here no
00:36:36 no um i just
00:36:37 um i just we'd explored a way another opportunity to talk to andrew mckay about accessing it and i'd obviously probably been involved in talking to it about getting
00:36:48 involved in talking to it about getting staff or control staff access to it and and it was just that they were going to come down and provide some familiarization training about how to log on to the system and then
00:36:59 and then access the instant messaging bar right can we go back to paragraph 17 of your witness statement on page seven
00:37:09 uh i want to ask you about call coach you've got a heading call coach there yes 2010 to 2012 and you say one technical function that i was responsible for delivery during this
00:37:20 responsible for delivery 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
00:37:31 procuring a new quality assurance system in 2010 which was call coach we use this program to monitor and review nfb's call handling standard i exhibit a note which sets out in detail this process supervisors have a
00:37:43 this process supervisors have a responsibility for three or four cros and say they listen to three calls a month for each of these individuals and graded them against the control call handling standards cras received a monthly appraisal of their call handling
00:37:54 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 cras through this process
00:38:05 process did this process of monitoring and reviewing cro's call handling occur before the introduction of call coach
00:38:13 coach no i don't believe so do you recall when call coach was introduced i would imagine 2010 do you know why it was possibly sorry possibly 2000 late 2009
00:38:25 possibly 2000 late 2009 do you know why it was introduced yes because lfb had no quality assurance system for monitoring calls
00:38:35 calls and was it introduced as a response perhaps an early response to the latino house fire no um i think one of my main reasons and one of my main tasks when i had when i
00:38:47 one of my main tasks when i had when i was brought into lfb and was successful was to procure a quality assurance system for control um right even though you were in charge of technical
00:38:58 of technical nonetheless this was you regarded this aspect of quality assurances falling within your responsibility so yes because it was a technical solution it would have required a
00:39:09 solution it would have required a technical solution to do it which is why it felt unfair under my responsibility the core handling standard that you can create and add into the technical
00:39:20 create and add into the technical solution
00:39:21 solution that was formulated by um control staff predominantly and but lindsay oversaw that project too now you say that supervisors listen to three calls a month for each of these
00:39:32 three calls a month for each of these individuals yes as you say can we just look at lfb double zero one two one two three one
00:39:40 three one this is the note that you exhibit as js2
00:39:45 and this details the process if we look at page 1 on the screen this is version 5 10 may 2010 and the title here is call quality management application call coach
00:39:58 management application call coach and if you look at paragraph 1.4 it says a minimum of one call per month per cra will be assessed through call coach
00:40:07 coach and then at page two of paragraph 3.2 it says
00:40:13 it says assessors should select one call from the selection available and discard the remaining media by deleting these from the individuals folder
00:40:23 folder is it actually the case that assessors would review one call per individual not three i i think that might have changed as we
00:40:34 i i think that might have changed as we got used to the system and as we got used to using the system but you're right as it says there i i can't be sure right uh
00:40:45 uh it
00:40:46 it to be fair to you it's not crystal clear if we go to page six of this same document under part two
00:40:55 this is part of appendix a identifying calls in the third paragraph there it says uh if not dup this will be the first of the three
00:41:06 this will be the first of the three calls for which wav files are to be sent for assessment now
00:41:11 now first what is dup uh it's just an acronym for a dupe a duplicate oh right it's a shorthand duplicate and that does refer to three calls yes um how does that fit with the
00:41:24 calls yes um how does that fit with the reference to one call in earlier in the document
00:41:27 document so i think originally just looking at the the start of the document that tsg may have provided three calls uh three random calls and that the uh
00:41:40 three random calls and that the uh senior operations manager with the control officer would have picked one of those right but but i believe that was expanded
00:41:48 expanded and then it does go on to refer to three calls in the in the next few paragraphs uh now you say in the same paragraph of your statement as i've shown you that ost were responsible for the random
00:41:59 ost were responsible for the random selection of these calls from the call log as this was a manual technical task who in ost would respond be responsible for that selection so that would have been uh paul pope and
00:42:10 so that would have been uh paul pope and graham bonney and how would they go about identifying which calls to select so they had a standalone recording system that they would just um
00:42:24 system that they would just um search on the operator id so all our control staff have a unique identifier and they would just search on that and then download three calls making sure that one of them wasn't a duplicate call
00:42:36 that one of them wasn't a duplicate call right so there was a random selection but for duplication yes i see
00:42:43 if we go back to page one of this same documents same document it goes um into some detail in paragraph 1.3 it says all calls will be assessed by an officer carrying out a higher role
00:42:54 officer carrying out a higher role within the control room this will include long-term temporary promotions which can be estimated as being longer than three months
00:43:03 uh can you explain how the calls were assessed
00:43:10 so the call coach project had the ability to add in a call handling standard which is what i referred to before with the had input from control staff
00:43:22 had input from control staff that was placed onto the system and therefore um when uh
00:43:30 it says team leader here but when a senior control officer was sitting with a control operator they would go through the various elements of the call and mark those against the call handling
00:43:41 mark those against the call handling standard i see um now you refer to the call handling standard i think we have that on page seven of this document yes um which is appendix b nfb call handling excellence standard is
00:43:52 nfb call handling excellence standard is that the standard you're referring to yes i see
00:43:55 yes i see and um if you look at the right hand side you can see some red numbers in boxes
00:44:01 boxes is that the or are those the scores to be given to cros based on their performance i believe so the maximum score and that would give an overall score out of 100 which i think we get at the paragraph 3.11 on page three i don't need to take
00:44:13 3.11 on page three i don't need to take you back to that um and is it right that the scores would be would be fed back to cros in a private session yes uh and are you aware of any of the supervisors and i i assume that that's
00:44:25 supervisors and i i assume that that's aoms and soms is that right no the supervisors would have been aoms or
00:44:32 or forced
00:44:33 forced the call handling for aoms would have been the om aoms and oms yes right are you aware whether the supervisors of
00:44:44 are you aware whether the supervisors of those ranks undertook that review routinely on a monthly basis during the period 2010 to 2012 when you left for the cfa cfoa i believe so
00:44:55 i believe so did anybody check if they were carrying out that assessment routinely yes i think the team the ost team from you know tsg paul and graham
00:45:07 you know tsg paul and graham would have monitored that because they were responsible for placing the calls into the folders
00:45:14 did you ever learn
00:45:16 learn that it wasn't being carried out routinely
00:45:20 routinely uh
00:45:21 uh not that i've come recall no not specifically and when carrying out the audit of the calls
00:45:28 calls how many cras were involved was it all of them or just it would have been all of them right do you remember whether uh you or um
00:45:39 uh you or um paul graham identified additional learning or training points for cras through this process
00:45:47 process i don't but i don't think it would have been for
00:45:50 been for tsg to to do that so that would have been uh the aom's and the on he was assessing the calls right just just to take a step back
00:46:01 just to take a step back when the assessment took place and the schools were arrived at and fed back to the cros were those schools then fed back up the chain to
00:46:11 to a supervisor so om or aom yes so the the the aom would have been able to see the scores as well it was on the system so it was a system that
00:46:23 the system so it was a system that showed the scores so they would have been able to see those scores and but they would have talked to the control officer just about the various elements and if they scored below and they would
00:46:34 and if they scored below and they would address those and that would have either been done locally on on the watch or if there had been something significant i would assume that they would have asked ost in terms of chris and nikki to
00:46:45 ost in terms of chris and nikki to assist
00:46:48 uh and that was on the training side rather than the technical side of ost yeah did you have any insight into what the
00:46:59 you have any insight into what the training side of ost was learning uh about
00:47:05 uh about cra performance in these assessments no you didn't no not really i think just from from my recall about uh cool coach and because it was a
00:47:16 uh cool coach and because it was a manual system which took a lot of ost's time
00:47:19 time to create i think in general terms between senior managers there may have been some frustration that
00:47:26 that when we rolled out a new change to procedure or practice within the control room that we weren't easily able to identify all those calls relating to
00:47:38 to identify all those calls relating to that change and therefore it was very difficult to quality sure whether that change had
00:47:47 had been received well and actioned to the extent that you were involved was the call coach auditing process effective in identifying additional learning or training points
00:47:59 additional learning or training points um i i didn't hear to the to the country otherwise would you have done had there been a problem maybe not right are you able to say how often fsg calls were included in call coach reviews never
00:48:11 included in call coach reviews never never never why not that sounds like a rule was that the case it was yes i think that was written into the the policy i think that was a
00:48:23 the policy i think that was a i think there were two issues there i i think
00:48:25 think um
00:48:28 as a an overall management decision the decision was taken uh not to put fire survival guidance calls into cool coach and and i think
00:48:39 cool coach and and i think the
00:48:39 the call handling excellent standard that was created um
00:48:43 um [Music]
00:48:44 [Music] it was a new system and we were just getting used to it and and the detail that would have been required for uh for survival guidance and would have been difficult to capture
00:48:59 so how did supervisors quality assure fsg calls
00:49:06 in terms of just providing support and assurance to them when a control officer was taking a fire survival guidance call as you know they weren't um
00:49:18 weren't um right so they weren't trained or assessed
00:49:23 uh as part of this process no did you or anybody else draft any kind of report so as to be able to inform senior management for
00:49:34 able to inform senior management for example scott hayward or ac brown about the outcome of the call coach reviews that were taking place no i wasn't asked to do that and i believe
00:49:44 believe the decision to not
00:49:46 not take
00:49:47 take fsg calls was taken with the um when we had a deputy assistant commissioner in charge of control i think there was an agreement with that between him and the representative
00:49:59 between him and the representative bodies that uh survival guidance calls weren't quality assured
00:50:05 assured uh you say you weren't asked to do that in general can you tell us were senior management so haywood and brown ever informed of the results of these reviews on any regular basis
00:50:17 no no oh
00:50:19 oh sorry can i caveat that with actually they would have been discussed at brigade control management meetings and they may have been discussed at joint secretaries of the the joint sex meeting
00:50:31 secretaries of the the joint sex meeting were any target set we've seen the scoring but we're only target set like a minimum score uh
00:50:40 uh possibly
00:50:41 possibly i do have a vague recollection of that but i'm i'm not entirely sure right uh can we go to lfb double zero one zero nine zero
00:50:50 nine zero eight two
00:50:56 uh this is what we've come to know as the kelly report
00:51:01 report third of august 2010 drafted by sm steve kelly otherwise known as ned i think and this was an audit of the grade controlled training department and specifically the fsg
00:51:13 department and specifically the fsg training course first do you recognize this document it is only the first page and i can show you more of it of course no i'm aware of sm kelly's report you
00:51:24 no i'm aware of sm kelly's report you are yeah uh did you see it at the time i i didn't recall when i was asked about it but i
00:51:32 it but i yes i probably did just in my normal course of being a senior operations manager within the yes in fact i think we know a bit more than that because you actually commented on it didn't you yes yes and if we go to
00:51:44 yes and if we go to page one
00:51:47 page one uh well page nine i think is probably the best place to go page nine if we go there
00:51:52 there um there's paragraph sixty-seven which i'll read to you and this is underneath the heading quality management and assurance sixty-seven control officers and team leaders are subject to a monthly review by line
00:52:03 subject to a monthly review by line managers calling using the call coach system a confidential assessment of performances conducted against set criteria on a one-to-one basis using the imported audio files to support discussion and feedback this provides
00:52:15 discussion and feedback this provides for a very effective workplace assessment of staff and we can see some comments now before i show you the comments um the
00:52:27 the call coach system is the same system we've just been examining yes yes and where it says this provides for a very effective workplace assessment of staff there's a comment in the comment box j23
00:52:40 there's a comment in the comment box j23 on the right hand side dated 8th of november 2010 which you can pick up on page 13. if we just go to page 13 we can we can pick up the comment date there
00:52:59 uh as j23 you can see towards the foot of the page
00:53:04 uh it's your comment you see that yes on the on that well it's 1108 2010 in fact i think that's
00:53:15 2010 in fact i think that's uh
00:53:15 uh the 11th of august 2010 rather than the 8th of november 2010. yes yes
00:53:23 yes yes and if we get back to the comment uh please
00:53:27 uh please on page nine we'll look at it in the comments box
00:53:33 uh you have commented team leaders do not have a monthly review
00:53:39 review and then underneath that you've written not according to our data and the opinions of our om and that's against the statement this provides for a very effective workplace assessment of staff
00:53:50 staff can you explain what you meant by that comment that second comment i would imagine that the operations managers had provided some feedback to us as the senior
00:54:01 some feedback to us as the senior management team that it wasn't um as
00:54:06 as successful or that it was difficult maybe to achieve in the day and it may be because at this time we had moved location and and there was some difficulties in
00:54:19 and and there was some difficulties in finding
00:54:20 finding areas
00:54:21 areas in the new environment in merton and it took some time to set up the call coach systems because they were stand-alone systems that may have been why i've made a comment about the data
00:54:41 the move to merton as i recall it from uh mr hayward's evidence took place in february 2012 i think yes right yes and this is august 2010
00:54:54 yes right yes and this is august 2010 i always say our apologies right so
00:54:58 right so just going back on your your answer perhaps more generally let me ask you more generally why was call coach at least in the opinion of your om not a very effective way to assess staff's call handling
00:55:12 staff's call handling i i'm not sure i would imagine that i just would have received feedback that it wasn't
00:55:18 it wasn't as
00:55:18 as effective did that mean that it wasn't an effective way of identifying new training or learning points for cros
00:55:27 um i don't think so i don't believe i had that opinion i thought it was apart from it being a manual system i thought it provided lfb some assurance
00:55:40 lfb some assurance why were you the one providing feedback on this report and not lindsey turner i'm not sure lindsay didn't provide feedback and i would have just provided feedback
00:55:52 feedback um and a lot of the comments i noticed are just
00:55:55 are just you know corrections to make sure the document reads right so i correct senior instead of right a team just to make sure the the language is correct and that it is reflective of
00:56:07 reflective of controls procedures and practices i mean this section of this report and indeed much need much of the report is about training why were you um commenting on
00:56:19 why were you um commenting on the quality of the training given that it didn't fall within your and your remit or the ambit of your work within the ost
00:56:30 within the ost do i i'm not i'm not sure i comment on the training i think i comment on on what's written in the report and trying to make sure that that is reflective of actually what controlled you and my
00:56:42 actually what controlled you and my understanding of what control do and manage
00:56:45 manage so i don't think i comment generally on the training
00:56:57 when you
00:57:00 uh received this callback this feedback from uh at the om did you or anybody else think of the time to look at adopting a different method for assessing call handling
00:57:11 assessing call handling um no but i i don't think we would have not actioned it i think everything that came up and and through us from management meetings we would look um about how we could make
00:57:24 we would look um about how we could make it better right do you know whether your comments were fed through to the final version of this report
00:57:31 i don't those comments probably were just
00:57:33 just shared with scott and lindsay
00:57:37 we haven't been able to find any any final version of the report which showed any reaction to this comment so can we take it that there wasn't one i would imagine that it was just shared between scott and lindsay yes right
00:57:51 what happened to cool coach if anything in the light of the fact that at least one om
00:57:56 one om um thought that it was not a very effective workplace assessment as i said we would have worked on those comments
00:58:05 comments and tried to make sure that people thought it was an effective tool now this is only a few weeks before you uh well
00:58:15 uh well when you went you went away in january i'm so sorry to try this again when you went away in september 2012 was call coach still running at that stage yes
00:58:26 stage yes when you came back from secondment in january 2015 was it still running at that stage yes did it run consistently between your departure in september 2012 and your
00:58:39 departure in september 2012 and your uh re-arrival in in the lfb in january 2015
00:58:44 2015 i have no reason to believe not but i i couldn't
00:58:47 couldn't be sure
00:58:48 be sure when you came back in january 2015 did you find out did you take steps to find out where the cool coach had been running in those intervening years um no i didn't but i would have um imagined whoever was performing my role
00:59:01 imagined whoever was performing my role would have taken that on and that would have been a normal responsibility of someone
00:59:07 someone ms smith i'm going to pause at this point because it is now 11 o'clock okay well it's just coming up to 11 o'clock um
00:59:16 um as i think you all know today is armistice day and so i invite you all to stand and observe the two-minute silence in memory of those who died in two world wars and subsequent
00:59:29 in two world wars and subsequent conflicts around the globe
01:01:34 thank you thank you very much
01:01:41 [Music]
01:01:45 smith from january 2015 was cool coach used thereafter i believe so now uh in
01:01:55 in scott hayward's first witness statement uh paragraph 96 and 97 at page 39 and we don't need to go to it he says that in november 2015 so you were back at the lfb by then yes at the same time as the
01:02:07 lfb by then yes at the same time as the introduction of the vision system call coach was replaced with a system called nice
01:02:13 nice and the discussions about nice were still continuing in 2019 is that right yes that's correct can you help us what does nice stand for i don't believe it stands it has an acronym i think it is
01:02:25 stands it has an acronym i think it is just the nice quality assurance system and recording system
01:02:30 system right so it's not even an acronym no right
01:02:34 right is it right that no reviews of calls were taking place from at least then november 2015. not in a quality assurance um
01:02:46 not in a quality assurance um review process just that would have just been um happening on watch with control and supervisors so just on ad hoc basis right so during the call coach
01:02:57 basis right so during the call coach years that presumably was happening as well yes it was yeah uh and so what happened was that that aspect of quality assurance continued on watch with supervisors watching
01:03:09 watching uh
01:03:10 uh with call coach and then that fell up call case just fell away did it uh yeah so the change of mobilizing system brought a new quality assurance system and because um we
01:03:21 and because um we had to we were no longer using the previous recording mechanisms for that then we couldn't use call catch right i see so
01:03:32 right i see so is it the fact that the technical changes in the control room with the coming of the vision system meant the cool coach no longer fitted yes yes i see and until
01:03:45 yes yes i see and until the introduction of vision in november late 2015
01:03:51 late 2015 uh
01:03:52 uh was there any time when fsg calls were used in cool coach
01:04:08 can i then turn to fsg and go to page eight of your inquiry witness statement please paragraph 18.
01:04:16 you say there in addition to my role before i was seconded to cfoa i reviewed all fsg calls after the latin house fire i recall i
01:04:27 after the latin house fire i recall i asked the tsg to collate every fsg call and high rise call which was entered onto a system i listened to all these calls to ensure that the correct advice was given in accordance with pn539
01:04:39 accordance with pn539 and our general call standard was achieved exhibited above at js3 this fsg call review process was not a formal requirement following the fire at national house but it was one i
01:04:50 national house but it was one i undertook of my own initiative having informed the pom scott hayward of this any fsg calls stroke high-rise calls that were dealt with well by cros may have generated positive feedback to the
01:05:01 have generated positive feedback to the call handler and i exhibit an example of such feedback at js4 if any issues arose with the call handling this would be highlighted to the relevant line manager who would be expected to discuss these
01:05:12 who would be expected to discuss these issues with the cro and assess whether there was any whether there was need for further training first can you tell us when you carried out that review
01:05:24 so probably started late 2009
01:05:28 2009 and carried on through until i left the seafarer what prompted you just to carry out that review the
01:05:37 the lack of house inquiry and the findings that we'd um
01:05:44 the findings from that and that we were rolling out a change to some of the training and and it was a way to check that that training was effective
01:06:03 did you report your review findings to anybody
01:06:07 anybody uh
01:06:08 uh yes so the if i had any issues with any particular calls or any information given during a particular call i would speak to the operations manager
01:06:19 operations manager and to speak to the cro about that or the aom and there were probably some general themes or maybe one in particular
01:06:31 in particular that we would have discussed and that would have gone into training was that we had noticed or i had noticed that um
01:06:40 um instead of being quite specific in terms of the protect advice with blocking using blankets or towels or bedding to block the doors for the smoke coming in
01:06:51 coming in some control officers were saying just use anything and i think we fed that back in or i fed that back in to the training to make that more specific right let me see if i can break this up
01:07:03 right let me see if i can break this up a little bit um so late 2009 after the latin house fire you decide to review all fsg calls yes uh now those fsg calls were those uh
01:07:16 uh now those fsg calls were those uh only those received at uh at lachnal or were they
01:07:20 were they previous uh calls as well and indeed some after lachlan so
01:07:24 so apologies if i can just ex it might be easier if i explained every fsg call was uh
01:07:31 uh captured on a database so we had a database for all our fire survival guidance calls and when a control operator took a fast survival guidance call the supervisor or the operations
01:07:42 call the supervisor or the operations manager would enter the details onto that database and so they were always listened to routinely whoever was the duty brigade control senior managers would have done
01:07:53 control senior managers would have done would have done that on duty at the time and and often we would have listened to them together in the room we shared an office so um lindsay and i would listen to them together it wasn't unusual that scott
01:08:05 together it wasn't unusual that scott was also in there too and but this was specifically to do with high-rise incidents um and i
01:08:13 um and i listened to all high-rise calls some of which were fire survival guidance and had fire survival guidance causing them and how far back
01:08:24 causing them and how far back in time did your review i didn't i didn't go back so it was from the point that i started to listen to them in 2009 onwards
01:08:35 onwards i see so i'm just trying to get a feel for this process so as of late 2009 you started
01:08:41 started as this right to review all fsg calls as they then happened thereafter yes where they had come where they had come from high-rise calls high-rise buildings and other calls from
01:08:52 high-rise buildings and other calls from high-rise buildings that were not fsg yes
01:08:56 yes and
01:08:57 and you would review those would you review those regularly or only when they happened when when they happened so i think i set up a process where
01:09:08 up a process where tsg
01:09:09 tsg would look and see if the control room had dealt with any high-rise incidents in the 24-hour period and then they would download the call recordings
01:09:21 they would download the call recordings for me
01:09:22 for me and send them to me did they form part of the post-incident debriefing that the control room carried out
01:09:30 um [Music]
01:09:33 [Music] no no this was just a review that i undertook uh in my
01:09:40 in my in addition to my normal day-to-day duties and would you um crystallize your findings from your review uh in a document
01:09:53 review uh in a document yes i think os tsg provided a spreadsheet with the list of calls on them and i would annotate
01:10:02 annotate any comments that i had on that would you
01:10:06 would you send those comments within that spreadsheet up the reporting chain to scott hayward no i would talk directly to to the operations manager or talk to scott and lindsay if like i say if there were any
01:10:19 lindsay if like i say if there were any trends or anything particular and they were all aware if a cro had um generated some positive feedback as i said in my statement they would have been aware of those letters
01:10:31 been aware of those letters i would have drafted were you the only one carrying out that review
01:10:36 review or did others help you with it or carry out their own review i think at one point
01:10:41 one point the control commander in tsg may have helped me
01:10:45 helped me by that time it was peter suarez um but generally yes
01:10:50 yes just done to me and was your review carried out on this rolling basis i think as you've described it until you left for the cfoa in september 2012. yes
01:11:04 left for the cfoa in september 2012. yes did you
01:11:05 did you do the review carrying did you carry out the review using call coach no it was just listening to the calls that had been assigned to the database yes
01:11:19 how many calls do you think you reviewed during the period late 2009 to early september 2012.
01:11:30 early september 2012. um
01:11:30 um [Music]
01:11:34 i would only be guessing if you asked me about the incidents um probably about
01:11:42 maybe 45 50 and and some of those could just have one call attached to it and others might have five or six or some could have ten but yeah
01:11:52 yeah and you say as i've read to you if any issues arose with the call handling this would be highlighted to the relevant line manager who would be expected to discuss these issues with the cro and assess whether there were there was need for further
01:12:03 there were there was need for further training do you remember actually raising any issues with call handling by the cras
01:12:09 the cras i i would imagine i i did yes can you give us an example
01:12:17 um there might have been one or two where i would have suggested that the cro was clearer maybe there was um the questioning technique maybe they
01:12:28 the questioning technique maybe they talked over the caller and not listened to what the caller had said on occasion
01:12:37 and was any training ever identified in order to remedy uh any
01:12:42 uh any particular problems or trends that were emerging
01:12:46 emerging so the trend of of not being that specific with towels and bedding and everything i i believe was one example of that i see
01:12:56 i see and just so that i'm i'm clear about this you were measuring what you heard on an incident by incident basis against the policies is that right against
01:13:09 the
01:13:12 against 1093
01:13:16 1093 i would say was upper boost in my mind and
01:13:20 and with regard to high rise that we were following
01:13:23 following um
01:13:24 um the
01:13:25 the government guidance on
01:13:28 on stay put
01:13:31 uh right so that i'm clear 1093 is the 1993
01:13:36 1993 uh home office circular yes the dear chief officer and the
01:13:42 and the um
01:13:43 um government guidance on stay put was that gra 3.2 at that stage the 2008 edition no i
01:13:52 no i i don't believe it was there was during our lack of investigations just from a review on
01:13:59 review on had produced some guidance for callers in high-rise residential premises and and
01:14:06 and and it was that guidance
01:14:14 what about the brigade's own policy on emergency call handling 539
01:14:23 539 which had been issued in 2007 and i think was then reviewed in early september 2010 so in late 2009 when you started this
01:14:34 so in late 2009 when you started this review process did you not use pn539 as well as a yardstick by which to measure the quality of fire survival guidance calls so
01:14:44 so the appendix to 539 which is the fsg and five survival guidance i
01:14:52 believed was in line with the principles of 1093 anyway so i would have used the principles in 1093 which would have aligned with pm539
01:15:04 pm539 right
01:15:05 right of course one of the um one of the questions was whether 539 did align with 1093 because that was the purpose of the gap analysis wasn't it
01:15:16 it prior to
01:15:17 prior to the lacking our house fire yes well
01:15:22 well after the latino house fire the gap analysis was started it wasn't yes yes and it produced its findings in april 2010 yes yes uh and therefore when you started
01:15:33 started uh when you started your exercise in late 2009 that gap analysis hadn't yet been completed no but i think we identified some lessons and that was just probably the process until it had
01:15:45 just probably the process until it had been published but i think we'd identified the key issues so it was one of the reasons you didn't use pn39 as your yardstick against which to measure fsg calls as part of this review that it had
01:15:57 calls as part of this review that it had departed from national guidance and you felt safer using national guidance no not particularly i don't think i i i saw it that this was just uh
01:16:08 i i saw it that this was just uh to make sure this review was just to make sure in my own mind that basically what we were reviewing and what the outcomes from the the lack of
01:16:19 the the lack of board and our investigations were actually
01:16:23 actually making real changes in the control room in terms of when we were talking to callers that that was my soul in purpose for undertaking that review
01:16:34 yes
01:16:36 really what i'm trying to get to the bottom of is given that the brigade had appendix 3 i think it was to policy number 539 at the time you started this review and continued to have it right the way
01:16:48 continued to have it right the way through why you didn't use that as your your measuring stick against which to measure the quality of the fsg calls probably because we knew that we had some changes to make to pm 539
01:17:00 some changes to make to pm 539 and while those were being changed uh we'd been familiar with 1093 and i'd been familiar with 1093 and its content from reviewing it and and just used
01:17:11 from reviewing it and and just used now we know that 10 that pn 539 we'll come to this in detail later in your evidence but just
01:17:17 just for the present on this review process we know that pn539 was amended in early september 2010
01:17:27 as a result of the gap analysis we'll look at that later but after that why didn't you use pm 539 appendix 3 as your yardstick to measure fsg calls
01:17:39 measure fsg calls um i
01:17:40 um i i may well have done right i may well have done it was just my learning and my experience from uh lacanal and what as a control room i believed
01:17:51 and what as a control room i believed we'd learnt from that and employing that in when i was just listening to all high-rise calls right okay mr chairman is that a convenient moment for a break yes i think it is thank you well as uh mr minute said earlier we
01:18:04 well as uh mr minute said earlier we have a short break during the morning as well and during the afternoon i think this is a good time to take the morning break we'll stop now please and resume at 25 to 12 and as with all the other witnesses i
01:18:16 and as with all the other witnesses i have to ask you please not to discuss your evidence or anything relating to it with anyone else while you're out of the room okay thank you sir thank you very much would you like to go to the ocean
01:18:37 thank you 25 to 12 please
01:36:10 would you ask me swift to come back in please
01:36:26 all right all ready to carry on yes thank you sir good thank you very much yes thank you mr chairman um miss smith can i just ask you to be shown this morning's transcript please uh at page 36.
01:36:40 uh at page 36. um where i i asked you a question about a report
01:36:43 a report um being sent up either to scott hayward or ac brown about the outcome of the call coach reviews your answer at line 15 was no i wasn't asked to do that and i believe the decision
01:36:54 i believe the decision not to take or put fsg calls was taken when we had a deputy assistant commissioner in charge of control i think there was an agreement with that between him and the representative bodies that far survival guidance calls
01:37:06 bodies that far survival guidance calls weren't quality assured now i just want to ask you about that decision can you give can you date that decision so i think that would have been very
01:37:18 so i think that would have been very early on uh shortly after we procured the the cool coach system when was that i think that was 20 or yeah 2009.
01:37:29 20 or yeah 2009. before or after
01:37:32 that uh i
01:37:35 i maybe before but i'm not entirely sure right
01:37:39 right was
01:37:40 was lachnal not an occasion on which to revisit that decision
01:37:46 uh potentially potentially i i just know from when we were beginning to implement um
01:37:59 um call coach and we were going about and the staff were going about designing the quality assurance that there had been an agreement made for survival guidance calls or any calls
01:38:12 for survival guidance calls or any calls that would have been subject to any disciplinary procedures or hearings weren't to be evaluated
01:38:22 who was party to that agreement by which i mean who the who in the brigade
01:38:30 brigade was ultimately responsible for agreeing that fsg calls would not be part of the call coach review process so as i say i think that was agreed by the deputy
01:38:41 think that was agreed by the deputy assistant commissioner control and mobilising at the time and and i think that might have been agreed at a
01:38:49 at a a union meeting and who was the dac alan payton
01:38:53 payton and then payton yes do you remember whether either scott hayward or dave brown or both of them had any
01:39:00 had any role to play in that agreement uh they possibly any discussions uh about that would have been held at a a joint committee meeting and which scott
01:39:11 joint committee meeting and which scott would have been present um
01:39:14 um and
01:39:15 and ac brown might have known and i think he might have had line management responsibility for alan payton then was this not discussed at a brigade control management meeting at the time it might have well been
01:39:26 the time it might have well been discussed at a management meeting um and
01:39:31 um and they might have had the similar opinion and that might have been fed up to the dac at the time i i really can't recall i'm sorry
01:39:46 can i then take you back please to your inquiry witness statement page 8 paragraph 19 this time we looked at 18 can we get back to 19
01:39:59 and you say i do not know if this review of all fsg stroke high-rise calls continued when i was seconded to cfoa in 2012 but when i returned in 2015 i once again
01:40:12 but when i returned in 2015 i once again requested and reviewed all fsg calls now
01:40:17 now first did you provide anybody in your team with a handover of this review task that you had undertaken and had been running for the previous uh three years or so before you
01:40:28 previous uh three years or so before you left to the cfoa
01:40:31 yes so the the senior management team were aware that i was doing that they may have been aware but did you provide a handover of the tasks do you say to anybody i'm going to the cfoa could you please continue my review of
01:40:43 could you please continue my review of fsg calls
01:40:47 no i am i believe i might have spoken to uh scott and said who will do this in my absence
01:40:57 that's a question did you get an answer from scott hayward um
01:41:03 um not that i recall but i
01:41:06 but i i it was
01:41:08 i it was it wasn't something that
01:41:12 scott had given me to do it was something that i had been doing just because i wanted to make sure that the changes were being implemented yes absolutely i understand that and at
01:41:24 yes absolutely i understand that and at the point you left were you not concerned that this self-appointed task that you'd taken on and been and been running for three years was continued in your absence
01:41:36 not particularly because all fsgs would have been reviewed anyway um and i knew they were probably entering into
01:41:45 into some significant workloads with uh procurement of a new mobilising system and they were in the middle of outsourcing i believe or have that had possibly been resolved by them but um
01:41:57 possibly been resolved by them but um no no i saw it as a task that i gave myself that i undertook and mainly in my own time to just make sure just breaking up that answer if i can you say all fsgs
01:42:08 up that answer if i can you say all fsgs would have been reviewed anyway yes as what part of what's um system or or practice would they have been reviewed just as part of a practice that when i joined the senior management
01:42:19 that when i joined the senior management team
01:42:19 team as an ap con that was done the the calls were entered onto a database and the duty
01:42:27 duty control manager would have listened to those calls as i said sometimes we shared that because we sit in the same office yes but the purpose of your review was to as you say in paragraph 18 still on
01:42:38 to as you say in paragraph 18 still on the screen to ensure that the correct advice was given in accordance with pn539
01:42:44 pn539 so
01:42:45 so was there when you left a system or practice in place whereby that quality review that you had been doing continued not for high-rise calls but for all five survival guidance calls
01:42:57 but for all five survival guidance calls yes
01:42:59 yes and who was and what was and who was carrying out that that review who would have been doing the review in your absence in that way all fsg course whoever was on duty
01:43:11 on duty uh at the time an fsg call was received that
01:43:16 that as you probably know from the data five survival guidance schools aren't frequent um
01:43:22 um on on average one a month it wasn't a lengthy task it was just part of their role like they would have picked up any organizational or operational issues that had occurred
01:43:33 that had occurred uh when they had been called in to a room for a large-scale incident um now
01:43:40 um now further in that answer you refer to the new mobilizing system and the significant workloads with procurement now you left in early september 2012 vision wasn't installed until the latter part of 2015.
01:43:54 did the procurement exercise which drained all this workload as you say start
01:44:00 start as early as september 2012 so yes there were there was some there had been some talk on that there they were starting to look for to procure a new system and why did that
01:44:12 to procure a new system and why did that create such a workload within uh within
01:44:16 uh within the control room that that might uh that might detract from the quality control or quality assurance exercise in relation to fsg calls
01:44:27 to fsg calls i don't know that was only my assumption of what had happened when i was away at seafarer i wasn't there okay and you say you also mention uh outsourcing yes in fact that had been completed on the first well by the first of april 2012
01:44:39 first well by the first of april 2012 but it didn't relate to control at all did it
01:44:42 did it i had a significant impact in control in terms of staff morale and it also meant that control staff weren't involved in the
01:44:53 control staff weren't involved in the requirements gathering for the new mobilising system so there was a knock-on impact that was felt all the way through to vision i follow now um can i then uh ask you um about
01:45:05 now um can i then uh ask you um about what mr hayward said in his evidence and i summarized but it's day 199 page 64 lines five to six and he told us that som diamond and som
01:45:17 and he told us that som diamond and som bagnol took over from you when you went to the cfoa yes um is that correct yes and did you know that at the time you left yes you did when you came back did you see any
01:45:28 when you came back did you see any any feedback or reports of their work by way of review such as it was on fsg calls
01:45:37 calls no
01:45:38 no did you ask
01:45:42 no was that
01:45:44 was that just because they knew they were well aware of their responsibilities as a duty brigade control senior manager as was i was when i left so they would have known that that was a task to undertake
01:45:55 known that that was a task to undertake and and would have ca i've no doubt that they would have carried that out i mean when you left and you say this task this fsg call review process as you call it was one you undertook of your own initiative
01:46:06 initiative when you left for the cfoa did you ask scott hayward to make sure that that initiative was continued by uh som diamond and or som bagnol
01:46:18 som diamond and or som bagnol so the high rise uh listening to all high-rise calls no i i didn't as i said i can recall a conversation with scott i did several things
01:46:29 things um
01:46:30 um before prior to my departure at seafarer one was a performance report that i used to produce monthly for all the watches and and
01:46:40 and and listening to those high-rise calls as well and both um he knew i wasn't going to be able to do when i
01:46:47 when i left the seafarer now when you came back as you say in paragraph 19 you say i once again requested and reviewed all fsg calls it
01:46:58 requested and reviewed all fsg calls it was no longer possible to monitor all high-rise calls due to the volume of calls the lfb now receives in relation to high-rise incidents
01:47:07 when did you review all fsg calls when you returned was that something you did straight away you you took up the reins again or was it a bit later no i think every time we had an fsg call into control if i was
01:47:19 we had an fsg call into control if i was the duty i would review it and i would say more often not even if i wasn't the duty i would listen to it and by that stage
01:47:27 stage 2015 were you reviewing fsg calls against
01:47:32 against the
01:47:33 the by now
01:47:34 by now uh
01:47:35 uh ria re-amended or re-re-ampended pn 539 appendix 3 um
01:47:43 um i'm not sure i was no it was probably just based on my experience and my understanding and haven't listened to a vast amount of
01:47:55 a vast amount of five survival guidance calls over the year having known 1093 and 539
01:48:02 539 i wouldn't say it was against any particular standard but just my experience and knowledge of all those documents
01:48:11 documents and the requirements now
01:48:14 now uh
01:48:17 during your time at cfoa yes which was some two and just under two and a half years were you involved at all with fire survival guidance or developments in far
01:48:28 survival guidance or developments in far survival guidance i would like to have thought so one of the main reasons for taking uh the circumference to see pharaoh was to understand after we'd been through the the lachenal fire to understand other
01:48:41 the lachenal fire to understand other fire and rescue control rooms and and how they worked and how they operated and as well as undertaking the review of the changes that control rooms were making to mobilizing systems
01:48:53 making to mobilizing systems and me and my colleague were
01:48:57 were allowed to run a number of seminars and and that involved
01:49:04 involved gathering all control managers from across the country and to come and discuss various topics we talked about buddy arrangements and the buddy system we talked about resilience
01:49:16 we talked about resilience and
01:49:17 and electronic uh data transfer and
01:49:20 and one course we ran was on fire survival guidance so i think we had opportunity and
01:49:28 and to explore that because we were in in a unique position that hadn't been afforded to anyone from control again that we could gather those staff together
01:49:38 together and and i think following the the lack of fire
01:49:42 of fire um and the recommendations that we wanted to make to 1093 i felt that was a really good way to pursue that and get input from other fire control
01:49:53 and get input from other fire control rooms
01:49:57 during that period am i right in thinking that you didn't re review fsg calls in the same way that you'd been doing say when you were at the brigade no i didn't no i didn't have access to them no did you learn anything during your two
01:50:09 did you learn anything during your two and a bit years at the cfoa about the quality of the call handling that you had heard before you left or the fitness for purpose of the lfb zone
01:50:20 fitness for purpose of the lfb zone policies
01:50:22 policies no i i i really moved to a more national level
01:50:27 level and and that national level involved interaction with dclg i think the main lesson i learned that there was no mechanism and there didn't appear to be any mechanism
01:50:38 any mechanism to pursue a change to 1093 with the recommendations that we've made and we'd come across from lack of fire right i certainly understood
01:50:49 fire right i certainly understood talking to my national colleagues that no other fire control had experienced what we had experienced in for for the lack of fire some shared learning and an
01:51:00 some shared learning and an understanding about the way different control rooms manage those calls when you came back then in january 2015 from the cfoa did you investigate what changes had been made
01:51:11 investigate what changes had been made to call handling policy uh
01:51:14 uh policies in relation to communication with the incident ground or call handling practice or call handling training so far as fsg was concerned in your absence no i didn't
01:51:27 why is that because i i'd come back from a row i'd left um
01:51:33 left um my role
01:51:34 my role someone else had been doing my role during that time there had been consistency uh scott was still in charge keith diamond was still in a senior operations manager
01:51:45 still in a senior operations manager role i wouldn't have thought there would have been any need to to check now you say it was no longer possible to monitor all high-rise calls due to the volume of calls the lfb now receives in relation to high-rise incidents do you
01:51:58 relation to high-rise incidents do you mean you alone couldn't carry out the task
01:52:01 task prior to june 2017 yeah i
01:52:05 yeah i i apologize i think that's a bit misleading it was really about the the the high-rise incidents we appeared to be going to as lfb now and not so much the number of
01:52:17 as lfb now and not so much the number of calls it was just the the incidents um but
01:52:22 but in terms of that it's because uh my workload increased considerably um when i returned from 20 in 2015 due to
01:52:33 to the introduction of the vision mobilizing system could you not have delegated that task to others
01:52:42 um i think as my workload increased so did the workload of ost with the vision mobilizing system they certainly didn't have capacity to be able to do that
01:52:54 have capacity to be able to do that given that call coach as a means of quality assuring calls although not fsg calls as you've told us
01:53:02 told us it seems had fallen away after 2015 was it not as important to institute or reinstitute some kind of quality assurance calls in relation to
01:53:13 quality assurance calls in relation to high-rise buildings even if not fsg calls
01:53:17 um i i think that would have been possible
01:53:20 possible that would have been possible but i think um
01:53:22 think um because
01:53:24 because these high-rise incidents what maybe would be coming larger that actually on watch we'd i'd left um a debrief process in place so control
01:53:34 control um
01:53:35 um in 2010 maybe 2011 introduced a structured debrief process and so there that was there that wasn't there before which would have dealt with high-rise incidents and allowed control
01:53:46 high-rise incidents and allowed control officers supervisors and operations managers to feed in any of their findings and discuss that and watch with themselves
01:53:58 now at the end of paragraph 19 you refer by way of exhibit js-5 to a
01:54:04 a standard
01:54:05 standard which
01:54:06 which is current i just want to identify that if i can that's at lfb double zero one two one two three six
01:54:19 now this is entitled quality room sorry control room quality assurance 29th may 2020 and it's watermarked as a draft is that the policy currently in place
01:54:31 is that the policy currently in place and being followed yes it is so it's no longer a draft it's in actual uses it is yes
01:54:36 yes [Music]
01:54:37 [Music] can i then turn to your role in control after your secondment had ended and therefore looking at the period january 2015 to 2017
01:54:48 january 2015 to 2017 um can we go back to your inquiry statement please at page three
01:54:54 and page three paragraph eight you say
01:54:59 you say uh
01:55:00 uh during my secondment i retained my rank but it was not relevant to my role as part of a project team at cfoa keith diamond covered my road in a temporary position while i was at cfoa and he
01:55:11 position while i was at cfoa and he stayed on in a temporary som role once i returned
01:55:15 returned when you came when you did come back did you have any sort of handover with keith diamond
01:55:20 diamond uh
01:55:22 uh some
01:55:23 some in terms of that we again we went back to sharing an office so just general day-to-day stuff would be covered
01:55:32 covered he didn't actually sit you down and say this is what i've been doing for the last two and a half years this is what you need to know here are the meeting minutes you need to read them to refresh yourself no
01:55:42 no not in that level of detail although he would have taken time to explain some changes that i weren't aware of and why those had happened
01:55:53 why those had happened did he explain any changes in policy in relation to emergency call management or
01:56:03 or communications with the fire ground no i don't believe so did he explain any changes that had occurred in relation to fsg calls either in relation to policy changes or training changes or training
01:56:14 changes or training changes or training training delivery changes no
01:56:18 no did you ask him any questions about that no i think
01:56:25 i would have if i'd had any questions about that i would have spoken to ost directly properly right can we turn the page then and look at paragraph nine
01:56:36 page then and look at paragraph nine you say at the top of the page
01:56:40 it's disappeared just bear with me paragraph nine top of the page this is your inquiry statement lfb double zero one two one two one nine page four
01:56:56 you say that i returned from cfoa in january 2015 and took on overall responsibility for oi for ost which included line managing the training
01:57:07 included line managing the training element of ost
01:57:10 now lion managing the training element uh
01:57:14 uh scott hayward says in his second witness statement
01:57:18 statement and his paragraph 68 page 13 for those who want to see it that uh
01:57:24 that uh you had overall responsibility for training from january 2015. is that correct yes
01:57:32 yes um who
01:57:34 um who were you line managing in respect of training
01:57:39 training so i i think i'm just referring to here when i left um my role prior to that i had line management responsibility for um the two technical uh tsg team in
01:57:53 um the two technical uh tsg team in there and when i came back and i had all of ost so the technical element and the training the line management for for chris sharp and nicki o'shea that i hadn't had before
01:58:04 hadn't had before right did you have any kind of induction or training or preparation before you assumed
01:58:13 assumed line managing the training element of lst
01:58:16 lst no i did not did you ask for any i would throughout my uh career asked for development in lfb and no i didn't
01:58:29 lfb and no i didn't why didn't you clay um because i think uh as a senior management team we were all very supportive with each other um and i would have been able to bounce
01:58:41 and i would have been able to bounce ideas off of them and and talk to them and
01:58:45 and the
01:58:47 the ost team by that time had been
01:58:51 had been well established chris and and nikki had been trainers for
01:58:55 for a significant period of time in a long period of time and had understand the initial fsg training so and i always knew i could rely on them for support and help as well
01:59:08 um yes
01:59:10 yes chris and nicki being chris sharpe and nikki o'shea yes and as you go on i think to say in paragraph 10
01:59:21 if you scroll down page four you identify them there in the second line you say there was continuity with chris sharp nicki o'shea and later sheila lewis kate ranson and jane reen
01:59:33 ranson and jane reen and then you go on to say two lines on chris sharp retired in 2016 both chris sharp and nikki o'shea i think
01:59:42 i think something in 2015 uh
01:59:46 uh do do i take it that the result of whatever it was that happened to them which has been rejected out you were without their expertise from some point in 2015.
01:59:56 in 2015. on occasions now
02:00:01 did you have anyone else assisting you with the ost training function in 2015 other than for some of that time chris sharpe and nicky o'shea yes so as i've said there 2015 one of my
02:00:15 yes so as i've said there 2015 one of my first uh
02:00:16 first uh tasks given to me by scott when i returned was to create a training plan for all 100 staff and in how we could train uh on the new
02:00:28 and in how we could train uh on the new vision mobilizing system so that was quite a a task to achieve and and i would have used chris and nikki's support and and i can remember drafting that report
02:00:41 can remember drafting that report and and
02:00:44 and and keith myself and scott discussing it and but that was a that was a priority and we were due to go live we'd already uh delayed going
02:00:55 go live we'd already uh delayed going live with the vision mobilising system once and we were due to go live i believe in the summer of 2015. and so that was trying to arrange over 2000 hours worth of training for
02:01:06 over 2000 hours worth of training for control staff on the vision mobilizing system and that was prior to actually having a version that we could actually see and use and begin to use and before all
02:01:19 and use and begin to use and before all the problems were identified so we were always looking for staff to support the role out of that now we know that you ran the technical support side of the ost before you left
02:01:31 support side of the ost before you left for the cfoa in september 2012. when you came back in january 2015 who then ran the technical support side once you've taken over responsibility for training
02:01:42 for training i i would have had responsibility for for both elements by that time they'd merged into into one i think that happened with the retirement of both paul and graham and and they were just the operational
02:01:53 and they were just the operational support team then and they all did all the functions right so the functions then merged yes um together now and once you came back in
02:02:04 together now and once you came back in 2015 were you being managed by pom hayward yes and and did the line management um in practice work in the same way that it had before you'd left probably better but yes in what way
02:02:16 probably better but yes in what way better the um we probably um spoke
02:02:23 spoke more that
02:02:24 more that we probably were tasked with a number of projects and the vision mobilizing system is a is a good example of how that took up a great deal of of
02:02:35 that took up a great deal of of everyone's time and to get that in
02:02:40 yes did you meet regularly yes did you minute your meetings no did you ever report to ac george once he was imposed after march 2016
02:02:53 um no not directly did you report to ac brown at any time not directly um maybe on occasion when scott was absent um and i had some dealings with ac brown
02:03:06 um and i had some dealings with ac brown and ac george uh after the vision mobilising system went live
02:03:12 live can we go to page six of your statement please paragraph 15.
02:03:19 now you say there i took over responsibility for the ost upon my return and then you go on to say
02:03:31 in
02:03:35 the second sentence as part of both of my line management responsibility for ost and my responsibility for delivering operational changes into control i would have been involved in reviewing the relevant training package and ensuring
02:03:47 relevant training package and ensuring that the technical needs of the control room and the cras were met just pausing there you say that you would ensure that the technical needs of the control room and the cras were met
02:03:58 the control room and the cras were met were you also responsible for ensuring that the training needs of all of the staff
02:04:03 staff for example the cras and the supervisors were met
02:04:08 no i wouldn't have said that that that was my role delivery of training and the ost creating training packages i would have said was my responsibility i wouldn't have said my resp my
02:04:19 wouldn't have said my resp my responsibility was
02:04:22 was deliver and making sure that all the training needs for the control room staff were met no
02:04:31 um you're drawing a distinction i'm not sure
02:04:33 sure fully grasped um are you saying that there was there were ost training packages but there was other training uh that the control room would have to
02:04:44 uh that the control room would have to undergo which was not your responsibility yes what was that what did that into so i think you've had examples of supervisor training a lot of on watch training would have under been undertaken yes so you wouldn't have had any involvement
02:04:56 so you wouldn't have had any involvement in that um i may have had some conversations as over the period of time that we're talking about i am i think i manage three oms at one point i sometimes and
02:05:07 three oms at one point i sometimes and then my responsibilities change it again and i'm managing six oms and the ost team
02:05:13 team and then
02:05:14 and then i think that changes again so over the time i would have had conversations as line manager for some operations managers right um and
02:05:25 and their staff and some development of their staff and but what i was trying to draw a distinction was that in my role as ost and we were responsible for delivering
02:05:36 we were responsible for delivering operational changes some of those were system changes some of those were technical changes more often they were both dovetailing to one and creating training packages and making sure
02:05:48 training packages and making sure that cross understood those training packages the responsibility for training all cros i don't believe fell under me
02:05:59 i don't believe fell under me what training packages and training delivery were you not responsible for what areas of the control room's activity
02:06:08 activity were you not responsible for so far as training was concerned
02:06:16 so sorry i i the development of control staff that was done on watch um
02:06:24 um i would have been responsible for ensuring that ost were able to provide some training and training on changes to
02:06:35 on changes to operational changes and any changes on the system
02:06:45 now if you go to um
02:06:50 paragraph nine of your statement please go back uh to um page four
02:06:58 page four [Music]
02:06:59 [Music] uh you say there
02:07:13 that you would not re you would not review every training package
02:07:17 package um
02:07:20 just in general terms
02:07:24 did you review every training package and if you didn't who did
02:07:29 in general terms now i didn't review every training packages i just don't think my
02:07:35 think my my workload would have allowed for that and
02:07:39 and there were training there were people in the ost
02:07:42 the ost that
02:07:43 that were creating those training packages and
02:07:46 and the role of of ost
02:07:49 of ost has has changed over time but it is still a unique role where not only do you have to understand the change that's been introduced from an operational point of view understand
02:08:00 an operational point of view understand what they are required what the operational element requires then understand how that needs to change in control then understand the technical
02:08:11 understand the technical support that needs to be given to that change to deliver that change then create a training package to deliver that change and then deliver that to a hundred staff it's not by any means easy
02:08:22 hundred staff it's not by any means easy and that is not their full responsibility as well they have to do other tasks as well so it is quite technical they are at subject matter experts and they are extremely knowledgeable on those facts and
02:08:34 knowledgeable on those facts and i like all us the senior management team would have relied on those and their interaction with the control room that what they were putting in their training packages were was appropriate
02:08:47 were was appropriate for control staff and and especially with with nikki o'shea and chris they were very well respected control officers and people
02:08:58 respected control officers and people listened to them um and liked their style of delivery were you responsible or were you not responsible for fsg training for all staff after january 2015.
02:09:13 no i wouldn't have said i was personally responsible for fsg training for all 100 staff i
02:09:22 i in my time in charge of ost spent a lot of time trying to work out especially in 2015 with the vision changes and everything that was happening with the mobilizing
02:09:33 that was happening with the mobilizing system how we could go about delivering fsg
02:09:37 fsg and training to 100 staff i was really conscious when i came back that we had committed to training and feeling um refresher training
02:09:48 refresher training every year and
02:09:51 and and i would have said throughout that time even though the mobilizing system was being introduced even though we were rolling out a significant amount of training training to control staff on a new
02:10:02 training to control staff on a new mobilising system and to put it in context this was a system that everything changed for them and even their functionality down to their keyboards their telephony system
02:10:14 keyboards their telephony system whatever they were using it changed and and that took time and
02:10:20 even during the unfinished journey sorry i was going to say even during that i i know i i tried very hard to roll out for survival guidance training in 2015.
02:10:38 breaking this up a little you were after january 2015 is this right som in charge of training
02:10:47 in charge of ost which included delivering trainer-led training to control staff yes that was your uh
02:10:57 uh domain yes yes and within that domain is this right fell far survival guidance that was one of the training courses
02:11:08 that was one of the training courses amongst many that we yeah rolled out to control staff was there anybody else at your level in the reporting chain with whom you shared
02:11:20 with whom you shared that responsibility
02:11:25 um no
02:11:30 now you mentioned a training plan did i can i just show you what scott hayward says in his second witness statement
02:11:39 statement lfb triple zero eight six two one three
02:11:45 page seven paragraph thirty seven
02:11:54 he says and this is in answer to the question please explain who was responsible for ensuring that the recurring program was established and maintained he says ost was responsible for
02:12:06 he says ost was responsible for establishing and maintaining the recurring training plan as directed by the som
02:12:11 the som 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 delivered this would have sat with ac
02:12:23 delivered this would have sat with ac chandler and thereafter ac tom george prior to 2016. between 2009 and 2019 i delegated training responsibilities to a number of
02:12:34 training responsibilities to a number of soms all of whom were controlled staff and so would have held the appropriate knowledge and experience to oversee this training you see that uh yes
02:12:45 uh yes just pausing that do you agree with that does that accord with your recollection yes um and in 38 of his statement appropriate
02:12:56 38 of his statement appropriate knowledge and experience within how the control room ran and was managed and but no i didn't have any specific knowledge and experience in training delivery
02:13:08 training delivery and if you turn to page eight paragraph 39 he says i delegated responsibility for this training as follows som lindsey turner was responsible from
02:13:19 som lindsey turner was responsible from 2009 until 2012. som vic bagnell was responsible from 2012 until 2015 and som joanne smith was responsible from 2015 until 2019
02:13:31 from 2015 until 2019 looking at the last of those three bullet points which refers to you do you agree
02:13:35 agree yes yes
02:13:39 and
02:13:41 did you see it that scott hayward was not accountable for training until he became head of service in 2016 or did you think that he he was as your line manager as my line manager and principal operations
02:13:54 my line manager and principal operations manager for control i would have assumed that yeah now
02:13:59 now if we go back to your witness statement please and smith at page five paragraph 13
02:14:09 there's a question above paragraph 13 as follows how the ost went about training identifying training needs developing training to meet those needs and delivering that
02:14:20 meet those needs and delivering that training
02:14:21 training and you say the ost training team identify create and deliver training to new entrants and existing control room staff for example the ost training team identify issues
02:14:32 the ost training team identify issues highlighted during an incident or a call and would discuss how best to address these issues
02:14:41 was it your responsibility to ensure that ost
02:14:45 that ost identified created and delivered training packages after january 2015
02:14:54 um
02:14:57 yes in terms of newly created packages in terms of uh some operational changes that
02:15:05 that were coming that we needed to implement some
02:15:09 some of the training that they would have undertaken would have been between themselves and the operations managers on a watch had they asked them to do that
02:15:18 that yeah
02:15:20 yeah and was that so only after your stint at the cfoa or uh was it the case also before you left for the cfoa no i think that was
02:15:31 for the cfoa no i think that was that was after only after yes yes would you seek to identify training packages that were needed for control staff
02:15:41 staff uh yes and that would have been through my work
02:15:45 my work just with other operational departments in lfb so um
02:15:52 so um one of them would an example would have been the liaison that we'd had with the operational resilience team in terms of training staff for an mta incident
02:16:05 an mta incident um a marauding terrorist attack so that would have been one example where um
02:16:11 um london fire brigade would have been preparing
02:16:14 preparing an operational response and then we would have worked with them to create the control room response and
02:16:21 and and therefore i would have gone to ost and asked them to create a training package uh with some key issues in it and what we needed to achieve you say you would have gone to ost and
02:16:32 you say you would have gone to ost and asked them to create a training package yeah um yeah just to be specific and we're obviously talking about the period after january 2015 yes who would it have
02:16:43 after january 2015 yes who would it have been or who was it who actually created those training packages at your request from what i recall the individuals in ost we would sit down and discuss it and one of one of the
02:16:55 and discuss it and one of one of the staff would take the lead on it you say one of the staff at what level one of the members of ost the iom level they were all uh assistant operations managers so before
02:17:07 operations managers so before at some point in 2015 that would be um chris sharp and nicki o'shea would it or would you yes they and and we would have had uh new members in
02:17:18 we would have had uh new members in there i think i refer to a number of staff that would have joined um and remained after uh
02:17:26 uh they'd given their assistance to introducing the the vision mobilizing system so they would all have taken
02:17:33 taken a subject and delivered that subject and would you review those packages on occasion i might have had some input when they were developing them and we would have talked about if that was
02:17:44 would have talked about if that was going in the the right way and and
02:17:49 and on occasion that would have happened yes you say on occasion i mean was that a formalized system or was it just a spot check by you what would occasion the occasion it wouldn't have been a spot check with me but we
02:18:00 have been a spot check with me but we were working closely with them so i would have talked to them about um the need to create it and where that come from they would have gone away and done some work like i say they probably would have covered some technical issues
02:18:11 would have covered some technical issues and elements that we would need to have changed
02:18:14 changed along with um some changes to procedure that we would have needed to work out and we would have sat together and discussed whether they needed to be in a training package how that training
02:18:25 in a training package how that training package should have been worked out and delivered how long the training would have been
02:18:30 have been and how we would achieve that
02:18:36 did they provide the training package to you for your review comments feedback or or did they come to you with specific questions problems features and ask for
02:18:50 questions problems features and ask for your comments uh maybe a mix of both i don't recall ever receiving a completed training package to to look at but i think just in the normal course of
02:19:02 in the normal course of of how we ran in ost we would have had a meeting and run through the training package would you be required to sign off the
02:19:13 would you be required to sign off the training packages no there was no no process in place i'm not aware that there's ever been a formal process to sign off training packages so at what point would
02:19:25 packages so at what point would a training package be understood by you as ready for delivery i i don't think again if there was ever a a set up like that
02:19:39 there was ever a a set up like that they would have gone away and created it we would have had some meetings in between made sure that the points were covered that we wanted to to get over from the changes and then
02:19:53 to get over from the changes and then they would have delivered those changes now scott hayward says in his uh his first statement uh it's paragraph 54 at page 19 that the som responsible for
02:20:04 page 19 that the som responsible for training would liaise with ost and do the training um is it right that the som would do the training
02:20:16 no sit so in in terms of doing the training be part of training delivery or sit as a cro to do the training
02:20:29 are you asking me yes sorry well i'm just putting to you what he says perhaps i'll show it to you and just and ask you whether he's right or wrong can we go please to his first statement uh lfb triple zero five five
02:20:41 uh lfb triple zero five five one nine one page nineteen paragraph 54
02:20:46 i'll show it to you on the screen and then ask ask you whether you agree he says in paragraph 54
02:20:56 in the third line at the som responsible for training would liaise with ost and do the training
02:21:03 training is that right or is that not right no no i i don't believe so so i i my interaction with ost would have been prior to the training being rolled out
02:21:14 prior to the training being rolled out and
02:21:15 and ost would have done the training delivery
02:21:18 delivery uh right i see so not the som responsible um the
02:21:24 um the ost members yes and who would they those have been until the departure of nikki o'shea and
02:21:35 the departure of nikki o'shea and chris sharpe so so chris retired in december i believe 2016 but nikki o'shea is still in the ost team right but would it have been would have been one or either of them
02:21:45 them yes on occasions and we had other members that had to come in right so it would have been the oms yes
02:21:53 yes right
02:21:56 so the training was being delivered to cros
02:21:59 cros by those who were immediately line managing them
02:22:04 no the members of rst didn't line manage any cros
02:22:11 any cros forgive me but they had a rank of aom they had a rank of aom and cros and aoms from the watches and oms from the watches would have attended the training sessions
02:22:23 the training sessions run by ost aons i i say forgive me i but is this right that those aoms sitting in the ost were not actually operating aom's in the control
02:22:35 actually operating aom's in the control room or were they no that's correct thank you now um who had oversight of who in control was receiving this training in and from 2015
02:22:49 uh so ost uh would have kept a spreadsheet um would have kept me up to date and the oms would have been aware of who was receiving training
02:23:00 receiving training on their watches uh now
02:23:03 uh now they would have kept a spreadsheet yes how was that kept was that kept on a um
02:23:10 um a control system or was that spreadsheet kept on a brigade-wide system so i think it was kept on a spreadsheet on a database in ost and then it was uploaded it was sent
02:23:23 ost and then it was uploaded it was sent to information management on either a monthly or quarterly basis to upload onto
02:23:29 onto training records right brigade-wide training records that was step wasn't dude i believe so yes uh and
02:23:37 and uh
02:23:39 uh who was it who um created the inputs into that spreadsheet so far as uh control training was concerned so that would have been whoever was training whoever was the
02:23:50 whoever was training whoever was the training lead and delivering the training on for that session would have entered in the session and entered in the attendees and you say that you saw that
02:24:01 and you say that you saw that spreadsheet from uh you you would check it um
02:24:05 it um a check would probably be a wrong assumption so i knew where the spreadsheet was and we would have had discussions when we rolled out some training about the amount of staff we
02:24:16 training about the amount of staff we were training who was left to train and any mop up or catch up sessions
02:24:24 you say that
02:24:28 that ost would have kept you up to date yes would they have regularly sent you the spreadsheet for you to review so that you could
02:24:36 you could monitor
02:24:37 monitor periodically the state of training of the control room staff no they would have sent the training records up to information management to go on the step and would have just kept
02:24:49 go on the step and would have just kept kept me up to date with how they were progressing if they hadn't managed to do any of the session a pre-planned session because there was an incident or we might have
02:25:00 there was an incident or we might have been short of staff and then what they were going to do to catch up with those staff
02:25:05 staff right
02:25:07 right so
02:25:08 so does that tell us that you were kept up to date on an ad hoc basis uh when we were delivering yeah ost training uh i would have said that that was pretty frequent
02:25:22 that was pretty frequent and i think a lot of the training especially that we had to undertake in 2015 2016
02:25:29 2015 2016 um
02:25:31 was changes to operational processes and procedures which all control staff needed to know to do their to answer calls so there wasn't an occasion where we
02:25:43 there wasn't an occasion where we couldn't not train people and make sure that they were familiar with the change because that needed to be done and sometimes we we weren't able to do that prior to the change going live and
02:25:54 prior to the change going live and sometimes we had to do that after that and other times uh it was done on watch which wasn't ideal either yeah well we'll come to look at that slightly different topic in a moment i'm just if i can i want to stay on the
02:26:06 just if i can i want to stay on the question of your involvement in monitoring the receipt of training you say you were you were you were kept up to date did you yourself
02:26:17 up to date did you yourself ever periodically spot check the spreadsheet and make sure that the right number of control room staff were receiving that training no so just to be clear on what i was
02:26:29 no so just to be clear on what i was trying to say the the change that we'd rolled out that we would roll out training for needed to be undertaken so it wasn't a case of spot checking to see if it had been completed i would have been aware
02:26:40 been completed i would have been aware of what was happening how they were delivering it and then if they hadn't managed to achieve it without looking at the spreadsheet and just remind me how frequently did this spreadsheet go go to step was it
02:26:52 this spreadsheet go go to step was it monthly
02:26:54 monthly it may have been monthly or it may have been quarterly i think it changed over a period of time so i think originally it was quarterly maybe it changed to monthly were you not interested just to look at the spreadsheet to know the
02:27:05 look at the spreadsheet to know the numbers
02:27:06 numbers how many had received training and on what during that period well as i say they were all related to changes
02:27:15 changes and
02:27:16 and i would have known that we were training the majority of of control staff in those changes because they needed to know those changes to do their role so
02:27:26 so so what was it then that the ost training team did by way of keeping you informed if you you were already aware of what was happening that's through them i would have been aware of through them
02:27:37 them and also if they hadn't if there had been any issues with training on the watch that would have been discussed at brigade control management meetings as well with the operations managers they may have raised that it may also have
02:27:49 may have raised that it may also have come up and i think sometimes did at joint control committee meetings
02:27:57 now we may come to this in some detail later on but just while we're on the point did you ever uh do anything at this time to satisfy yourself that the record keeping by the aoms of those
02:28:10 record keeping by the aoms of those control room staff receiving the training uh was adequate
02:28:16 um i i think
02:28:18 i i think there would have been some discussions um
02:28:22 um i think at one point and this is only a vague recollection that there was some um
02:28:28 um we identified or someone had identified that the courses were being put down in differently depending on the trainer that was delivering it and i think there was an
02:28:39 delivering it and i think there was an exercise to streamline and and to create some course codes so it was clearer for staff can we look at scott hayward's first statement please at page 18 paragraph 52
02:28:53 statement please at page 18 paragraph 52 and i want just to come back on come back to the point you mentioned a moment ago about interruptions uh he says here due to the need to ensure that control is able to continue
02:29:05 is able to continue to to carrying out its day-to-day functions most training by necessity is delivered to staff who are on watch this means that if there is a significant incident or a sudden increase in calls the staff including
02:29:17 increase in calls the staff including the ost might be recalled to their positions in the control room to answer and handle 999 emergency calls how would the training be completed if a training session was interrupted by a
02:29:29 training session was interrupted by a significant incident or a sudden increase in calls so if it was just a sudden increase in causes a spike in calls or then uh the control staff would have
02:29:40 then uh the control staff would have returned to training after that had come down but if it was a significant incident the training then would have just been rescheduled at some point how did you
02:29:51 rescheduled at some point how did you oversee and ensure that everyone completed their training either by picking up the reins at the end of the incident or the rescheduling i didn't that would have been a task for the ost trainer to do so you
02:30:02 a task for the ost trainer to do so you said that wasn't your task no they would have been proficient to do that like i say we all knew that the changes needed to be um rolled out to all staff and they would
02:30:13 rolled out to all staff and they would have made their best endeavors to make sure that they picked stuff up the next time they were on duty or when available why was the training organized when the staff were on watch
02:30:25 so the vision training wasn't i think we'd had occasions where we had arranged and made arrangements for staff to come in off duty and to deliver some of the training i think
02:30:36 deliver some of the training i think that happened um in 2010 um and i think that that happened that was part of the training plan we i delivered in 2015 for vision training
02:30:47 training and
02:30:48 and but
02:30:49 but we had moved to a shift pattern with variable staffing that provided a four-hour training window and
02:30:57 and which was daily so as a watch rotated round
02:31:02 round and
02:31:03 and out of every three days on watch um they would have had a four hour training
02:31:10 training period in which to undertake any training and and we had a minimum of 20 staff on duty during that time so that would have allowed us to take a number of staff out in the
02:31:22 to take a number of staff out in the room and
02:31:26 to deliver that training so the the training time uh was seen as sufficient and adequate right to deliver tall stuff i mean in practice
02:31:39 i mean in practice uh after january 2016 was
02:31:44 2016 was was it a problem that uh training would be interrupted by uh by calls or call handling needs or or on the whole did the on watch training succeed in
02:31:56 did the on watch training succeed in getting the training across to cras within the four hour slot no so in um when i returned from seafarer in 2015 the four-hour training slot had changed to a two-hour training slot
02:32:08 to a two-hour training slot to accommodate the resource management team that had come in and i believe uh that was the discussion um
02:32:17 um to accommodate uh the undertaking of the standby module and so the four-hour training slot had moved to a to our training slot right um which probably due to uh
02:32:30 which probably due to uh the
02:32:32 the staffing deficiencies as well and made it very hard and unachievable to to facilitate all the training in that period but i i think we'd recognize that
02:32:45 period but i i think we'd recognize that certainly
02:32:46 certainly um when ac george was in um
02:32:49 um and undertaking his review we were looking to propose a new shift pattern which gave staff a whole day's training i believe every six weeks
02:33:01 training i believe every six weeks and
02:33:03 and ac george had set up a peer group with some control officers and some aoms and he asked me to present that shift pattern there and
02:33:13 and so we were always looking for that i think we'd also raise and during 2015 we had raised the issue with the representative bodies about moving
02:33:25 about moving apologies it would have been after uh the sbm function moved back to stratford about moving the short shift back to 10 o'clock to give us that four hour
02:33:36 o'clock to give us that four hour overlap period so four hours in training again did you ever consider a system whereby you trained cras routinely off the watch
02:33:47 yes and like i said we did use that for vision training in the end um i think that relies on um obviously staff having to come in in addition to their training on watch and
02:33:59 addition to their training on watch and which some staff may not wanted to do and there was always the pressure within the cost that that would involve
02:34:13 did you or anybody else evaluate or review the training packages or the delivery of the training
02:34:24 review the delivery of the training so did i know it was taken place did i know that sometimes we weren't able to achieve that yes
02:34:35 achieve that yes did you evaluate or review it for quality
02:34:39 quality quality assure it
02:34:42 no only in terms of my
02:34:46 my original
02:34:47 original discussions with the ost why did why did you not or why did the brigade not evaluate or review the training packages or delivery for quality
02:34:59 or delivery for quality um
02:35:01 um i don't know i i wasn't uh quality obviously trained in any quality assurance and it would have only been through feedback
02:35:12 it would have only been through feedback from the operations managers at bcmb and
02:35:16 and at jcc that we would have looked if had there been any particular issues and feedback from the staff and i hope that i would have addressed those
02:35:28 those from january 2015 at least how much of your time was dedicated to your training role
02:35:34 role or your responsibility for training uh within the ost can you i know it's a well one thing to estimate but can you give us a rough idea
02:35:44 idea i i would have said um from the beginning of 2015 um until the middle of 2016 possibly the end of 2016 my role with uh
02:35:59 possibly the end of 2016 my role with uh vision
02:36:00 vision and the mobilising system was all-consuming so
02:36:04 so not much
02:36:05 not much is it would be the answer in terms of the amount of training we had to deliver to all our staff in terms of training for the vision system yes a considerable amount
02:36:17 yes a considerable amount um as well as all the technical challenges we faced prior to go live and and then after go live
02:36:28 um i'd like now to turn to lachenal
02:36:31 lachenal and lacrimal action points uh and the ac and the latino action plan and i'd like to start within that uh major topic uh with action five which is the gap analysis uh and action 10 a
02:36:45 is the gap analysis uh and action 10 a review of emergency call handling policy 539
02:36:50 539 can we start please with the assurance report
02:36:54 report of november 2012 lfb
02:36:58 lfb 404801
02:37:06 this is the latin house incident assurance
02:37:11 review of august 2018. now if we go to page 12 in that please it says action 5
02:37:23 on at the right hand side at the bottom undertake a gap analysis of brigade national and brigade fire survival guidance policies and guidance in order to produce a report identifying where
02:37:35 to produce a report identifying where brigade controlled fire survival guidance policy differs from the national guidance
02:37:41 and if we go to your witness statement to paragraph 20 uh on page nine you say there that you worked on that
02:37:53 you say there that you worked on that gap analysis yes i did i'm summarizing quite a long paragraph you also say that you worked on it with scott hayward tom davis uh pete german zick and tim
02:38:05 tom davis uh pete german zick and tim cut bill
02:38:07 cut bill yes
02:38:08 yes what was your role in that review
02:38:12 i'm from a controlled point of view to look at
02:38:17 look at the extent national guidance and compare that to lfb policies procedures and
02:38:25 and training materials
02:38:31 and identify the gaps
02:38:36 now if we then look back to the november 2012
02:38:41 2012 of control report we have that at
02:38:46 at a number of places this one is at hom four zeros one one two four
02:39:01 uh you can see that this is dated november 2012. now this report obviously is something we're going to come back to a number of times
02:39:10 times you had left i think by november 2012 for the cfoa i had yeah a couple of months before but do i take it that you're you were familiar with this in draft before you left and became
02:39:22 this in draft before you left and became familiar with it once you came back uh
02:39:26 uh yes
02:39:27 yes i mean we'll see how we go with it but as a general top general proposition can we then go to page four and look at paragraph three
02:39:40 and that says there this report comes at the end of a long piece of work and builds on a gap analysis between national guidance and lfe policy and training included in this report at nxb which was completed in april 2010
02:39:54 which was completed in april 2010 just just for the best of your recollection is that correct the gap analysis was completed in april 2010 yes yes now if we go back to your witness statement please at page nine
02:40:05 statement please at page nine you tell us there at paragraph 21 in terms of methodology i recall we reviewed the circumstances of the fsg calls taken during the latin house fire against the extant national guidance at
02:40:17 against the extant national guidance at the time including fsc fire service circular 1093 and 54 2004.
02:40:27 first is it right to say that as part of your gap analysis or at least that part which with which you were involved you compared the lfb's policy on call
02:40:38 you compared the lfb's policy on call management policy number 539 against the national guidance
02:40:44 so lfb policy but we also use the training and the procedures so the rif against national guidance yes now you suggest
02:40:55 national guidance yes now you suggest that you compared it against both
02:40:58 both fire service circular 1093 and fire service secular or fsc 54 2004 um scott
02:41:08 um scott haywards
02:41:09 haywards says and he told us this on day 199 at page 158 and 159 that after a discussion with dac cut bill and tom davis from lfb's legal
02:41:20 bill and tom davis from lfb's legal department he said it was felt it wasn't required
02:41:25 required fsc 54 2004 wasn't required is that right
02:41:31 right so uh yes i think that is correct so we looked at 54 2004
02:41:36 2004 and
02:41:37 and we'd gone back in the archives archives and tried to find out where a decision has been taken not to adopt 54.04
02:41:47 54.04 and
02:41:48 and i think in in scott hayward's evidence he says about the needing a number of prompts and a mobilizing system to support that and i think we agreed with that but i think we
02:42:00 think we agreed with that but i think we had also looked at the documents or the detail in 54 2004 and were assured that everything in
02:42:11 everything in relating to fsg was covered in the body of tex
02:42:15 of tex in fire service circular 1093
02:42:20 so it's never been adopted previously by the brigade was that the reason why it then wasn't reviewed
02:42:27 reviewed for the purposes of the gap analysis no i i don't think so i think we looked at that and thought that everything contained in 54 2004 relating to fire survival guidance was contained in the
02:42:39 survival guidance was contained in the body of text in fire service circular 1093 and therefore if we just reviewed 1093
02:42:48 1093 that would have everything in it
02:42:56 yes i think you've said in your police statement and we can look at it if you like that
02:43:04 54 2004 included prompts for a number of scenarios like chemicals crbn and the water incident yes
02:43:13 yes and because the technology available in the control room and the mobilizing system couldn't support that framework you didn't implement that guidance so that wouldn't have been a decision that i would have made in lfb in 2004 i wasn't there so
02:43:27 made in lfb in 2004 i wasn't there so that's only just some historical from discussing it and
02:43:32 and if it helps when i was in essex fire brigade it wasn't adopted there either i see i see so this is predated your time yes um
02:43:44 so this is predated your time yes um now
02:43:45 now scott eva scott hayward said in his evidence
02:43:49 evidence and again we don't need to see it it's paragraph 20 on page six of his first statement first bullet point that that lfb's policy 539 emergency call management was compared with to the fsg training
02:44:01 was compared with to the fsg training package in place at the time of the lachenal house fire do you recall that
02:44:08 yes so i think yeah from my understanding of the gap analysis we use fire service circular 1093 and compared it with all uh extent lfb policy
02:44:19 lfb policy but also training notes and procedures so yes pn 539 would have been reviewed in like that as part of the comparator
02:44:32 as part of the comparator were you comparing 539 as it then stood which was the 2007 edition with a document issued by the home office in 99 in 1994 called keeping
02:44:43 office in 99 in 1994 called keeping people safe um
02:44:47 um i i don't
02:44:49 i i don't call
02:44:51 call that document is that not 54 no no
02:44:55 no no sorry
02:44:56 sorry indeed it's annexed as annex c to this laptop this report the latino control report i'll show that to you if you go please to
02:45:09 lfb404750 please
02:45:17 that is the first page of the annexes to the november 2012 lfb control report for lachnal and if we go to page 25 in this document we can see nxc
02:45:30 in this document we can see nxc which is
02:45:33 uh the home office document from 1994 entitled making people safe let's go to page 26 please in the first page of the document
02:45:48 there is a lino cut graphic emergency call handling techniques for survival guidance does that look familiar to you so that looks familiar as a training package
02:45:59 looks familiar as a training package that came with 1093 right in fact it was published the following year but oh it doesn't matter when you refer to the training package with 1093 we can take it that included this we can
02:46:11 we can take it that included this we can now um
02:46:13 now um let's go back to your statement then please at page 10 and let's look together at paragraph 23 uh you say there in the first line following the finalized gap analysis we
02:46:24 following the finalized gap analysis we used the report to ensure that the fsg training covered all elements of fsc 1093 and to update pn 539.
02:46:34 539. now
02:46:35 now is the update to pn539 that you're referring to there the one approved on the 3rd of september 2010
02:46:47 i would presume so and is it right that you also use the findings of your gap analysis to create the fsg reference information files for both operators and supervisors
02:47:00 both operators and supervisors yes
02:47:02 yes now i'd like to look first if i may then at the findings of your gap analysis and the changes that were made to pn539 can we start that exercise with paragraph 34 of your witness statement
02:47:14 paragraph 34 of your witness statement at page 14 if we move on a few pages page 14
02:47:19 page 14 and you say this at paragraph 34 and you'll note the question um paragraph 34 you you say uh
02:47:29 we reviewed uh
02:47:33 uh this is the end of the third line we reviewed pn539 in light of the gap analysis conducted after the latter house incident i recall that i would have looked through the policy with scott hayward identifying relevant and
02:47:44 scott hayward identifying relevant and non-relevant items and considered where amendments should be made based on our findings in the gap analysis and you refer earlier in that paragraph
02:47:55 in that paragraph to the
02:47:57 to the version of 539 at the time and you note the document history at page 22
02:48:04 page 22 which set out the entirety of of the policies history can we look at the document you exhibit js 11.
02:48:16 that is lfb double zero one two one two two two please
02:48:30 now that is uh
02:48:33 uh emergency call management now that version
02:48:37 version is the one reviewed in march 2014 and that can't therefore have been the one you were reviewing when you did your gap analysis
02:48:49 no um nonetheless if we go to page 22 we can see the full document history i think which is i think what you were referring
02:49:00 which is i think what you were referring to
02:49:04 uh audit trail and you can see that
02:49:12 uh the changes are described in the middle column whole document reviewed as current and updated this is the second entry down whole document reviewed as current and updated throughout additional and
02:49:24 updated throughout additional and amended appendices statistics created for emergency calls taken from january to december 2009 date third of september 2010
02:49:36 so we can use that data think can we safely as the date of amendment in response to the gap analysis is that right
02:49:45 right uh
02:49:46 uh now the owner of the policy at that stage was was the head of operational response wasn't it possibly yes and that would have been dave brown
02:49:58 and that would have been dave brown i believe so did he have final sign-off on these changes oh sorry i'm not sure it would have been in 2010 right who would have who would it have been
02:50:07 been it may have been sorry all right right okay did he have final sign-off on these changes on the changes which we're going to look at um
02:50:15 um no not that i no not that i recall that we would have made some changes um and they would have been submitted to lfb document management
02:50:29 and after the amendment of the policy on the 3rd of september did control room staff receive specific training on the changes that had been made
02:50:38 in relation to the policy yes um know if they had received any an update that may have been through an email to let them know that those changes had
02:50:49 let them know that those changes had been made
02:50:51 been made and
02:50:52 and any of the changes i'm sure we worked hard to make sure they were reflected in the training that was rolled out
02:51:04 now we can see from this page that after the third of september uh
02:51:10 uh the policy was further amended uh a number of times up to and including the 6th of april 2017 yes yes
02:51:21 would you have made or reviewed those changes
02:51:27 um
02:51:34 not that i can recall maybe they're altered to reflect the latest reference information file on fsg in 2011.
02:51:45 who would have had final approval on those changes if not you
02:51:51 uh i think that would have been there
02:51:55 that would have been the poem
02:51:58 poem they would have come through you though wouldn't they uh
02:52:02 uh no no not all the time they would have come through me um the other senior operations manager could have updated them they might have been generated um [Music]
02:52:13 [Music] internally in in lfb so the change from team leader to assistance operations managers they could have come from a variety sources
02:52:23 sources what would be the route for approval of any amendment to a policy such as this i would imagine it would depend on the change so if it was a change that
02:52:36 change so if it was a change that as we've said here in terms of um you know changing the appendices it depends if it was just one word change or if it was just an update
02:52:47 or if it was just an update uh maybe they would have done that themselves uh ost could have done that just to
02:52:53 just to effect to change at other times if it was a major change we would have all been aware of senior operations managers and principal operations managers we might have discussed it at a brigade control
02:53:05 discussed it at a brigade control management meeting too can you just help me with this presumably someone holds a master version of every policy or
02:53:16 version of every policy or comparable document yes who holds the master version of this one so this is heard we have a an internal department in lfb that holds all documents well so when i say who
02:53:28 all documents well so when i say who holds it i mean who ultimately has responsibility for deciding whether a change should be accepted or not so if i wanted to change because we'd made a change to a policy or procedure
02:53:41 made a change to a policy or procedure and and that i wanted to update the policy then um i would request it from document management and they would send it through to me i would make track changes at the audit trail at
02:53:52 make track changes at the audit trail at the end
02:53:53 the end and send it back and
02:53:56 and it's common practice now that that is undertaken by the ost team and they do that they have done that and do that to date and i'm having just difficulty you see
02:54:07 and i'm having just difficulty you see an understanding quite who is
02:54:10 is has the ultimate authority to decide whether a change is made or not now document management is presumably a body within the lfb which simply holds all the documents it
02:54:21 which simply holds all the documents it does but is there no provision for determining who whose authority is required to make a change
02:54:33 to make a change um
02:54:34 um no i'm i'm not aware of anyone uh
02:54:38 uh anything that i would have made a change to that i would have needed to go and seek permission from because the change would have been reflected of the policy or procedure we just implemented and the document would
02:54:49 just implemented and the document would have just been updated for that fact all right thank you
02:55:02 well let me just see if i can explore that a little bit further can we look at the version that was amended in september
02:55:12 september 2010
02:55:14 2010 uh that is at lfb 404735
02:55:25 which has been described in the audit trail
02:55:28 trail as amended throughout and here is the first page of it uh its
02:55:35 uh its uh issue date is as we've seen before november 2007 reviewed as current third of september 2010 owner head of service delivery and mobilizing
02:55:47 delivery and mobilizing now who was it as at third of september 2010 who was head of service delivery and mobilizing i'm sorry i can't remember it may well have been ac brown right
02:55:57 right and
02:55:58 and whether it was or him or somebody else the is it the owner of
02:56:04 of the policy who has ultimate sign off on its contents well i would say yes but in practical terms i don't believe that happens
02:56:15 terms i don't believe that happens or that happened back then right why is i say how comes which is a rather broad question what would be the process or what was the process whereby this document was
02:56:28 whereby this document was authorized for use
02:56:32 so a change of policy or procedure would have usually come um as a point of several departments may wish to change a policy or procedure in
02:56:43 wish to change a policy or procedure in terms of the control ones that we owned if we had an amendment and a change of procedure or policy as i said whoever was dealing with that change would have requested the document from
02:56:56 requested the document from document management would have made the updates and would have sent that back to document management and may have actually either informed us if the change was being made lower
02:57:09 us if the change was being made lower down or i would have informed the pom that i'd made the change or the pom himself may have made the change to reflect that it could have been a variety of
02:57:20 it could have been a variety of individuals in practice i can understand how what you just told us would would create the document but who signed this off
02:57:37 i i i don't believe anyone signed it off i would imagine if this as a result of the changes that we identified from the gap analysis both scott and i would have
02:57:48 gap analysis both scott and i would have worked on the changes would have edited it and updated it and one of us would have sent it off to
02:57:57 let me ask you this way
02:58:00 is it right that that this document would not have been deployed for use by the control room unless you were fully satisfied with its contents
02:58:14 [Music] yes with this version if i was aware of that if i'd been editing it yes i would have been satisfied that the amendments i had made
02:58:25 the amendments i had made would have been correct did any board exercise any oversight of these amendments which came into this policy at this time
02:58:36 at this time they may well have done because the the gap analysis had been agreed by the the latino
02:58:41 latino board um and so they probably
02:58:45 probably saw a copy of the changes we've made to emergency call management
02:58:50 did you as a matter of corporate governance did you have to to present a a significantly amended policy such as this to the latino board
02:59:01 this to the latino board um
02:59:03 um from recollection i can recall there was a great degree of scrutiny over control and so i would have thought that we would have done that and they would have wanted that
02:59:14 would have wanted that do you remember yourself from your recollection going to a latkinal house board meeting and taking them through this newly amended policy and explaining the
02:59:25 newly amended policy and explaining the differences between it and its predecessor no not specifically um but if i hadn't maybe dac tim kupper would have done that because
02:59:36 that because everything we we did in terms of the gap analysis and review what was done jointly with him and tom davis our records show from the minutes of the latino board in
02:59:48 from the minutes of the latino board in september november and december 2010 that although the latino board were told that this policy was being and had been uh
02:59:58 uh amended
02:59:59 amended um no approval of that board appears to have been sought and we see no record of any detailed explanation of this policy to it that with that accord with your recollection
03:00:11 recollection yes possibly i don't recall giving a presentation on the detail of emergency call management although i do recall um some general comments about the policy
03:00:22 some general comments about the policy being very unwieldy the policy containing more information than policy guidance and i'm not sure if that came from that time or or later yes thank you
03:00:34 that time or or later yes thank you mr chairman is that a convenient moment well it is but i'd just like to ask one other question before we break and i think you
03:00:40 think you told us a little while ago that sometimes
03:00:44 sometimes um a policy was amended to reflect a change in practice is that right yes well no i'm going to ask you the same sort of question whose authority was required for a change in practice
03:00:58 required for a change in practice so a change of practice would have been usually generated by a change of um equipment or an introduced introduction of of a change from the operational side
03:01:09 operational side and so that would have been discussed and taken through various boards operationally and agreed and then the change of practice would have been for control to implement because
03:01:21 because realistically any change of policy or practice on the instant ground or new equipment would have a knock-on impact in control so it would have changed our practices
03:01:32 practices right and did someone need to even if it's only a case of rubber stamping need to approve the change in practice within the control room someone at a fairly senior level
03:01:45 someone at a fairly senior level yes i think that would have been whoever was dealing with the operational element and the changes and certainly i took on a more focused operational if you like role
03:01:57 operational if you like role when i returned in 2015 2016. so the change in the agreed change of practices would have yeah i would have signed i would have agreed that you could do that could you yes
03:02:10 could do that could you yes all right thank you very much you want to follow that up okay right well thank you very much um we'll break at this point have some lunch we'll resume please at two o'clock
03:02:22 resume please at two o'clock and once more please don't talk to anyone about your evidence or anything to do with it while you're out of the world okay all right thank you thank you very much
03:02:31 very much [Music]
03:02:41 thank you very much
03:03:40 you