London Fire Brigade Evidence - Thursday 11th November 2021 (2/2)

Full transcript

00:00:10 Would

00:00:26 you ask Miss Smith to come back in, please? Thank you.

00:00:38 Yes, please sit down. and make yourself comfortable. We ready to carry on? Yes. Thank you, sir. Good. Thank you very much. Yes, Mr. Yes. Thank you, Mr. Chairman. Miss Smith, I now want to turn to aspects of

00:00:49 Smith, I now want to turn to aspects of non-compliance with national guidance as revealed by the gap analysis. And I'm going to start with the first subject matter there, which is um warning about the danger of offering

00:01:00 warning about the danger of offering reassurance to callers. Can we start with the gap analysis please which you'll find at LFB 404750 page 11

00:01:15 and on that page you will see uh uh in the third column entitled gap analysis comparison of national guidance against LFB policy guidance and training uh and

00:01:27 LFB policy guidance and training uh and the gap identified there between the national guidance and the LFB policy guidance and training was stated to be as follows. Uh national guidance 1093 acknowledges the possibility that an

00:01:38 acknowledges the possibility that an emotional bond may be formed between control operator and caller as the call progresses. However, emphasizes is to be is given to the fact that this relationship may be adverse and lead to

00:01:50 relationship may be adverse and lead to the caller providing answers that they believe will be the desired response and caution should be used when offering reassurance in case this leads to a full sense of security. LFB training package

00:02:01 sense of security. LFB training package tends to encourage a strong attachment between caller and fire control operator and reiterates the use of reassuring phrases which may be construed as offering a false sense of security.

00:02:14 offering a false sense of security. I want to focus particularly on that last sentence there. If we look across to the first column on this page, page 11, um you see um it says attempt should

00:02:26 11, um you see um it says attempt should be made to reassure the caller without promoting a false sense of security. That is what is set out in FSC 1093, isn't it?

00:02:35 isn't it? Yes.

00:02:35 Yes. Yes. Now, pausing there, do you agree that the training package in place before lack did encourage the CRO to create a strong attachment with the caller?

00:02:45 caller? Yes, I do. And in the third column of the gap analysis in respect of that comparison, there's no mention there of any gap with policy 539 uh and national guidance that the 2007

00:02:57 uh and national guidance that the 2007 version of of PN539 didn't include a warning akin to what we see uh here. Is that uh No, it doesn't look like it. No.

00:03:09 and and do you accept that that was a gap which should have been expressly identified in the gap analysis in terms of the current policy 539 not

00:03:21 in terms of the current policy 539 not um having that in I'm sorry I I can't recall what the 2007 guidance had in it did it have about an emotional

00:03:32 did it have about an emotional attachment in PN539 uh no it didn't have an express warning in PN53 39 that no emotional attachment should be formed and you mustn't offer a full sense of security. It didn't have

00:03:43 full sense of security. It didn't have that. So what I'm putting to you is that there was a gap between uh policy 539 and uh and national guidance in that respect

00:03:53 respect that we didn't make it explicit that they shouldn't have a contact. Uh no we didn't. No, I agree. Why is that? Um I think because uh it

00:04:04 Why is that? Um I think because uh it was uh to be put into the training and associated documents uh rather than uh in the policy. I think we had been or

00:04:15 in the policy. I think we had been or the general feeling was that um the policy our our emergency call management policy was a bit too detailed um and covered general information rather than

00:04:26 covered general information rather than policy. But um I accept that could have gone in there as a a point. If you look at the recommendation in the last column, it says place the LFB training guidance on call psychology

00:04:38 training guidance on call psychology more into context with 1093 national guidance to ensure although fire control operator adopts aspects of reassurance such as exchanging names. Other suggested phrases during training do not

00:04:49 suggested phrases during training do not allow the quotes emotional link unqumed and advice given is proactive and supportive without providing false reassurance. Those last few words there are important. Now we can see that that

00:05:00 are important. Now we can see that that recommendation, can't we? Focuses on amending the training guidance. Can you explain why or or whether you considered amending policy 539 specifically to to include the fact that CRO should not

00:05:13 include the fact that CRO should not form an emotional link with callers and be careful not to provide false reassurance? Um uh no I can't recall the conversations we would have had about that but I think I I believe from

00:05:25 that but I think I I believe from reading it that we would have thought that those elements would have been covered and reiterated in the training to to all control staff. If we look at policy 539 that was amended on the 3rd of September 2010 a

00:05:38 amended on the 3rd of September 2010 a date we've already seen that is at LFB 404735.

00:05:45 We looked at this just before the lunch break.

00:05:49 break. Uh if we go to page 16, we will find appendix three via survival guidance. Uh and uh if you uh look at the the

00:06:01 Uh and uh if you uh look at the the bottom of the screen, bottom of the page, you've got uh assess, reassess, protect. And underneath protect, there's a paragraph that starts if the caller

00:06:12 a paragraph that starts if the caller cannot escape. And it says if the caller cannot escape, offer reassurance. Be positive. Exclamation mark. Suggested phrases to use. Listen to me. I'm going to help you. We'll get through this

00:06:24 to help you. We'll get through this together. Stay calm. I'm going to help you. Do what I tell you to do. The firefighters will be with you very soon. The firefighters know where you are. And then over to page 17.

00:06:37 then over to page 17. Reassuring the caller will be beneficial as people will breathe more slowly when calm, making them less susceptible to the effects of smoke. Do you know why this version of PN539,

00:06:50 Do you know why this version of PN539, policy 539, which was amended after the gap analysis had been completed earlier in 2010, referred to those detailed instructions about re reassuring the caller without warning that doing so

00:07:03 caller without warning that doing so might provide false reassurance? I don't and and that version there is not something I recognize from whenever I've had any involvement in updating

00:07:14 I've had any involvement in updating policy 539. Right.

00:07:20 Right. I mean looking at the last two if you go back a page to the bottom of page 16 looking at those last two bullet points those are

00:07:31 those are uh promises or statements of fact aren't they? uh which uh might very well create a false sense of security in the caller, mightn't they?

00:07:43 mightn't they? Yes. The firefighters will be with you very soon. I agree. Yes. Uh can you explain I think you can't explain can you how it came about that

00:07:55 explain can you how it came about that those at least those two bullet points remained in this policy which was amended 6 months or so after the completion of the gap analysis in order

00:08:06 completion of the gap analysis in order to bring it in line with um with circular 93. No, I can't. And I'm surprised that it is in there after our update on the gap analysis.

00:08:20 update on the gap analysis. Who would be able to explain why those two bullet points remain in that policy? Notwithstanding the precise gap identified in your gap analysis.

00:08:31 identified in your gap analysis. Uh, I don't know. I apologize. I don't know who updated that policy um and why that was still left in there.

00:08:42 left in there. or remained in there.

00:08:52 Now, we know that there was a later version of this. Let's just look at this. This is at LFB302861.

00:09:02 There's a later amendment to this policy.

00:09:14 Uh, and if you go to at the bottom of the screen, it's a slight it's slightly strange this I wonder if you can help me with it. Uh, the reviewers

00:09:27 with it. Uh, the reviewers the reviewer's current date as we've just seen if we scroll back to the top of page one remained 3rd of September 2010. If you scroll to the bottom of page one, you can see that it says last

00:09:39 page one, you can see that it says last amended date 3rd of February 2011. Ju just on that why wasn't the date at the top of the page amended to February 2011 and but

00:09:51 page amended to February 2011 and but remained instead 3rd of September 2010. Do you know? No, I don't know. I think that just must have been an admin error. What kind of error? or that someone had

00:10:02 What kind of error? or that someone had updated the policy on the 3rd of February 2011 but not updated it on the front page. Right. If we go to page 16,

00:10:13 Right. If we go to page 16, please look at fourth line from the bottom.

00:10:18 We do see in in this policy uh what we I think can fairly identify as the equivalent part of the 2000 September 2010

00:10:31 of the 2000 September 2010 amended version where you have four lines up from the bottom. Reassure the caller and reassess the caller's situation. Example questions are, has that stopped the smoke coming in? Let me

00:10:43 that stopped the smoke coming in? Let me know if the smoke gets thicker. Turn the page, please, to page 17. Question at the top.

00:10:50 the top. What's happening now?

00:10:55 Nothing there about telling the caller uh that uh the fireman know where you are. Now, it looks as if those two bullet points at

00:11:06 looks as if those two bullet points at least had been removed from this policy. uh and replaced with the reassure and reassess the caller situation. Um and that is the way it remained until the Grenfell Tower fire in 2017.

00:11:21 the Grenfell Tower fire in 2017. Do you know can you explain that change between September 2010 and February 2011? Uh I I can't recall that. I can only

00:11:34 Uh I I can't recall that. I can only assume that if someone had updated it that maybe myself or Scott had looked at it or someone else had identified that it

00:11:45 someone else had identified that it hadn't actually been updated and that we then updated it. Right. Do you know whether the that reassurance advice was removed in this February edition if you like of of 539

00:12:01 February edition if you like of of 539 because of the warning in FSC 1093 about not reassuring the caller? Yes. And our investigations into the Lacano House fire as well contributed to

00:12:13 Lacano House fire as well contributed to it.

00:12:14 it. No. What? Well, that is a a fair conclusion, but do you know as a fact that the reason the person who made this amendment

00:12:25 amendment uh made it was in response to the gap identified in the gap analysis? Yes,

00:12:33 Yes, you do know that from your own knowledge. I do. Um because if you look at general um I would imagine this is at the same time that I had some involvement with

00:12:44 time that I had some involvement with policy uh 790 um and the general information looks like the information uh that was on the control information form at the bottom.

00:12:56 control information form at the bottom. Can we go back then in the light of that to the fire service circular 1093 and that is at LFB 40 3617

00:13:14 page one paragraph two last sentence and you'll remember this from phase one Miss Smith additionally in circumstances such as these a fire control operator

00:13:25 such as these a fire control operator may need to take into account that the normal procedure of calming the caller may not be appropriate and may even be dangerous in some circumstances. Now,

00:13:37 Now, if we keep that on the screen and then go back, please to the 3rd of February 2011 edition of policy 539 that we were

00:13:48 2011 edition of policy 539 that we were on a moment ago at LFB028601,

00:13:53 page 16.

00:14:02 uh we see no uh reference or or or uh even quotation of that warning in FSC

00:14:15 of that warning in FSC 1093

00:14:18 1093 on the page in front of you in the February 2011 version of PN539 or the next page either. Can you explain

00:14:30 or the next page either. Can you explain why not?

00:14:32 why not? Uh just that I would have imagined that we had removed it from all the training documents. We'd removed it from a previous version of the

00:14:43 previous version of the um policy and that there might have been clearer instruction in the training and the riff. Um

00:14:54 well there might have been. Do you know whether there was

00:15:00 um definitely in the training um I couldn't confirm the right well we'll come to look at that in in a little more detail later on but do

00:15:11 in a little more detail later on but do you agree with me that there is nothing here in this remended policy now post the gap analysis that spells out to

00:15:22 the gap analysis that spells out to CRO's

00:15:24 CRO's uh that it the normal procedure of calming the caller may not be appropriate and may even be dangerous in some circumstances. That's not spelt out in the policy, is it? No, it's not spelt out.

00:15:35 No, it's not spelt out. And what I'm trying to work out is why that is so given the prominence given to that concept in the 1993 fire service circular and the LFB's desire to close

00:15:46 circular and the LFB's desire to close the gap with it, which was what the anal gap analysis was for. uh as I've already said I think because we were comfortable and the lack of board was comfortable

00:15:57 and the lack of board was comfortable that it was in the training and had rem and items of reassurance had been removed from the policy um and the training and the procedures that control

00:16:09 training and the procedures that control staff follow would have been more relevant to them than being in a policy. Could you just help me with that answer? Um

00:16:20 Um what would be the purpose of a of a policy? What what's a policy for?

00:16:31 What what's a policy for? To provide guidance is in to undertake a a task or a role. And why would the LFB

00:16:42 And why would the LFB uh be content that training should not reflect what was in the policy? Well, I think they were I think that the key principles of escape uh assess,

00:16:55 key principles of escape uh assess, protect and rescue were in the policy um the finer detail was contained in the the training um that control staff could relate to.

00:17:06 relate to. Right?

00:17:08 Right? Put another way, why would the LFB be interested in updating or closing the gap between national guidance and training but not wish to close the gap between national guidance and pol and

00:17:19 between national guidance and pol and its own policy? Uh can I say I think there was always a desire from my understanding of the gap analysis it was to compare the national guidance to all elements. One of that

00:17:31 guidance to all elements. One of that was policy but there was training as well and um practices and procedures. M now let's look at the lacal control report published in November 2012 that

00:17:43 report published in November 2012 that is at LFB 404724

00:17:48 it can also be found because I've used this reference at hom 4001124 but I'd like you to use the LFB reference which we have on the screen can we go to page 50 in that please

00:18:04 on page 50 uh you can see that paragraph 293

00:18:09 293 uh it says or finds uh as follows and I should just tell you putting it in context that this is in section F6 of this report which is conclusion about handling of the fire at Lacnal 3rd of

00:18:21 handling of the fire at Lacnal 3rd of July 2009 paragraph 293 expectations that callers would be rescued and stapled advice cos had a clear expectation that fire

00:18:33 cos had a clear expectation that fire crews would reach the callers quickly their experience was that fire appliances arrive quickly and that people are rescued by the brigade. This is borne out by the fact that only rarely where FSG is given do people die

00:18:44 rarely where FSG is given do people die in fires. C-section E3 as rescues by crews were not immediate. There is a question whether the CO and or callers could have assessed the risk of attempting to escape from the flat and

00:18:55 attempting to escape from the flat and whether the risk of moving closer to the fire but escaping was less than staying put and awaiting rescue. CA relied on advising callers to stay put, expecting that this would call keep keep callers

00:19:06 that this would call keep keep callers safe from fire. Now, you confirmed, I think, in your evidence of phase one of this inquiry that you were familiar with this report at the time, and I think you told us the same again this morning. Yes.

00:19:16 Yes. Did you assist in drafting this conclusion in this paragraph? Um,

00:19:22 Um, no. Like I say, I think it had been rewarded, but the uh the conclusion um was what we had identified. Yes. Yes. So, so in broad terms, did it broad

00:19:35 Yes. So, so in broad terms, did it broad it reflected your input? Did it? It did.

00:19:37 It did. Yes.

00:19:38 Yes. And presumably you gave that input before you departed for the CFOA. I did. Yes. Yes.

00:19:44 Yes. And when you gave input into that conclusion, was was any thought given at that point as to how this lesson the lesson to be drawn as identified here could be reflected in policy such as policy 539.

00:19:59 Uh in terms of stay put advice, do you mean and if that was explicit in policy 59 39? Well, not not li not

00:20:13 in policy 59 39? Well, not not li not exclusively. No, I don't mean that at all. I I I'm showing you the paragraph uh and asking whether when you drafted that paragraph,

00:20:25 that paragraph, the conclusion that it is inviting the reader to draw uh was one that you thought ought to be reflected in policy 539.

00:20:37 Uh so I think uh when we drew that conclusion that was from a specific instance

00:20:46 instance um and in the training we made sure that there was an assessment phase placed and the CRO's and the CRO's would go through an assessment phase before they advised

00:20:58 an assessment phase before they advised stay put that was of a specific incident a piece of advice where previous we hadn't asked the caller if they were being directly affected by

00:21:09 they were being directly affected by fire, heat or smoke before we advised them to stay put. Uh I think there was some deliberation with the board and with uh between the group of four of us that were working on

00:21:21 group of four of us that were working on this report that um the stay put advice was to be re-emphasized but that was the government guidance and we were just to follow that. So no, I don't think it

00:21:33 follow that. So no, I don't think it would have made it into policy in case that would have changed. Now when you came back to the LFB from the CFOA in January 2015, did you yourself do anything to assess whether

00:21:45 yourself do anything to assess whether the lessons that you had identified in the lack of control report had been implemented into policy or training? No, I No, you didn't.

00:21:56 No, I No, you didn't. Whilst

00:21:57 Whilst No. So I I left to perform another role. um and a competent and capable individual would have done that. Um Scott was still there um and would have been consistent as was DAC Tim Cut Bill.

00:22:11 been consistent as was DAC Tim Cut Bill. Um and there would have been a review on that. So no, I wouldn't have felt the need to do that. At the time you came back, January 2015, uh not only had the gap analysis been

00:22:23 uh not only had the gap analysis been completed some years before, but we'd seen the control report November 2012, we'd had the inquest in January to March 2013 and then the the coroner's rule 43

00:22:34 2013 and then the the coroner's rule 43 lacal recommendations thereafter and the establishment of the lackal house working group and all of the work that followed that. when you arrived back in the LFB in January 2015. Did you ask the question

00:22:47 January 2015. Did you ask the question along the following lines? Um I've been away a long time. What has changed so far as policy and training are concerned which reflects the lessons drawn from

00:22:58 which reflects the lessons drawn from Lacel House? It's a broad question. Did you ask it? Uh no I didn't. But I think I shared um my frustrations that uh the letter to

00:23:10 my frustrations that uh the letter to DCLG hadn't been sent. Um and I think I provided some knowledge of the work that I had been doing on a national level to try and change the status of 1093 and

00:23:23 try and change the status of 1093 and progress that to a a modern useful document uh based on some of the findings in the the lack of report. So instead of asking what had changed in LFB, I tried to impart what I had done

00:23:36 LFB, I tried to impart what I had done and tried to do um and my work with the national operational guidance team um to influence that on a larger scale. So just to be clear, when you came back in

00:23:47 just to be clear, when you came back in in January 15, you didn't seek even for your own satisfaction to do an exercise to see what had changed in in the policy documents and what had changed in the training packages which would reflect

00:23:59 training packages which would reflect your own work on the gap analysis and your input into the November 2012 lacal control report. No, I would have assumed that that would have been um done by whoever replaced me

00:24:11 have been um done by whoever replaced me at the time. Um but I also would have kept a a breast of issues that were going on. Um and I certainly knew the outcomes from the the

00:24:22 certainly knew the outcomes from the the coroner's interest. I had a vested interest. It was about London control. How could you have um taken up the reigns as essentially head of OST by by this time? uh and certainly in charge of

00:24:36 this time? uh and certainly in charge of training if you hadn't followed the thread through from your gap analysis through through the changes uh and worked out whether or not they had been reflected in policy and training

00:24:49 reflected in policy and training because I had a I had uh the principal operations manager and another senior operations manager alongside me and we worked as a team. um the operations or the senior operations

00:25:01 the operations or the senior operations manager that had been doing the role with training was on watch and I could have spoken to them and they could have updated me on that. I didn't receive any of those briefings and just would have assumed that a competent capable person

00:25:14 assumed that a competent capable person would have fulfilled those requirements that were written in the lacel house report. It wouldn't have been for me to check that. That wasn't my role. Let's turn to another topic then under

00:25:26 Let's turn to another topic then under this the gap analysis heading which is the need for continual reassessment. Uh if we go to the control report annex back to the gap analysis that is at LFB

00:25:38 back to the gap analysis that is at LFB 40750

00:25:40 40750 page 14

00:25:44 and here we see

00:25:48 in the last column another recommendation and this is in relation to the effects of smoke.

00:25:57 of smoke. Uh and under the recommendation it says C41 above fire safety stroke fire behavior presentation needs to include any possible effects of heat and smoke on callers. National guidance 1093

00:26:08 on callers. National guidance 1093 highlights the possible effects of smoke on callers but fails to offer the fire control operator any practical suggestions to deal with these possible changes. Uh any updates to 1093 national

00:26:19 changes. Uh any updates to 1093 national guidance needs to provide a suggestion that fire control operators should continually reassess the situation not only to remain aware of changing conditions within the premises but also

00:26:30 conditions within the premises but also the state of mind of the caller.

00:26:35 Uh and just focusing there on the words should continually reassess the situation. Keep that in mind. And then if you then go to um page 17 of the same document,

00:26:47 go to um page 17 of the same document, there's a further recommendation. We can see in the right hand column, national guidance 1093 and LFP training material recognize the importance of initial assessment as the first stage of an FSG

00:26:59 assessment as the first stage of an FSG call. However, both documents do not convincingly explain the benefits of continual assessment or possible reassessment further into the call to ensure the situation or individual circumstances has not or is not

00:27:11 circumstances has not or is not changing.

00:27:13 changing. C can you explain what the purpose was of explaining the benefits of continual assessment or reassessment?

00:27:22 Can I explain the benefits of continual reassessment? Yes, because then you will be able to uh so the both documents uh had an initial phase of assessment where

00:27:33 had an initial phase of assessment where you would gather uh the situation that the caller was in but throughout the call which could last a period of time. There was no place in the guidance or in

00:27:44 There was no place in the guidance or in our training to go back to the caller and ask how the situation had changed. Um, and we thought that was particularly beneficial when you were talking to a

00:27:55 beneficial when you were talking to a caller to know the circumstances that they were in. They might not tell you that the smoke had worsened and therefore that might be affecting them and their individual circumstances. Um,

00:28:07 and their individual circumstances. Um, and that would be essential for a control officer to know to pass to the instant ground. Yes. Essential. Yes. Um, we can look at it. Uh but would do you remember that

00:28:21 it. Uh but would do you remember that the 2007 version of PN539, the one current at the time of this gap analysis,

00:28:29 analysis, uh does not say anything about the the need on the part of the CRO continually to assess or reassess the situation.

00:28:40 situation. We can look at it if you like. No, I'll take your word. And given that, can you explain why this recommendation doesn't say anything about

00:28:52 doesn't say anything about uh the need to amend policy 539 so that it does bring home to the control room operator that essential point or that essential activity? No, I can imagine

00:29:05 essential activity? No, I can imagine like it's the the the issues raised before that it was in training um and later then amended in 2011 to reflect reassess. I'd be surprised if it wasn't

00:29:16 reassess. I'd be surprised if it wasn't in the updated version in 2011.

00:29:23 Uh well before we get to that um because we can see that there was no recommendation. My question is why was the recommendation focused on amending

00:29:35 the recommendation focused on amending uh both the national guidance and the LFB training material but not LFB's policy 539 as it then stood the 2007 original version.

00:29:47 original version. I I I no I'm sorry I can't answer that. I I don't know why. Now, in fact, policy 539, notwithstanding the absence of a recommendation, was amended to reflect

00:29:59 recommendation, was amended to reflect the essential need for continual assessment and reassessment. Can we look at it? It's at LFP 404735.

00:30:08 This is the 3rd of September 2010 amendment. If we go to page 16 where we were before, you could see just above the passage I I put to you before um

00:30:21 the passage I I put to you before um some words in bold uh assess, reassess, protect. You see that? Yes.

00:30:27 Yes. Uh and under the reassess, it says reassess continually throughout the call. Keep checking on the caller situation. So

00:30:37 So notwithstanding the absence of a recommendation in the gap analysis, is it right that that amendment did nonetheless encapsulate the principle of continual reassessment?

00:30:48 continual reassessment? Yes, I would agree with that. Um then let's keep that on the screen please and move to the February 2011

00:30:59 please and move to the February 2011 version or further amendment at LFB3028601

00:31:04 page 16.

00:31:13 So to be clear on the left hand side you've got the 3rd of September 2010 amended policy 539 that does reflect the gap or reflect the

00:31:26 that does reflect the gap or reflect the need for for continual reassessment to be brought home to the control room operator. And then if you look at the right hand side we've got the 3rd of

00:31:37 right hand side we've got the 3rd of February 2011 a further amendment. And if you compare the two reassessment sentences, uh, in February 2011, it's become this.

00:31:50 uh, in February 2011, it's become this. Four lines up from the foot of the screen on the right. Reassure the caller and reassess the caller's situation. Now, can you account for why there was a

00:32:02 Now, can you account for why there was a change there and the words the word continually throughout the call were omitted?

00:32:11 No, I I just guess we'd moved to a a a point where um we were putting in some example questions that

00:32:22 example questions that control officers could use

00:32:27 and I think in reading it um it would mean the same thing. Certainly on the the training there was a focus on on reassessment.

00:32:38 reassessment. Um

00:32:39 Um continually I suppose if you are picking up I think that was implied maybe not written specifically in policy but definitely in the training um and

00:32:51 but definitely in the training um and there would have been continual reassessment and engagement with the caller while they provided advice. Now this is February 2011. Yes.

00:33:03 Now this is February 2011. Yes. Uh, making all allowances for your role within OST at that time, did you notice uh that the words continually throughout the call present in the 3rd of September

00:33:15 the call present in the 3rd of September 2010 version of PN539 had been omitted from the 3rd of February 2011 version? No, I didn't. And those that worked with me on the gap analysis and on the policy

00:33:26 me on the gap analysis and on the policy updates

00:33:28 updates obviously didn't either. I think we one would have assumed that um

00:33:36 that um it meant the same right we were trying to get the same message across.

00:33:40 across. Who would have undertaken the exercise of making that change say would have on the on the basis of your knowledge of the organization at the time who was it do you think who who

00:33:52 the time who was it do you think who who did that? I I don't recall. I would imagine that it might have been members from the operational support team. It might have been training team. Um

00:34:04 might have been training team. Um I

00:34:06 I now we know that the RAFs, the riffs were amended. Uh let's just see what they said. This is LFB 403542.

00:34:22 Uh and if we go to page three, this is the FSG operator riff as opposed to the supervisor riff. If we go to page uh three,

00:34:32 three, uh you can see uh

00:34:36 uh uh in the at the bottom reassess regularly. So you've got the point about continual reassessment there. You see that?

00:34:45 that? Yes. Um, but going back to the point earlier that we were talking about, you've still got the reassurance being given uh along the lines of they're on their way, the firefighters are on their

00:34:56 their way, the firefighters are on their way, the firefighters know where you are, the firefighters are there, the firefighters are dealing with the fire. I think you would accept all of those contravene the clear warning in the last sentence of paragraph 2 of fire service

00:35:08 sentence of paragraph 2 of fire service circular 1093. I think we uh had uh a many conversations about this and actually uh whilst on the surface they may feel like

00:35:20 whilst on the surface they may feel like they're exactly the same as before the lack house actually the firefighters on are on their way would be a true statement um as were the firefighters know where you are because we would have

00:35:31 know where you are because we would have passed that information to the instant ground and they would know where you are. the firefighters are there again would have been that they would have attended and they were in attendance at the incident. Um and and it would be

00:35:43 the incident. Um and and it would be true to say that the firefighters are dealing with the fire. I think between us and I'm not sure if if that was a debate that ever reached the board but certainly um between uh control and uh

00:35:57 certainly um between uh control and uh Tim Cutbell and Tom Davis that was certainly discussed and those were felt that they were true statements not misleading. Well they're not always true statements

00:36:08 Well they're not always true statements are they as we discovered on the night of the Granville Tower fire in terms of the firefighters are dealing with the fire. Do you mean? Well, the firefighters are on their way. They know where you are. They are there very often

00:36:19 where you are. They are there very often as we know from the evidence on the night of the fire itself. The firefighters didn't know where people were.

00:36:25 were. I think yes, I I take your point, but I think from a control uh perspective, the information that we passed because we'd gathered that information and passed that on to the instant ground. We felt

00:36:37 that on to the instant ground. We felt comfortable that that was coming back to not misleading. I'm so sorry. I'm so sorry. I cut across you.

00:36:43 you. Sorry. I said that we felt comfortable that that wasn't misleading. Coming back to the reassessment regularly point as we can see it was inserted into the riff when they were amended

00:36:54 amended but not in to to policy as we can see because although there was an amendment to insert continual reassessment into policy it was then amended out wasn't it

00:37:05 policy it was then amended out wasn't it and you can't explain why. So the question then is why was there a a mismatch uh between the riff as we can see here and policy 539 as it eventuated

00:37:18 see here and policy 539 as it eventuated in February 2011 as the only explanation I can give is that the the policy wasn't as detailed as both the training the training notes

00:37:29 as both the training the training notes and the riff which operators would have relied on. Can we then turn to a different subtopic which is lack of consolidation before we move away from the gap analysis. Can we go back to the

00:37:40 the gap analysis. Can we go back to the gap analysis please at page 8 that's LFB 404750

00:37:44 404750 page 8.

00:37:53 If you look at the third column, um

00:37:59 um this is in relation to policy 539 appendix one which is uh the fire survival guidance. No issues identified. However, the information is found in a number of LFB documents and needs to be

00:38:11 number of LFB documents and needs to be consolidated. Before you were secounded to the CFOA, did you take any steps to remedy the need for consolidation? Uh not that I can recall. Why was that?

00:38:26 Uh not that I can recall. Why was that? Um I don't know. I I would imagine that I had worked on the gap analysis um and that we had some actions to deliver from that. Um and any actions that I were

00:38:37 that. Um and any actions that I were received from that I would have implemented and actioned. I don't recall being tasked with identifying the amount of documentation

00:38:48 identifying the amount of documentation and updating that. Now we'll come back to this gap analysis in due course in relation to later specific topics Miss Smith but for now let's move away from it. I want next to go to action 13 as it was identified in

00:39:01 go to action 13 as it was identified in the August 2018 laconal assurance review report and that's the letter to DCLG the draft letter to to DCLG. Can we go to your witness statement at paragraph 24

00:39:14 your witness statement at paragraph 24 please on page 10.

00:39:21 And you say that you say there this Scott Haywood and I also drafted an initial version of the Lacnal House report in control and then handed this

00:39:32 report in control and then handed this over to LFB. This report included recommendations arising from the gap analysis including controls recommendations to improve FSG. The recommendation was to write to DCLG

00:39:43 recommendation was to write to DCLG recommending that they revise national guidance to one provide further guidance on call handling techniques during an FSG call. Two, emphasize the importance of reassessment during an FSG call.

00:39:55 of reassessment during an FSG call. Three, include fire safety input for different types of buildings with high-rise premises flagged as a particular example. and four provide further guidance on effective communications between the control room

00:40:06 communications between the control room and the incident ground which should be a two-way flow of information. Um now we have two drafts of that document one in November 2011

00:40:21 document one in November 2011 uh and uh I'm sorry December 2011 and one in February 2012. Um those dates do they roughly configure with your recollection about when you drafted this with Scott Haywood?

00:40:32 drafted this with Scott Haywood? Yes they do. Do you know what had had prompted that letter or that drafting exercise I should say? Uh the work from our gap analysis that had identified

00:40:43 had identified um that we had some recommendations that we thought after going through the lacor fire would be extremely useful. um the discussions that we'd had that uh the

00:40:54 discussions that we'd had that uh the guidance was written in 1993 and we were in 2007. So there was a possibility that lots had changed since then and that would be worthwhile even just reviewing

00:41:06 would be worthwhile even just reviewing it on DCLG's behalf. Um and so I believe when we raised these with the board um we were asked to draft a letter to DCG.

00:41:17 we were asked to draft a letter to DCG. Who who asked you to do that? I I I think that came from the board. Um or maybe that was something that we'd been asked to prepare for the board um

00:41:30 been asked to prepare for the board um on the results of our gap analysis.

00:41:36 Uh why was it felt why did you feel that it was necessary for DCLG to revise the national guidance in the terms that you've outlined in your statement there? those foreheads.

00:41:48 those foreheads. Um,

00:41:50 Um, again through our experience that we've been through with with Lacol, as I've said, the the guidance was drafted in 93. It was over 10 years later. Um, and

00:42:03 93. It was over 10 years later. Um, and a lot had changed. Even technology had moved on in that time and that was uh imperative. I I've really always pushed for national guidance for control staff.

00:42:15 for national guidance for control staff. Um I was conscious that even though we as a control room had been through lacel which had been a unique incident at that time no other control room fire control room had had been through that and

00:42:26 room had had been through that and experienced that that actually our findings probably didn't capture everything that had gone on in different fire control rooms and in the different sector. Um and that there was a

00:42:37 sector. Um and that there was a responsibility that someone from um with that experience needed to invest in um reviewing um and investigating what

00:42:51 um reviewing um and investigating what new methods were out there that could help control stuff and and what just looking at uh call handling techniques, the first of those, what further particular guidance did you want the government to provide?

00:43:03 want the government to provide? Um from recollection on the gap analysis I think that was example questions. So we talked um we'd looked at proactive and reactive techniques um in from 1093

00:43:17 and reactive techniques um in from 1093 and we'd put those into our training in LFB but there were no national examples of how to ask proactive questions or what proactive questions to ask.

00:43:28 what proactive questions to ask. Right. Was your uh was your assumption that that just as the LFB had um made mistakes to be blunt about the way in

00:43:39 mistakes to be blunt about the way in which the control room had responded to the Latin house fire you wanted you were assuming that other fire and rescue services might very well do the same and therefore would benefit from what you had learned.

00:43:51 had learned. Yes indeed. Yes. Looking at fire safety input, what particular fire safety input did you want the government uh to flag?

00:44:02 want the government uh to flag? Well, specifically high-rise premises. So, we had um we'd reviewed 1093. I think you've shown you've just shown the the excerpt where it says about high-rise, but I understand I believe

00:44:15 high-rise, but I understand I believe that that was the only reference to high-rise residential buildings. Um and obviously it did doesn't mention stay put or the guidance um and we thought

00:44:26 put or the guidance um and we thought that would be essential. Now given that initiative before you left for the CFOA did you take any steps to ensure that your own LFB guidance your own policies adequately address

00:44:39 your own policies adequately address those four areas of concern you set out there.

00:44:46 I think yes the gap analysis as well um indicated those and I think through either commenting on training packages or discussing it as a group of three um

00:45:01 or discussing it as a group of three um I would have believed that that was happening. Now, can we then look at uh LFB 308439

00:45:14 to see what the Lacal House board was doing when they received the draft? These are the minutes for the 12th of December 2011 of the Lackl board. Uh and

00:45:27 December 2011 of the Lackl board. Uh and you can see that you were one of those present fourth from the bottom of the list just below Scott Haywood. Yes. S Soom control. If you go to page two,

00:45:39 Soom control. If you go to page two, it says under section 8.1 under the heading control, the draft letter to CLG has been reviewed by control and legal and is now ready to be sent to CLG. The

00:45:50 and is now ready to be sent to CLG. The commissioner confirmed that the letter should be sent. Action JSH to provide the final letter to the commissioner to be signed. See that now? Uh, do you agree that at

00:46:02 See that now? Uh, do you agree that at that stage it was ready to be sent? Yes, I do. Did you or Scott Haywood provide the final letter to the commissioner for it to be signed? Uh, I believe it was in draft. Yes, I

00:46:14 Uh, I believe it was in draft. Yes, I believe Scott did. I I wouldn't I I'm not sure directly to the commissioner. But now you you you say at paragraph 25 of your statement, and we don't need to go back to it, Miss Smith, but you say, I

00:46:25 back to it, Miss Smith, but you say, I understand that the commissioner did not sign and send this letter. Uh and there are lacklouse board meeting minutes for a period after you'd left to go to the CFOA which confirm that and

00:46:37 go to the CFOA which confirm that and the decision that the letter should not be sent. Do you know why it wasn't sent? No,

00:46:41 No, we don't. When you returned in January 2015, did you investigate what had happened to your draft letter? No, I knew it hadn't been sent. Did you Did you ask the question, why

00:46:52 Did you Did you ask the question, why hadn't it been sent? Frequently with Scott. And what did he tell you? um I I can't recall but that it wasn't sent and I had been disappointed and voiced my

00:47:03 been disappointed and voiced my disappointment because I felt that I had been working from another angle um in my role of at CEO um to try and uh change and get some national guidance and some

00:47:15 and get some national guidance and some up-to-date national guidance especially for fire survival. You asked the question frequently with Scott and you were disappointed and voiced your disappointment for the reasons you've just given. You you you

00:47:27 reasons you've just given. You you you sure you can't remember even a a trace of what Scott Award told you by way of explanation when you investigated? Probably that they didn't want it sent LFB.

00:47:37 LFB. Is there a What could the reason have been?

00:47:40 been? I'm not asking you to speculate. I'm asking you to search back into your memory to see if you can retrieve a reason.

00:47:46 reason. I don't know. I don't know why it wasn't sent. I thought it was a valid letter and it had some valid points on it and that it should have been raised. Do you know whether the letter was ever reviewed after the inquest was concluded

00:47:59 reviewed after the inquest was concluded in uh March 2013? I don't know.

00:48:07 Uh if you go to page 11 of your uh statement please

00:48:15 uh at the very top of the page within paragraph 25 you say however in the period following my departure for CFOA I understand that OST ensured that steps were taken internally to address these

00:48:26 were taken internally to address these concerns such as training with the command units and training on how to communicate FSG information to the incident ground. Now, now let's go first, please, to LFB 40-4744.

00:48:39 first, please, to LFB 40-4744. This is the draft uh of the letter to to DCLG that you had prepared with Scott Haywood uh in December 2011, the first of the two. We

00:48:50 December 2011, the first of the two. We see we saw a later one date the 3rd of February 2011 with him. Uh but uh sorry, 2012 with him. I just want to ask you about one or two of the recommendations in here. If you cast your eye down to

00:49:03 in here. If you cast your eye down to paragraph two, if we could have that blown up a bit, please. It says, "Provide guidance to maintain the caller's safety. A review of fire safety advice to reflect more current fire safety developments, which would further

00:49:15 safety developments, which would further support fire control operators to engage with callers when assessing the situation and exploring any possible means of protection and escape. What were the current fire safety developments that you wanted revised

00:49:27 developments that you wanted revised National Fire Safety Advice there to reflect?

00:49:31 reflect? I don't think we knew what they were. I think that's why we wanted a review because I I don't think we assumed that we were experts in that and certainly not at fire safety and that we wanted

00:49:42 not at fire safety and that we wanted some detailed research into what advice could then now be available that we could add into our guidance and share with other control rooms. So it it

00:49:53 with other control rooms. So it it wasn't something that we'd identified because we knew what what advice to give, but actually that we wanted support and someone to look into that and tell us what we could.

00:50:06 and tell us what we could. So you weren't working on the basis is this right that there were current fire safety developments that you were you knew about and wanted fire safety advice to reflect.

00:50:17 to reflect. Is that right? No. We made an assumption that the guidance was over 10 years old and that buildings had moved on and that fire safety had moved on and there may well be different advice that we could offer

00:50:29 be different advice that we could offer a caller. I follow. Looking at four, the four principles stroke assessment. Updated national guidance could recommend that fire control operators should continually assess, sorry, continually reassess the situation

00:50:41 continually reassess the situation throughout the call to remain aware of any changing conditions within the premises and the physical and or mental state of the caller. Why was it important for national guidance to be updated to reflect that? Well, I think

00:50:53 updated to reflect that? Well, I think that was one of our findings from from Lacno and we thought that would be beneficial as we've just explored about why we should continually reassess when we're talking to a caller in

00:51:08 uh given the importance of national guidance to that point. Uh does that explain well how does that explain the

00:51:21 explain well how does that explain the fact that the the policies were not updated uh to reflect uh continual reassessment as we've seen? Let me put the question a slightly different way. Um given that that uh the four

00:51:33 Um given that that uh the four principles and the need for continual reassessment uh were important and this is December 2011. Can you explain going back to the point we were on before why

00:51:44 back to the point we were on before why the why policy 539 at that stage which is after February 2011 did not reinforce or say anything about continual reassessment. No, not in in any more detail than I've

00:51:57 No, not in in any more detail than I've already explained. If you turn the page to item seven,

00:52:02 supervisory roles.

00:52:09 It says supervisory roles. In addition to recognizing the role other fire control operators can play in an FSG call, national guidance could go further to recognize and develop training for the supervisory role within the control

00:52:20 the supervisory role within the control room to better reflect current practices. The supervisory role should be able to offer support to control operators handling FSG calls and act as a conduit for information between the call taker and the incident ground. Uh

00:52:32 call taker and the incident ground. Uh did you take steps to make sure that the training was developed and put in place for supervisors to train them on how to offer to support CRO who were handling FSG calls? Uh no, that wasn't my role at the time.

00:52:44 Uh no, that wasn't my role at the time. Um but I was involved in the gap analysis and we did notice that um the supervisors um may benefit for some from from some

00:52:56 um may benefit for some from from some additional training um with some support mechanisms to support the control officer. Um and that's why it was recommended because it isn't in or it wasn't in 1093 and wasn't recognized as

00:53:07 wasn't in 1093 and wasn't recognized as a role and it was quite an important role

00:53:11 role we felt.

00:53:13 we felt. So, you say some of the training was updated.

00:53:17 updated. Does that be I I believe some of the training was updated. Yes. We'll come back to that in due course. Um, putting the gap analysis to one side, I'd next like to ask you about other aspects of policy 539 that were

00:53:29 other aspects of policy 539 that were updated in September 2010. We've seen that um version. Uh, can we go to LFB50737?

00:53:42 This is in fact the version reviewed as a current in March 2014.

00:53:50 Um but it follows on from the amendments that were done in in September 2010. If you go to page 16, uh we start with the definition of an

00:54:01 uh we start with the definition of an FSG call. And uh on page 16 in the first paragraph it says this. The London Fire Brigade define a fire survival guidance call as being a call to brigade control

00:54:12 call as being a call to brigade control where the caller believes that they are unable to leave their premises due to the effects of fire and where the control room officer remains on the line providing appropriate advice until either the caller is able to leave by their own means, is rescued by the fire

00:54:24 their own means, is rescued by the fire brigade or the line is cleared. Now um that definition uh it was different wasn't it from the definition of a first survival guidance call in the 2007

00:54:37 call in the 2007 original

00:54:39 original I believe um part of the work uh with the lacel house in investigation and the board we were asked um to define uh the

00:54:50 board we were asked um to define uh the yeah rewrite the definition of a fire survival guidance call. Well, so so that we can all see and compare and contrast the two, let let's keep that on the screen, left hand side, and have on the

00:55:02 screen, left hand side, and have on the right hand side the original 2007 edition, please. That is LFB 3028 28382,

00:55:12 28382, page 20.

00:55:14 page 20. LFB 3028

00:55:17 LFB 3028 382.

00:55:21 So on the left hand side, third of September 2010 amendment, right hand side, 2007 original. And if you look at the definition of survival guidance in the 2007 original, it says uh this.

00:55:34 the 2007 original, it says uh this. There may be occasions where during the course of handling an emergency call, it is apparent that the caller is trapped inside the premises and cannot escape. Prompts are in place on the computer aided mobilizing system to assist

00:55:45 aided mobilizing system to assist control officers in. And then um you get three bullet points. Providing a guidance to maintain the caller's safety. Provide reassurance to the caller that help and assistance is forthcoming. Strengthen relationship

00:55:57 forthcoming. Strengthen relationship with caller. You see that? Yes.

00:55:59 Yes. Now you then look across to the left and see the new definition in 2010 which I read to you in the first paragraph. My question comparing the two is this. Do you know where the definition that

00:56:11 Do you know where the definition that was used in the 2010 edition of PN539 to replace the definition of fast survival guidance in the original 2007 version came from?

00:56:22 came from? Yes, I believe it came from uh us as a control room working together with um the the Dak Tim Cup and Tom Davis and

00:56:34 the the Dak Tim Cup and Tom Davis and was agreed by the board the lacel board. So it didn't come from any national guidance?

00:56:40 guidance? No, I don't believe so. I think one of the recommendations sorry that we recommend to um see FOA was to uh define a fire survival guidance call

00:56:53 a fire survival guidance call possibly that may have come out of it. Um

00:56:58 Um do you know why the definition of fire survival guidance was changed from the 2007 original version?

00:57:07 version? So I think the the definition is just that looks like a complete lift from 1093.

00:57:15 1093. Um and from my recollection uh London Fire Brigade wanted a more robust

00:57:23 robust definition.

00:57:26 A more robust definition. Yes. Given that the definition had changed from the earlier version of the policy as we can see did you did you seek to test whether the definition that was adopted might work in practice?

00:57:40 was adopted might work in practice? Uh yes I think that's why um we agreed with the definition because we thought it would work in practice.

00:57:48 practice. Yes. But did you seek to test it? Did you road test it uh on the incidents that we'd previously dealt with in terms of fire survival guidance calls?

00:57:59 guidance calls? Yes, that was a true reflection of what they were.

00:58:06 Did you appreciate at the time that the far survival guidance call is defined uh among by among other things

00:58:20 uh among by among other things uh the fact uh that the control room officer remains on the line providing appropriate advice until the line is cleared.

00:58:31 cleared. Yes.

00:58:33 Yes. So, you don't know it's a fire survival guidance call until the end?

00:58:41 Uh, no, I don't believe it reads like that. My understanding is that it is a vice survival guidance call where you provide advice and where either the control room officer remains on the line

00:58:53 control room officer remains on the line or the caller is able to leave on their own means or is rescued. Yes. I mean, forgive the slightly semantic approach to this, but why did why was it thought appropriate by the

00:59:04 why was it thought appropriate by the group of people who created this definition to define a fire survival guidance call uh by the activity of the control room officer

00:59:15 control room officer as opposed simply uh to by the situation in which the caller found themselves? Uh I I think because it was uh

00:59:29 Uh I I think because it was uh Sorry, could you talk me through that again? Yes. Why Why did was it thought appropriate to define whether a call was a fire survival guidance call by reference to what the control room

00:59:40 reference to what the control room officer did as opposed to what the caller was telling them? Uh I don't think that was the aim of it. It was just to um

00:59:51 um bring a clarity that actually those are calls where the fire survival guidance calls are where we remain on the line to provide advice.

01:00:02 provide advice. Um and it just documented it there. Did you appreciate at the time when formulating that definition that if an FSG call required, the continued presence of a CRO on the line until

01:00:14 presence of a CRO on the line until clearance, then the number of simultaneous FSG calls that could ever be received and handled at one time could only match the number of CRO and supervisors available to handle them?

01:00:29 supervisors available to handle them? Um,

01:00:31 Um, yes.

01:00:33 yes. And did you consider what the practical effect of that would be? Um,

01:00:41 Um, yes, I think we did. We we thought that that was entirely possible that that was the process and that there was benefit for a control room remaining on the line um whilst providing as it

01:00:55 on the line um whilst providing as it says there the appropriate advice and guidance. um in terms of um availability and staff, we'd never um experienced um where a control our control room had

01:01:07 um where a control our control room had reached capacity that we weren't able to provide that and if we had uh we had a network and some arrangements with other fire and rescue service control rooms uh

01:01:20 fire and rescue service control rooms uh that would have been able to deal with that.

01:01:22 that. Now, continuing on that theme, can we look at paragraph 43 of your statement? page 17.

01:01:34 Before we go to that, can I just ask this? Um,

01:01:39 this? Um, was any training given to the uh control room officers to stay on the line as it were indefinitely or is that

01:01:50 line as it were indefinitely or is that what they were told to do? Well, I I think just from the history of it and my understanding of it and how it was managed and how I've managed it myself, um that you would stay on the line until

01:02:03 um that you would stay on the line until the caller was rescued or managed to escape.

01:02:06 escape. Why not? I mean, if you said to the to the caller, gave the advice about blocking up the entry of smoke and so on.

01:02:14 on. Yeah.

01:02:15 Yeah. And the caller said, "Yes, right. When I've done that, you might, particularly if you've got other calls coming in, you might think it was better to say, "Well, see how you get on and ring me back if there's if you still have a problem."

01:02:28 there's if you still have a problem." So I

01:02:29 So I and then you could deal with another call.

01:02:31 call. You could, but that in in my experience and our review um when we were looking at FSG calls specifically in London, that wasn't done. We stayed with the caller um and provided some further

01:02:44 caller um and provided some further reassurance whilst they were awaiting rescue.

01:02:50 Yes. Thank you. I'm sorry, Mr.

01:02:55 [Music]

01:03:00 Yes. Um can we look at paragraph 43 of your statement please? And you say there in response to the question how the control room should handle multiple FSG calls

01:03:11 room should handle multiple FSG calls that are received concurrently. As noted above in my response to question 6C, prior to the fire at Grrenfield Tower, it was considered that control would receive multiple concurrent FSG calls, two or three FSG

01:03:23 concurrent FSG calls, two or three FSG calls in relation to one incident. However, it was not envisaged that any additional measures were necessary to support those two or three concurrent calls. In addition to the current support arrangements with BT and buddy

01:03:34 support arrangements with BT and buddy control rooms documented in PN539 emergency call management, multiple FSG calls in the volume received on the night of the Granville Tower fire was not contemplated as a foreseeable event.

01:03:48 not contemplated as a foreseeable event. Now two or three FSG calls you say uh given that Lacel the Lacel House incident had five FSG calls including two from one flat why did you consider

01:03:59 two from one flat why did you consider that there would be fewer concurrent FSG calls at other incidents? Uh I don't think we did. I think we were just said that um there was we had only

01:04:11 just said that um there was we had only received one incident where we'd received um and we'd been talking to two or three callers providing fire survival guidance at a time for a duration

01:04:23 guidance at a time for a duration in one incident. Um and that was our first experience of it. Um and that we hadn't envisaged um that we needed any additional measures. The control room on the

01:04:36 measures. The control room on the blackenol house whilst busy never ex exceeded capacity. In fact, we had two senior control officers over at our Stratford fallback that weren't involved in the incident, but could have been had

01:04:48 in the incident, but could have been had they needed to to answer calls or deal with um other tasks. So um outside of the arrangements that were already in place with BT and our buddy

01:05:00 already in place with BT and our buddy control rooms, no we didn't foresee any other arrangements needed to be put in place.

01:05:05 place. Now you're dealing here with concurrent calls and you identify two or three uh a as those which control would or

01:05:16 uh a as those which control would or might receive from one incident. Um now at Latin there were five FSG calls.

01:05:23 calls. Yes.

01:05:24 Yes. Two of which were from the same flat and therefore by definition not concurrent. Uh how many calls do you remember at uh of the of the four uh were concurrent at lack

01:05:37 uh were concurrent at lack of of the five? Well there were five FSG calls in all. Two are from the same flat I think flat 68.

01:05:43 68. Yeah. Uh

01:05:44 Yeah. Uh that leaves um I suppose three. It could be concurrent. Of those three, were they all concurrent or were fewer concurrent? No, I believe at one point uh we had

01:05:57 No, I believe at one point uh we had three operators taking three FSG calls, right?

01:06:00 right? Um but there is a timeline in the lac report.

01:06:03 report. Yeah. Yes, there is. It was I thought it was quicker and easier to ask you there. Um so does that explain where the number three two or three FSG call concurrent

01:06:16 three two or three FSG call concurrent FSG calls comes from the fact that at Lacanol there were only three concurrent FSG calls five in all. Yes, I think that using the the history

01:06:28 Yes, I think that using the the history and when we were uh looking at the lacof we looked back at previous incidents and certainly since um I don't believe that there there had been any more.

01:06:40 there there had been any more. Nonetheless, did you give any thought to the risk that although there were three concurrent FSG calls, there were still four callers needing

01:06:54 there were still four callers needing FSG advice and therefore there was a a risk, I would suggest a real risk that the number three could be exceeded and could become four. um

01:07:06 um potentially. But again, I even if it had been four, we we weren't we hadn't exceeded our capacity and we had arrangements in place um if we did. And

01:07:17 arrangements in place um if we did. And and because an FSG call would be classed as a a life or a risk critical call that if um we were dealing with other calls say to a car on fire or smoking in the

01:07:30 say to a car on fire or smoking in the area that actually BT had a mechanism to alert us to those life risk calls and they would pass them through to us as a priority so they would be answered and dealt with. Now, can we go to page 12 of

01:07:42 dealt with. Now, can we go to page 12 of your statement, paragraph

01:07:45 paragraph 29,

01:07:48 you say at the foot of that page, in answer to the question, please explain what consideration, if any, was given to the challenges posed by incidents involving multiple FSG calls as part of the

01:08:01 multiple FSG calls as part of the revision of the riffs. You say uh we did not consider multiple FSG calls as part of the revision of the riffs in the control room. We can

01:08:12 riffs in the control room. We can receive multiple calls relating to one incident, but we train CRO to recognize when an incident is in progress to add their recordings to an incident. During the Lapal House incident, we received around five to eight FSG calls, but this

01:08:25 around five to eight FSG calls, but this was not the same scale as the FSG calls that arose during the Granfell Tower fire. at the time of the Grenfell fire quotes multiple FSG close quotes calls was not a known phrase or concept within

01:08:37 was not a known phrase or concept within the LFB or nationally. Now I just want to look at that a little bit more closely. When you say it wasn't a known phrase or concept nationally, what are you basing your uh your evidence on

01:08:48 you basing your uh your evidence on there?

01:08:49 there? Uh and I apologize. I think that might have come very unclear. Um but I think when I was asked that question um just in terms of multiple FSG calls I'm just

01:09:00 in terms of multiple FSG calls I'm just taken back to the Grenful Tower incident. Um but obviously I realized that the concept of multiple FSG calls and I knew and and we had planned for

01:09:11 and I knew and and we had planned for that there may be one or two FSG calls throughout an incident which would make it multiple FSG calls. I just meant in in the size and scale experienced at Grenful. So apologies. So, you weren't

01:09:23 Grenful. So apologies. So, you weren't saying that there were never there was never any discussion about or consideration of the possibility? No, I I realized how that reads, but I wasn't. Apologies.

01:09:34 Um, now can we go to LFB 30924,

01:09:40 30924, please?

01:09:44 Uh if we look at this run of emails and look at the second email on the page, you can see that this is an email from Helen Dows at West Yorkshire Fire and

01:09:55 Helen Dows at West Yorkshire Fire and Rescue Services on the 14th of July 2010 to you. Subject HSSE request. Hi Joe. At our YHRG

01:10:04 our YHRG meeting today, and I won't ask you what that stands for unless you can tell me. A request from the HSSE was discussed regarding fast survival guidance for large amounts of persons trapped in property fires. This I believe was as an

01:10:16 property fires. This I believe was as an outcome of the lack house incident. Do you currently have anything in place? I know from Humber's point of view guidance provided was mainly aimed at individual dwellings rather than HMOs and high-rise buildings. I'm going to

01:10:27 and high-rise buildings. I'm going to ask the question in in region, but I was just interested in your protocols. Regards, Helen, and you reply on the 16th of July 2010, two days later. Hi Helen, sorry for the

01:10:39 two days later. Hi Helen, sorry for the delayed response. It has been down to being locked away in a room for several days this week attempting to complete our report for the lacel incident. Uh can I ask what the YH

01:10:50 Uh can I ask what the YH RG is and the general discussions that that were held around FSG for large amounts of people? I can say that we have not identified giving FSG to multiple persons. Our training in FSG

01:11:02 multiple persons. Our training in FSG does reflect 1093. So, you're right in that it does not really cover high-rise or HMO. We're currently drafting a letter to CLG with some points which which will which will feel could be updated in 1093. However, where this

01:11:15 updated in 1093. However, where this goes with fire control project, I'm not sure. I'll keep asking the question, who is ensuring that we stuck to these ext documents such as fire service circulars, but CCOPs say they are question mark. Can we talk more at our

01:11:27 question mark. Can we talk more at our next S Soom meeting? If you need some further info before then, then let me know and I'll give you a ring. Now, um, there's quite a bit in that which I think we probably don't need to pursue, but were you aware that there

01:11:39 pursue, but were you aware that there had been general discussions around FSG or about FSG for large numbers of people at least in the West Yorkshire Fire and Rescue Service at the time? No, I think the YHR stands for the Yorks

01:11:52 No, I think the YHR stands for the Yorks and Humber side region. Um, and Helen D was a senior operations manager um, in charge of that region. um and was working towards um a fire control room

01:12:06 working towards um a fire control room for Yorks and Humber. Uh yes, but my my question is were you aware that there had been general discussions about FSG for large numbers of callers at least in her area?

01:12:18 of callers at least in her area? Yes, from the email she sent me. Did what did you understand her to mean when she said large amounts of persons trapped in property fires? Well, well, I don't think I really understood because as I responded, I'm I

01:12:32 understood because as I responded, I'm I say we've not identified giving FSG to multiple persons and I'm sure we probably followed that up at our next meeting or she may have wronged me um because yes, I would have been

01:12:43 because yes, I would have been interested about why and I may have thought that actually they must have un they may have misinterpreted what happened at the incident. Um but it was

01:12:54 happened at the incident. Um but it was probably something I would have taken on board to share with the senior operation managers group about how the lack of anal incident had happened and occurred and and what we were doing about it.

01:13:05 and and what we were doing about it. When you saw her expression uh large amounts of persons trapped in property fires, did a number come into your head?

01:13:15 Uh yes, probably. I would say large to me would would seem o over 10. Um, and I would have replied that that hadn't been identified at Lacano.

01:13:27 identified at Lacano. Did you understand at the very least that that the kinds of buildings which would present a risk of multiple FSG calls, large amounts of persons trapped in property

01:13:38 amounts of persons trapped in property fires, possibly 10, would be highrises and HMOs.

01:13:43 and HMOs. Yes, I think we both identify that. Now, you refer to drafting a letter to to CLG. Was that the letter we discussed earlier?

01:13:50 earlier? Yes.

01:13:51 Yes. And you asked her if you could talk more at the next S Soom meeting. Were there regular meetings between S Sooms, between different um fire and rescue service control rooms? Yes, we would all meet as a collective

01:14:03 Yes, we would all meet as a collective uh around the country whilst we were working to establish fire control. Um but I noticed that's in 2010. So whether we had any meetings after that um

01:14:14 we had any meetings after that um because I believe the project was disbanded in at the end of 2010. Yes. And during those S Soom meetings, did the subject ever come up about how control rooms would handle concurrent FSG calls, particularly from high-rise

01:14:27 FSG calls, particularly from high-rise buildings? Um, not that I can recall specifically. I I'm sure we would have um maybe discussed it as a peer-to-peer group. Um, we were talking about a range of issues um and how to implement the

01:14:40 issues um and how to implement the changes that DCLG were wanting to make to policies and procedures and how they would uh work in a fire control network. Um,

01:14:50 Um, after this email exchange, did you consider whe further whether you should prepare for giving fire survival guidance

01:14:58 guidance uh to large numbers of persons? No. Uh, I I think I probably responded is what I'm trying to respond to her is to say that that wasn't in our experience. We hadn't done that. So,

01:15:09 experience. We hadn't done that. So, right.

01:15:09 right. No, that wasn't a consideration. So, did you take this topic any further either with her or internally within the LFB?

01:15:18 LFB? uh not internally with the LFB and I'm sure we would have discussed it at our next meeting but 201 I'm sorry I can't recall.

01:15:29 I'm sorry I can't recall. Yes, Mr. Chairman, is that a convenient moment? We're about to Yes, I think it is. Thank you very much. Subtopics. I think it's time we had a break for the afternoon. We'll stop now. We'll resume please at half 3. And again, please

01:15:41 please at half 3. And again, please don't talk to anyone about your evidence while you're out of the room. Okay. All right. Thank you. Thank you very much.

01:15:58 Thank you. How far please? Thank you.

01:32:31 Thank you. Would you ask to come back in, please? Thank you.

01:32:41 [Music]

01:32:45 All right. Very good. You ready to carry on?

01:32:47 on? Yes. Thank you, sir. Thank you very much. Yes, Mr. Yes, Mr. Chairman. Uh, Miss Smith, I'd like to ask you now about the uh exercise called the Haygate Challenge which took place on the 16th of June

01:32:58 which took place on the 16th of June 2011. Do you remember it? Vaguely. Yes. Vaguely. Uh, it was a an eight pump exercise on the 16th of June to test both the then current high-rise policy

01:33:10 both the then current high-rise policy and the new draft uh FSG policy, policy 790. Do you remember that at that time it was still in draft. It was called draft 155. Was it? Yes, I do.

01:33:21 draft 155. Was it? Yes, I do. Uh, now can we go then to um uh the plans for that exercise at LFB303345?

01:33:45 This is an email

01:33:50 uh at the foot of your screen from Andy Row of the 8th of May 2011 to a large number of recipients including you as you'll see and Scott Haywood. Yes. Yes.

01:34:01 Yes. Most of the recipients were um operations but you and Scott Haywood from the control room. Yes. Yes.

01:34:10 Yes. Hello all. Thank you for volunteering to act either as a participant or safety stroke observer for this exercise. And if you go to page um two please you'll see um that there is a list of

01:34:24 see um that there is a list of participants and halfway down the list you'll see that control observer stroke facilitators PM Scott Haywood SOM Joanne Stbard. Do you see that? Yes.

01:34:32 Yes. Misspell your name but there it is. And then if you go to page three he sets out the exercise structure and timings. and he says this uh the exercise is a wet drill situated in a derelict high-rise

01:34:43 drill situated in a derelict high-rise block in Soduk. Control are running a background exercise for their staff. So this will be run as a live incident on ProCad with dedicated airwave channel, a live control room, including an officer of the watch and control operators

01:34:54 of the watch and control operators dedicated to the exercise. MDT will be live as will as will CSS. Crews will be riding minimum on both the CU and the appliances. To add to the realism, crews will be mobilized by printer from their

01:35:06 will be mobilized by printer from their own stations. We will brief all crews at E35, E35 and H24 dependent on their base location in the morning before they return to their own stations for an early lunch ready to be mobilized and

01:35:17 early lunch ready to be mobilized and there there are some exceptions. Senior officers will be mobilized by pager as per a real incident but we will but will give will given a dedicated exercise number to ring paging to change status

01:35:29 number to ring paging to change status etc. We will brief all senior officer participants at STC stroke Union Street to be paged for the incident. uh and then obviously later briefing facilitators and safety stroke observers

01:35:41 facilitators and safety stroke observers will also be briefed later in the morning and we'll then make our way straight afterwards to the exercise venue.

01:35:47 venue. Um now can you um explain what he meant, what you understood he meant when he said controller running a background exercise for their staff. So from

01:35:59 So from recollection um I believe we ran a mini exercise in control um in line with this exercise where we inputed a number of

01:36:11 exercise where we inputed a number of calls and some FSG calls um for staff um and then the information was passed to the instant ground as a trying to

01:36:22 the instant ground as a trying to simulate a a live incident.

01:36:27 Do you remember attending the exercise as a control observer or facilitator with Scott Haywood? Uh, no. So, I think I attended the control room. I think I was in the control room. Scott may have gone to the

01:36:39 control room. Scott may have gone to the incident to witness the exercise, but I believe I was in the control room when this was

01:36:44 this was Do you remember what you did specifically in the control room as part of that exercise? I think it was the role of facilitator um and ensuring the in the exercise timings ran to time and

01:36:55 in the exercise timings ran to time and the injects right

01:36:57 right were input successfully. And were there any FSG calls involved? I believe so. Yes. How many?

01:37:04 How many? I couldn't say. I would imagine two or three. Was any discussion held uh with Andy Row about how many FSG calls should be held

01:37:15 about how many FSG calls should be held as part of that exercise? Uh there might well have been but I can't recall. Apologies. Uh do you remember being in involved in such discussions even though you might not remember the detail?

01:37:27 not remember the detail? Um I don't know. Um and I don't know why um I'm not even sure how many FSG calls we input into the control exercise. I

01:37:40 we input into the control exercise. I can remember seeing um the exercise brief and some of the scenario session uh some of the the scenarios that we were using um but I can't recall who

01:37:53 were using um but I can't recall who determined the number of FSG calls. Was there any I I suppose it would follow from what you've just told us that there were no there was no discussion about testing

01:38:04 there was no discussion about testing concurrent FSG calls. Uh, I can't recall the timings. There may have been uh some timings where uh two were received at once, but I can't

01:38:16 two were received at once, but I can't recall that. I'm sorry. Was this not the opportunity to given the scale of of this this challenge, this exercise to test what

01:38:29 challenge, this exercise to test what had happened at Lacanel and have three concurrent FSG calls running, which was the number or potentially the number at at Lacanol. Uh it it may have been and we may well have done that.

01:38:40 we may well have done that. You don't recall? I I don't recall in terms of exercise timings. No, sorry. Can we look at LFB0033393

01:38:58 uh and this is an email run after the uh challenge had taken place. If we go to page two, we can see an email from Andy Row on the 30th of June, 2011. There it is. For again to a large number of

01:39:10 is. For again to a large number of recipients uh including uh uh um including not in fact including you as it turns out um but um that I don't think

01:39:23 out um but um that I don't think matters. He attaches a document that he says records all the feedback received in relation to the high the draft high-rise FSG policies and the incident information board. I've tried to record

01:39:35 information board. I've tried to record it as accurately as possible based on the minutes of the debrief and individual written comments submitted prior and post exercise. Apologies if I've missed anything, but there has been a massive feedback given. Please let me know if you think I've emitted anything

01:39:46 know if you think I've emitted anything vital. So that there's the there's what he says. Um, if you look at the feedback report he uh um sends, it's at LFB303384.

01:40:03 This is the report. Um, do you remember being part of any feedback meeting or discussion after the exercise? No, I don't.

01:40:16 Do you remember whether Scott Haywood uh attended the feedback meeting? No, I don't. Sorry. I don't remember that either. Looking at this report, if we go to page one, it's entitled feedback highrise and

01:40:27 one, it's entitled feedback highrise and FSG policies test exercise 16th June 2011 Soduk. Do you remember looking at this or seeing this document at the time? End of June 2011. You don't

01:40:38 June 2011. You don't do you remember looking at it at any stage?

01:40:40 stage? No.

01:40:40 No. Is this the first time you've ever seen it?

01:40:42 it? I believe so. Yes. Can you explain why that might be so given your your role in 2011?

01:40:49 2011? Well, I I can only assume that we weren't asked for the feedback because we weren't CCD into the initial right

01:40:57 right feedback request. It's odd that, isn't it? Because this is one of the things that's being tested is is the FSG policies. Is there any good reason why control would not have been at the front and

01:41:08 would not have been at the front and center of feedback? No. I I think in in in general terms um that control are often seen as a separate identity in the organization

01:41:20 separate identity in the organization and this probably focused on the operational response um and therefore it may not have occurred to them to include us um and the feedback we had.

01:41:32 us um and the feedback we had. Um

01:41:34 Um can we go to page 10 in this document uh please? And you'll see uh there there's a heading fire survival guidance policy.

01:41:46 You see in the middle of the screen there's a shaded box with the words fire survival guidance policy in it. I do. And in the right hand column

01:41:58 And in the right hand column uh opposite key point summary, introduction and then FSG call definition, you've got uh the feedback in the on the right. No commentary, no commentary, no commentary. In each case,

01:42:11 commentary, no commentary. In each case, separate feedback from control to be submitted. You see that? Yes. Do you know whether any separate feedback was given back was submitted in

01:42:22 feedback was given back was submitted in relation either to the introduction or the FS call definition? I don't know.

01:42:29 And then at the bottom of page 10 it says information gathered by control and there are two bullet points radio operators on the appliances and then the last one which I want just to focus with

01:42:41 last one which I want just to focus with you focus on with you. The consensus was that the carbonated form worked adequately for four flats as per the exercise, but would have been unmanageable for 20 plus calls as one CU

01:42:52 unmanageable for 20 plus calls as one CU had experienced at an incident the week before.

01:42:58 Now, this suggests that the exercise involved four FSG calls. Do you think that's right?

01:43:06 right? Yes, possibly. Right.

01:43:11 Does that tell us that more than two or three, which is the number you identified, uh was a real possibility? The receipt of more than

01:43:22 possibility? The receipt of more than three FSG calls was a real possibility. Uh, no. I think that acknowledges that there is a potential to receive more calls to an incident of that type, but I

01:43:35 calls to an incident of that type, but I don't think that indicates that more FSG calls there are potential for more FSG calls.

01:43:45 You don't? No. So, I think that there is a recogniz there's some rec that they recognize that um We, as a matter of course, could receive

01:43:58 We, as a matter of course, could receive uh numerous calls to a high-rise fire. Um, but one or two or or potentially three would require fire survival guidance. Um,

01:44:10 guidance. Um, but other calls wouldn't require that. Do you know who decided that four FSG calls should be tested in this exercise?

01:44:21 calls should be tested in this exercise? I don't know.

01:44:28 Did you or Scott Haywood have any input into that number? I I really don't recall. I I don't believe so.

01:44:39 Can you explain why even though five FSG calls in total were received at Lac House, only four were the subject of this exercise?

01:44:50 Um, no. It it would be useful to see the instant timeline um to see how the they requested that the calls come in. It might have been something that the the instant exercise that the exercise

01:45:03 instant exercise that the exercise facilitators had agreed to. You'll notice from the text I read out to you that one CU had experienced at an an incident the week before

01:45:14 an incident the week before 20 plus calls. Yes.

01:45:16 Yes. Now, do you know what that's about? Do you remember your control room receiving

01:45:23 receiving 20 uh calls?

01:45:29 Uh not specifically what the the incident that that's relating to, but uh acknowledgement that the control room had received 20 calls to an incident

01:45:41 had received 20 calls to an incident uh wouldn't have surprised me. Um well, it's the CU experiencing 20 calls.

01:45:47 calls. Yeah. So

01:45:48 Yeah. So the CU would would only experience 20 calls if if there were 20 which had generated information for the CU to receive from the control room and pass into the bridge head.

01:46:02 Is that right? Um so 20 calls with pertinent information um to contain I I I can't recall that incident. Um

01:46:14 incident. Um and I'm unsure that um the incident would have generated 20 separate uh pieces of

01:46:25 generated 20 separate uh pieces of information that needed to be passed to the C to a CU. Um but yes it it it could have especially this was in 2010.

01:46:36 have especially this was in 2010. So we we'd made some changes to the way we communicated with the the command unit and we were confident in as a control room that we were gathering all the information and passing it to the

01:46:49 the information and passing it to the instant ground. So that could have been possible. I mean this was 2011 in fact but the I mean to be clear here the comparison that's being made in this feedback form the point here is that the the carbonated form whatever that was

01:47:03 the carbonated form whatever that was perhaps it was the CIF worked adequately for four flats as per the exercise so four FSG calls from four separate flats

01:47:14 four FSG calls from four separate flats but would have been unmanageable for 20 plus calls now I'm not asking you to interpret the text of the feedback form. But what's indicated here is that at four it's fine, but at 20 it's not. Uh,

01:47:28 four it's fine, but at 20 it's not. Uh, and there had been 20 at a previous incident the week the week before, so sometime in early June 2011. My first question on that, do you recall the control room receiving a 20 fire

01:47:39 control room receiving a 20 fire survival guidance calls or 20 calls uh from separate flats, even if not strictly fire survival guidance in early June 2011?

01:47:50 early June 2011? Well, that's quite a big distinction. 20 calls from uh generated by a fire in a block of flats I wouldn't have thought would have been unimaginable and I would

01:48:01 would have been unimaginable and I would have thought we would experience that. 20 FSG calls? No. And historically and evidence goes to show that we'd never received that many prior to the night of

01:48:12 received that many prior to the night of Grenville. um and 20 separate pieces of information from individual flats possibly, but I would say that that was highly unlikely and I would have thought

01:48:23 highly unlikely and I would have thought from the incident and from the feedback on on this form that might have generated some additional work um for both the operational response and maybe

01:48:34 both the operational response and maybe that would have fed back into the control room.

01:48:40 And if you go a little bit further down on page 11

01:48:55 uh under recording of information, the consensus and specific feedback from the CUS was that even with only FSG C four FSG calls, the CU staff writing as

01:49:08 four FSG calls, the CU staff writing as only two could not deal with the workload. load associated with the FSG policy and and their normal duties. It looks digging deeper into this document that there were four FSG calls

01:49:20 document that there were four FSG calls at this exercise uh which

01:49:25 uh which even with those numbers made difficulties for the CU staff. That's that's what seems to have been fed back. Yes.

01:49:33 Yes. Yes, I agree. uh and and therefore 20 would have made life impossible, wouldn't it? That seems to be the feedback if you link the two passages together.

01:49:44 together. That appears to be the feedback, but I I'm I'm not um I don't know the process that the CUS undertake to record that information. And if we go to page 12,

01:49:58 And if we go to page 12, the top box, second bullet point, an individual suggestion was made that it would be an idea to mobilize a specific FSG response as with the FF emergency policy at a multiple FSG call incident.

01:50:10 policy at a multiple FSG call incident. This would provide an additional two SMS, station managers for FSG, a CU command unit, and crews to carry out the recording and specific search and rescue tasks associated. CSS was used

01:50:21 tasks associated. CSS was used throughout and found to be very useful in regard to FSG. So the the concept of multiple FSG calls coming back to it was clearly being examined in this exercise in June 2011.

01:50:33 examined in this exercise in June 2011. Yes.

01:50:33 Yes. Yes. And and the multiple there was four. Yes. Yes.

01:50:38 Yes. And that was found on the feedback to to create difficulties at least for the CU officers.

01:50:45 officers. Yes.

01:50:45 Yes. Yes.

01:50:51 And then in the in the box um below that you'll see eight advice to fire survival guidance callers. No commentary from crews. Separate feedback to control to be submitted again. Do you know whether

01:51:02 be submitted again. Do you know whether any separate feedback was ever submitted from control on that issue? I don't know. There was then a debrief meeting and we can look at the minutes uh for that

01:51:14 can look at the minutes uh for that please at LFB3056628.

01:51:21 If we look at page one you could see the start of it. It's it was on the 16th of June 2011 immediately after the exercise it appears. Do you remember attending that or do you remember whether yourself

01:51:33 that or do you remember whether yourself Scott uh Haywood attended that? I believe we both did. You think you both did? Yes. Then if you go to page four, looking at paragraph two,

01:51:47 subject two, draft fire survival guidance calls policy draft 155, paragraph 2, information gathering. And then if you look at the third bullet point down, it says, unknown. The whole

01:51:58 point down, it says, unknown. The whole FSG recording was hard enough to manage with four flats. It would be almost impossible should you have 60 flats involved. Can this information not be sent to the MDT?

01:52:09 sent to the MDT? Now, do you remember that discussion? I don't know. It looks from this note of it that the concept of large numbers of FSG calls in this case possibly 60 flats was being

01:52:21 this case possibly 60 flats was being discussed in the debrief, wasn't it? It looks like the the concern was that managing that amount of information

01:52:33 amount of information was difficult for a CU crew. Um, and presumably that's why they're asking for control to send the information to an MDT instead. Who came up with the number 60? Do you

01:52:44 Who came up with the number 60? Do you know?

01:52:45 know? I don't know. I mean, given that the number appears in this document, can we take it that the number of 60 flats involved in FSG recordings was not unimaginable.

01:52:57 recordings was not unimaginable. Um, I don't recall the conversation. So whilst it's it's documented there, I don't know who made that comment and and the reason for and their thinking behind that. Sorry.

01:53:08 that. Sorry. Between the date of the Lal House fire in July 2009 and the Granville Tower fire in June 2017, were you aware of incidents that had involved more than

01:53:19 incidents that had involved more than two or three fire survival guidance calls?

01:53:23 calls? Uh

01:53:24 Uh yes, I believe one or two. Can you tell us which they are? Um, I think there was an uh a far at a dare Tower in 20 late 2015. Was that

01:53:36 Tower in 20 late 2015. Was that beginning of 2016? 31st of October 2015. In 2015 um and one um at the Marriott Hotel in Docklands, although sorry, you

01:53:49 Hotel in Docklands, although sorry, you said more than four, didn't you? More than two or three. Yes. So, they're far at the Marriott Hotel. So the reason I've selected two or three is because you've selected that as your base number for multiple. Um

01:54:02 as your base number for multiple. Um Marriott hotel fire is the second of the two examples. I'd like to look at those with you. Um let's start with the Marriott Hotel fire. It was on the 11th of November 2010. So so 11 years ago to

01:54:13 of November 2010. So so 11 years ago to the day today. And it was a 10 pump fire in Popla.

01:54:17 in Popla. It was. Yes. Uh and I think you were in attendance on the night of the fire. I did. I was the control duty manager and I did attend. Yes. Yes. Do you recall that there were 17 FSG calls received at that fire?

01:54:29 FSG calls received at that fire? No, I don't believe there were. You don't believe there were? No.

01:54:35 I believe there were 17. There may have well have been 17 calls, but not 17 fire survival guidance calls. And the reason I put 17 to you is

01:54:46 And the reason I put 17 to you is there's a document which suggests it. That's LFB00109485.

01:55:01 And this is this is a a draft of polic of draft 155. uh uh and if we go in that which is I think then circulating

01:55:13 think then circulating uh and if we go to that

01:55:18 page three you'll see in page three there's a comment um

01:55:25 um uh inserted on the 14th of February 2011 by someone called Nickel uh and it's at the foot of the page. We'll need to blow it up. It's in the

01:55:36 We'll need to blow it up. It's in the blue bubble, the last blue bubble. Ah, and the reason I say 14th of February 2011 by nickel is at the end in the amendments part for those who want to see it. But if you look and see what he

01:55:48 see it. But if you look and see what he says in the bubble, he says this. Uh, at a recent 10p in Docklands, over 17 FSG calls were being processed. A dedicated officer was provided with a CU for this

01:56:00 officer was provided with a CU for this specific purpose. It might be prudent to mention the allocation of appropriate resources to allow the dedicated officer to carry out this function. Now leave aside the draft of the policy for the

01:56:11 aside the draft of the policy for the moment. We'll come back to that later in due course. But just on what what is said in the bubble there, uh do you disagree with what the

01:56:22 uh do you disagree with what the commenter there has said about the number of FSG calls being processed at that fire? I do. Yes. Why? Why do you disagree? because I was in the control room at the time um and attended uh or would have been involved.

01:56:35 attended uh or would have been involved. I think I must have talked to uh the officer in charge of control at the time, Keith Diamond, and discussed that. Um I didn't have any reports of 17 fire

01:56:47 Um I didn't have any reports of 17 fire survival guidance calls coming into control. I didn't witness 17 fire survival guidance calls. I don't believe there were is a record of 17 fire survival guidance calls. How many do you think there were?

01:56:59 How many do you think there were? uh from a vague recollection um potentially four not concurrent. I think two of them were concurrent and lasted

01:57:10 two of them were concurrent and lasted um maybe 45 minutes and one an hour. Um however

01:57:16 however that whole time they weren't um providing FSG advice. They provided FSG advice in the initial phases but then I believe stayed on the phone to just

01:57:28 believe stayed on the phone to just offer reassurance to the caller and and that took up a great deal of the conversation.

01:57:38 Uh can I ask you please to be shown Peter Cowup's evidence at day 195?

01:57:48 Uh, and I'd like you please to be shown page 101 in that. It's a transcript for his evidence to the inquiry.

01:57:59 to the inquiry. And he says at line 13,

01:58:05 it's p page 195. Line 13.

01:58:11 Line 13. Uh so the incident I attended was in popular and we had 36 calls and that was prior to the policy being in place and he's talking about 790.

01:58:22 in place and he's talking about 790. Uh

01:58:24 Uh and then it goes on uh are you able to help with the number 36 there? No.

01:58:35 You don't you don't know you don't recall 36 being the number of calls either FSG or otherwise? No, I I don't recall that. Um and I would say just in terms of uh our

01:58:48 would say just in terms of uh our experience of the control room, um it was a hotel fire. It was lower down in a kitchen. Um I would be surprised that we received 36 calls to that incident.

01:59:03 Uh, can we then look at LFB0110785?

01:59:17 This is an email on the 12th of November 2010. If you look at the foot of uh page two, I think you'll need to scroll to that. Page two, please. Foot of page two

01:59:28 that. Page two, please. Foot of page two and over to the top of page three. 12th of November 2010 from Andy Hickmouth to Scott Haywood, Dave Brown, and copy to Peter Cow, Richard Dexter,

01:59:40 and copy to Peter Cow, Richard Dexter, and Ron Dobson. Scott Dave, it says, and then over the page on page three, he says, "With regards to last night's 10pf, as I'm sure you've been made aware, this was a particularly challenging incident for control given

01:59:51 challenging incident for control given the number and nature of fire survival calls they handled, some of which went on for an over an hour. Despite the pressures, the way the information was passed to the fire ground, enabling searching and in some cases rescues to

02:00:02 searching and in some cases rescues to be undertaken seemed excellent. I visited control after I left the incident about 3:00 a.m. and thanked Keith D and his staff and his staff for all their efforts. It seems some of them really earned their money last night and you may wish to look into whether it

02:00:14 you may wish to look into whether it deserves formal recognition. Thanks Andy Hickman, assistant commissioner. Can you explain why it was a particularly challenging incident for control given the number and nature of our survival calls? as Andy Hickmouth has recorded

02:00:28 calls? as Andy Hickmouth has recorded there.

02:00:29 there. I can't know. I was in the control room when it was occurring and I believe I was in the control room when Andy Hickmot came right

02:00:37 right to visit as well. Um, in terms of capacity uh we had sufficient capacity in the control room for that night. In

02:00:48 in the control room for that night. In fact, as I said, the the the two calls that went on for uh a duration of approximately an hour um were because we had such capacity and we could uh they

02:00:59 had such capacity and we could uh they could afford to stay on the phone providing reassurance to a to some callers. So, I would imagine the initial um

02:01:08 um volume of calls um and dealing with an incident that was a 10 pump fire. So all the subsequent actions and makeups that control would have had to have done might have made it challenging. I'm not

02:01:19 might have made it challenging. I'm not sure what other incidents were going on in London at that time as well. I I can't recall um from that incident, but that may have added to that right

02:01:28 right as well.

02:01:30 as well. So do you disagree with Andy Hickmouth's statement that this was a particularly challenging incident for control given the number and nature of our survival calls they handled? Um I I think it was

02:01:43 calls they handled? Um I I think it was a challenge uh for them in in terms of ensuring that they were gathering the right information um and providing the right advice to call users and then relaying uh all that information to the

02:01:56 relaying uh all that information to the incident ground. Right.

02:02:02 Was that was that incident to put it colloquially all in a night's work?

02:02:08 work? I would have thought some operators and control staff would have thought that was all in a night's work. Yes. Can you explain why it was given that that

02:02:17 that Andy Hickman thought that that you ought to have some kind of formal recognition? Um I think it reads there that actually the the information that we passed to

02:02:28 the the information that we passed to the fire ground appeared to be excellent from his point of view. So that would have ensured that we had provided the right advice and guidance

02:02:40 provided the right advice and guidance that we had um collected all the information and passed it down to the instant commander enabling them to do their role. Getting it right all in a night's work isn't normally something that deserves

02:02:53 isn't normally something that deserves formal recognition, formal um praise. Does is it? No. And uh and as I said, I would have thought some control officers would have thought that that was all in a night's work and playing the role and maybe

02:03:04 work and playing the role and maybe others wouldn't. Maybe um Keith Diamond would have thought it was particularly challenging at points and deserve some recognition. I I don't know. I I don't I

02:03:15 recognition. I I don't know. I I don't I can't recall. There was nothing that Andy expressed to me on the night. Um but did say well done. Can we look at another email about this incident at LFB3033213?

02:03:33 Uh, this is an email from you on the 30th of November 2010 about that incident and you say, "Hi, Scott. I've asked Red Watch to carry out a debrief of this incident in anticipation of a

02:03:44 of this incident in anticipation of a PRC where we can either attend or feed back information relating to the communications. I imagine the outcomes from the PRC then being looked at in line with FSG work and any recommendations being then being taken

02:03:55 recommendations being then being taken to the board for approval. As I was in attendance on the night and I have already taken some relevant issues and discuss them with Pat at last week's meeting, it really is the information flow that Pat and I are working on. So

02:04:07 flow that Pat and I are working on. So it looks as if you did attend the debrief with Redwatch. Is that right? Uh yes.

02:04:13 Uh yes. And did you feed back information in relation to communications? Yes, it reads like I did. Yes. Do you remember what you fed back? No. Um but I I think just from reading

02:04:27 No. Um but I I think just from reading the two emails that the the communications from control to the incident grounds um were suitable and sufficient and was received positively. Um my

02:04:40 Um my reference to the information flow that Pat and I are working on probably meant that that was successful. Um and maybe we talked about maybe during that incident there were was information

02:04:51 incident there were was information received back from the CU2 control as well on progress of the incident and what was happening. I can't recall. Do you remember whether you fed anything back in particular about the number of FSG calls?

02:05:03 FSG calls? Uh I would think um just on um that initially people array had had raised the issue that there were 17 FSG calls

02:05:14 the issue that there were 17 FSG calls and then after the PR PRC had been held and that actually um there wasn't any further work on dealing with a large number of FSG calls like that that we

02:05:25 number of FSG calls like that that we may have clear clarified the number of FSG calls we received. Was there a performance review of command? Uh potentially, but I'm not sure. Um

02:05:37 Uh potentially, but I'm not sure. Um control were at that point invited regularly to PRC's. I could be wrong. Right. Um

02:05:45 Right. Um now let's look at um NFB033654.

02:05:54 This is a spreadsheet from the incident monitoring database. If we can have that in native form, please.

02:06:06 LFB033654.

02:06:17 And if we scroll down to line 34 and the date of the incident, 11th of November 2010, we can see the incident number.

02:06:30 at 1 191579101. You look and see that on the screen. That that's the Marriott Hotel temple fire.

02:06:41 fire. Uh and uh if you look across to column V, you can see some comments and it says bottom right hand corner of your screen, identified need to

02:06:53 your screen, identified need to systematically manage fire survival calls, appointed dedicated SM to deal and provided command support and resources in the form of an additional CU and appliance crews. Were you aware

02:07:05 CU and appliance crews. Were you aware of that identified need to quote systematically manage fire survival calls close quotes? No, I don't think um from my personal experience I didn't have uh access or

02:07:17 experience I didn't have uh access or receive comments from the IMP database until my return um from CFR in 2015. Right. I mean this is almost two years

02:07:28 Right. I mean this is almost two years before you left for CFOA. Did anybody feed back to you on as a result of this incident in November 2010 the need to systematically manage fire

02:07:39 the need to systematically manage fire survival calls? Uh no like I say I don't think control ever saw or were asked to comment on IMP entries um before 2015 maybe uh 2014

02:07:51 entries um before 2015 maybe uh 2014 when I was array that happened. Um but certainly the result of that so an SM and an additional CU and appliance crew um we were notified of because we

02:08:03 um we were notified of because we obviously had to then adjust our mobilizing system. Um I follow

02:08:08 I follow to take account of that. So is I follow. So nobody identified. Well, let me let me ask it this way. If the need to systematically manage fire

02:08:19 need to systematically manage fire survival calls was a need identified arising out of some kind of defect or deficiency in the the control room and the handling of the calls in the control room, would you have expected that to

02:08:31 room, would you have expected that to have been fed back to you? Yes. Um but in honesty uh I wouldn't have expected an operational performance of command uh to raise any actions that

02:08:43 of command uh to raise any actions that happened in the control room and that I am taking as an operational action which is why uh they've requested that they've suggested a command support vehicle and

02:08:54 suggested a command support vehicle and um staff

02:08:56 um staff right

02:08:56 right be added in addition although this is not your document and you didn't see it at the time is the is in your experience given that you were in the control room at the time. Is the fair way of reading that that that is a

02:09:07 fair way of reading that that that is a that is a a criticism of the handling of fire survival calls on the incident ground?

02:09:15 ground? Uh um yes, management of the information that we were passing to them.

02:09:31 Uh there's another event I want to ask you about which is in the February 2011. Can I ask you please to be shown LFB 3090336.

02:09:48 This is an email chain entitled FW for recent

02:09:53 recent recent high-rise incident 05022011 [Music]

02:09:59 [Music] from John Simpson to Peter Cowup. You were not copied in on it and I'm assuming you wouldn't have seen it at the time. Um but he says this at the incident on Friday when I responded to

02:10:10 incident on Friday when I responded to paging control told me that there were five fire survival calls in progress. So on arrival, I detailed an SM to gather information from control and others about number, location, and circumstances in order that I could

02:10:21 circumstances in order that I could accurately direct firefighting crews to their location to assist those in need. Uh now,

02:10:30 Uh now, do you remember that incident? No, I don't. I think you were on duty during that 24-hour period, and we can see that um from the documents below that. Let me

02:10:43 from the documents below that. Let me just let me just make that good for you. If you go down to page three, we can see the daily bulletin for Saturday the 5th of February 2011. The bottom of the page over to page four at the top it says

02:10:56 over to page four at the top it says duty officers for the 24 hours. Uh and I think I'm right in saying that's up to that point, isn't it? Uh no, sorry. Could you go back? The daily bulletin you've shown was for

02:11:08 daily bulletin you've shown was for Go back to the bottom of page three. the fifth

02:11:10 fifth RMC information bulletin has at 800 hours Saturday 5th of February 2011. Yes.

02:11:16 Yes. And then over the top onto page four it says duty officers for 24 hours. Yes.

02:11:23 Yes. Um do I take it that it's the 24 hours up to that time. So from the 5th to 0800 the next morning. Oh I see. Of the six.

02:11:34 morning. Oh I see. Of the six. I see. So this is actually the duty officers coming on as o on the uh the Saturday morning of the Saturday the 5th of February not going off after 24 hours

02:11:45 of February not going off after 24 hours if I follow. Nonetheless, are you able to recall details of of that incident where there are five survival calls in progress? No. And like I say, I I I appreciate I might have been on duty for the fifth

02:11:57 might have been on duty for the fifth and sixth, but I don't recall You don't recall this incident? No.

02:12:01 No. You don't recall any learning or feedback or anything of the kind? Nonetheless, no.

02:12:06 no. No. And

02:12:08 No. And as my role, I probably would have if we'd had that and I'd experienced that, I would have spoken to the the control commander and we would have had had a debrief. So, I'm not convinced. The fire was on the 5th, was it?

02:12:26 Well, the incident was on I think the the uh the 4th, the Friday the 4th. because I'm I'm going off the email I showed you. Oh, okay.

02:12:36 Oh, okay. So, I I don't know the answer to your question. Um but um if it is correct, taking the email on page one that I read to you that there were five survival calls in progress.

02:12:49 calls in progress. Uh

02:12:51 Uh is that not something that you would have expected to have found out when you did come back onto duty whenever that was after that date? I'm sure it would have been discussed,

02:13:02 I'm sure it would have been discussed, but if I if I wasn't on duty, then the duty brigade control manager would have dealt with that and raised any issues. That's that's how we worked. Any one that picked up an incident who was the

02:13:14 that picked up an incident who was the duty and that would have attended or been notified by patrol would have dealt then with the immediate issues. Can we then look at LFB00111471?

02:13:32 This is a draft of fire survival guidance calls policy uh 790 which at that time had been accorded the new policy number draft

02:13:43 accorded the new policy number draft 155.

02:13:45 155. Uh and this is the version current as the 10th of February 2011 still in draft form and you made comments on this document.

02:13:54 document. Uh if we go down to page five and look at paragraph 7.10 10. We can see what that draft paragraph says. 7.10 says the IC should consider the

02:14:06 7.10 says the IC should consider the early ordering of additional CU to assist in managing the FSG calls, especially if control is dealing with multiple FSG calls. Other personnel may be required to manage information if a large number of FSG calls have been

02:14:18 large number of FSG calls have been received. Control has experience of handling multiple FSG calls relating to a single incident. And then you can see a um deletion

02:14:31 And then you can see a um deletion uh

02:14:34 uh on the right hand side next to that where the words up to five have been deleted. You see that? Yes, I can. Uh, and I if you go to page

02:14:45 Yes, I can. Uh, and I if you go to page 14,

02:14:53 you can see uh that on the 1st of June 2011

02:15:04 on the 1st of June 2011 as the third entry down Stard J inserted multiple and deleted up to five. You see?

02:15:15 and deleted up to five. You see? Yes,

02:15:16 Yes, that was you doing that, was it? I would imagine. So, it shows my name. Why did you delete up to five and insert instead multiple?

02:15:29 instead multiple? I don't know. What was wrong with up to five? Uh, reading about it now, nothing. I I'm not sure if previously when we'd been

02:15:40 not sure if previously when we'd been changing documents, we'd been asked to put multiple or and not put a figure on it. So, I don't know.

02:15:50 At the time, you were assisting with the drafting of PN155, sorry, PN790, draft 155.

02:15:57 155. Did you have any discussions at that time, this would be now June 2011, with anybody about what was meant by the term multiple FSG?

02:16:09 Uh I think we had frequent discussions um myself and Pat and uh others um

02:16:21 others um throughout the lack investigation and whilst we were looking at uh policy 790 as well. Was there a consensus between you and

02:16:34 Was there a consensus between you and those with whom you were discussing the the potential numbers of FSG calls about what multiple meant? No, I I I

02:16:45 No, I I I don't believe so. Um and I think that actually uh we have uh a procedure in London control where we send additional attendants to multiple calls. Um and at

02:16:58 attendants to multiple calls. Um and at that point that was three. So we were familiar with a term of multiple meaning more than three. So perhaps that's when it it came in we used the same definition.

02:17:16 Why did you think it meant two or three when as we've seen there were incidents in the previous year a and at the time the Hgate challenge which contemplated

02:17:30 the Hgate challenge which contemplated more than three. So we've seen the four at Hgate Challenge which happened the same month June 2016 uh 2011. We'd seen um five perhaps at one incident which

02:17:41 um five perhaps at one incident which you can't recall in in the February of that of that year. and uh we'd seen uh four I think as you told us uh at the Marriott fire even if not 17. Why were

02:17:55 Marriott fire even if not 17. Why were you sticking to two two or three or your multiple?

02:17:59 multiple? I don't think I personally was sticking to anything multiple as I said a concept in LFB control is that we mobilize uh additional attendants on what was then

02:18:11 additional attendants on what was then um three calls to an incident. So perhaps and that was known as multiple calls and a multiple call attendance. So perhaps that's where conceptually LFB got

02:18:24 conceptually LFB got just used that as a term but in in my opinion multiple um not being specific and just putting multiple would acknowledge that we could receive up to five.

02:18:36 five. Now um taking a slightly sideways step, do you remember that G the revised version of GR 3.2 two was published by the DCLG

02:18:45 the DCLG in February 2014. No, I don't. You don't. Do I take it from that that you uh were not aware of it when it came out?

02:18:54 out? No, I wasn't aware of it when it came out. Um a and when I returned from LFB wasn't aware of it it existence and during uh the seminars we'd run with

02:19:05 during uh the seminars we'd run with national control room managers uh it hadn't been mentioned in any of those either when we were talking about national guidance for control. Do I take it that

02:19:16 Do I take it that [Music]

02:19:17 [Music] at at no stage, is this right, at no stage before the Grrenfield Tower fire did you ever have any discussion within the LFB or outside the LFB about that

02:19:28 the LFB or outside the LFB about that part of G3.2 which covered fire survival guidance calls?

02:19:32 calls? No.

02:19:39 Do you know whether anybody else to your knowledge within the LFB was any was involved in any such discussions? I don't know.

02:19:52 Can I then turn to the Adair Tower fire on the 31st of October 2015 which you mentioned as one of those fires where there had been fire survival guidance calls. First, were you involved in that

02:20:03 calls. First, were you involved in that incident?

02:20:04 incident? No, I wasn't. I wasn't the duty manager. Were you involved in any debrief after the incident? Uh, not that I recall in terms of debrief or or PRC. By that time, we were being invited to PRC. So, I I was I

02:20:17 being invited to PRC. So, I I was I don't believe I was involved in that either.

02:20:19 either. We were involved in any kind of review of the actions of brigade control as as a result of that incident. Uh, there might have been some discussion with uh either the senior operation manager that took that or the

02:20:31 operation manager that took that or the principal operations manager. I'm not sure who was on duty. We may have discussed it as a group. Um, and we may have discussed it at brigade control management meeting as well with the

02:20:42 management meeting as well with the operations managers. Are you aware of how many FSG calls were handled at that incident? Yes, I am. How many was that? Uh, I believe there was six.

02:20:53 Uh, I believe there was six. You believe there were six? Yes.

02:20:56 Yes. Uh now let's just look at the debrief proformer for the incident at LFB30's 35092.

02:21:09 Here it is. And if you go to page two, you can see what incident this was. It's it's Adair Tower identified. The date of

02:21:20 it's Adair Tower identified. The date of the debrief is 31st of October 2015. The same date as the incident. Have you seen this document before? Uh, not that I can recall. No. If we go to page two, uh, we're on page

02:21:33 If we go to page two, uh, we're on page two. You can see number of calls 24. Do you see that? And then on page five in the left hand column,

02:21:43 it says uh, between 0854 and 9008, nine FSG calls dealt with along with 15 other calls to premises. You see that? I do. Yes. Have you any reason to doubt

02:21:54 I do. Yes. Have you any reason to doubt the accuracy of those figures? Yes, I have, cuz I recently listened to the calls from that incident. And what is it about listening to those calls that gave you to doubt the accuracy of those figures?

02:22:07 accuracy of those figures? Because I could listen to the exchange of information between the operator and the control and and the caller um know when they were giving fire survival guidance.

02:22:21 And a number of those calls where that was occurring, uh, control officers were providing reassurance

02:22:30 and not fire survival guidance. And I think that's probably that's not a purposeful error. Um, but I would imagine if this was completed on the day as well that actually um,

02:22:42 the day as well that actually um, supervisors may not have had time to listen to and record all of them. I think Scott Haywood said in his evidence that sometimes um whilst they were categorized as an FSG call uh because

02:22:54 categorized as an FSG call uh because the superood FISA would record that as that sometimes they weren't giving FSG uh advice and guidance um but there was a period of reassurance going on and

02:23:05 a period of reassurance going on and just information gathering from the caller.

02:23:08 caller. Right. That answer tends to suggest another question which is is it right that whether or not a call

02:23:19 is it right that whether or not a call is an FSG call depends on interpretation. It depends on the exercise of judgment about the content of the call.

02:23:31 about the content of the call. No, I would say that it very much depends on what the caller is infor telling the control officer

02:23:46 and you listened to those calls and decided did you that based on what the caller was telling the control officer they didn't count or some of them three of them didn't count as FSG calls properly so called

02:23:58 properly so called based on what the caller was telling the control officer and what the control officer and how the control officer was speaking to the caller. So, somebody made an an error in

02:24:09 So, somebody made an an error in identifying nine when they should have said six.

02:24:13 said six. Yes. And I as I was trying to say if this was completed on the actual day of their their duty, maybe they hadn't got round to listening to those all those

02:24:24 round to listening to those all those calls in detail. that would suggest that the identification of a call of as an FSG call uh wasn't fully embedded in the brigade at this time. By which I mean

02:24:35 brigade at this time. By which I mean that that the identification of of a call of as an FSG call was something that not everybody could do accurately. Uh I I think that during the incident

02:24:47 Uh I I think that during the incident and that was a large incident and there would have been um I think there's a number of calls received as well as there or other 15 calls to a premises um it would have been very hard uh for a

02:24:59 it would have been very hard uh for a supervisor to determine that. They would have relied on the control officer as we usually do to make them aware of it um so they could provide support and and gather some further information. So by

02:25:11 gather some further information. So by the time uh a supervisor or an operations manager would act the instant was finished and would actually get down to listening to the calls in full then that might have been amended.

02:25:22 that might have been amended. In fact I think AOM Norman was at the debrief

02:25:28 and and indeed as you could see from the page had entered control and assisted the supervisory team. She is a pretty experienced AOM isn't she? She is. Yes. Well, she even then was in

02:25:40 She is. Yes. Well, she even then was in 2015. Yes. Yes.

02:25:42 Yes. Yes. So, she would know the difference between an ordinary call and an FSG call. No.

02:25:48 call. No. Yes.

02:25:48 Yes. Yes. Uh if we look at the bottom, well, we don't need to. I I think you would agree that even at six that was a multiple FSG situation. Yes.

02:26:00 multiple FSG situation. Yes. Yes. I would have agreed that at three calls. Yes. Yes. Now looking at the incident debrief form

02:26:08 form uh and I know you haven't seen it all um but one gets no sense from it that nine FSGs or even six FSGs was out of the ordinary nor the fact that for many CRO

02:26:20 ordinary nor the fact that for many CRO this was their first FSG call. One gets no sense that this presented any particular practical problem. Uh I mean take it from me that there's nothing in there that does that. This isn't

02:26:31 isn't uh a completely out of the blue unusual event.

02:26:35 event. Well, I I would just like to say on that through phase one and and this evidence uh specifically some control officers have mentioned ED tower and that would

02:26:46 have mentioned ED tower and that would um imply to me that actually this was a significant incident that was out of the ordinary and didn't take place on a a regular basis. uh it wouldn't have taken place on a regular basis, but would it

02:26:58 place on a regular basis, but would it be right at least that as at the 31st of October 2015 when this incident took place, control would not only have regarded nine or six, it doesn't matter.

02:27:09 regarded nine or six, it doesn't matter. FSG calls as unthinkably unrealistic, but actually considered such a possibility well catered for. Uh looking at the time that that

02:27:20 Uh looking at the time that that occurred between 8:54 and 9:06 we would have had um 15 staff on on duty. Um we might have had um and

02:27:31 on on duty. Um we might have had um and also some of the training or OST uh to support us. So I would get the impression from just reading this little bit that it was it was

02:27:42 little bit that it was it was manageable. But like I say, I wasn't the the on call duty brigade control manager. they would be able to provide you with a bit more detail.

02:27:52 Can we look at LFB0035109?

02:28:18 This is an email from Keith Diamond to Liz Himms on the 2nd of November 2015, a few days after uh the the Adair House, sorry, the Adair Tower incident. And we

02:28:29 sorry, the Adair Tower incident. And we can see a brief summary of the incident in the text. And four lines down it says uh Tony Biles uh who's the person who's speaking

02:28:40 uh who's the person who's speaking states the incident was very dynamic in the early stages and without the work undertaken by the control officers it may well have resulted in a number of fatalities as it was 50 persons were

02:28:51 fatalities as it was 50 persons were rescued 24 through FSG by control and 26 through onseen advice and rescue by operational crews. Remarkably, injuries were kept to a minimum and of a more minor nature.

02:29:04 minor nature. Now, even though the figure there appears to have been more like nine FSGs or six as you say through having listened to the calls instead of the 24 here, would you agree nonetheless that

02:29:16 here, would you agree nonetheless that by this stage, late October, early November 2015, you and and the NFB brigade control were well aware that an incident could

02:29:27 well aware that an incident could certainly result in well more than two or three FSG calls. Yes, I I the 24 might be referring to 24

02:29:38 Yes, I I the 24 might be referring to 24 individuals though. Um so even though we took uh six FSG calls, there may have been more than one occupier in that flat. Therefore, that's where the 24

02:29:50 flat. Therefore, that's where the 24 would have come from. Right. Well, we've got a range of numbers, I think, between your six and the 24 in this email and the nine in the debrief document we've seen.

02:30:02 debrief document we've seen. uh even allowing for um differences in how one arrives at those numbers. Nonetheless, did the Adair tower fire prompt you to review any of controls FSG core management

02:30:15 any of controls FSG core management systems?

02:30:19 No, not at all. So, I think that is that email from from Keith is is a positive outcome. um as were the assistants in in

02:30:32 outcome. um as were the assistants in in the debrief and I didn't see all the comments that that staff had made in the in the debrief but I I get the impression from this that it whilst it was challenging it was manageable um

02:30:45 was challenging it was manageable um there's no uh suggestion that control reached capacity um and calls weren't being able to received or we couldn't deal with anything that the instant had

02:30:56 deal with anything that the instant had required and had asked asked us for and that information about those callers were passed to the incident ground successfully. In a nutshell, does that tell us that

02:31:07 In a nutshell, does that tell us that the successful outcome of this incident meant that it there were no lessons to be learned from it for the future? No, I'd I'd have to look at the the

02:31:18 No, I'd I'd have to look at the the debrief um and maybe that the a conversation after um we had attended the PRC might have

02:31:29 we had attended the PRC might have raised some some additional learning points as well. At any rate, no learning points that prompted you to review controls FSG call management systems or training for

02:31:40 management systems or training for control room officers or supervisors? Uh, no, not personally. Again, I didn't attend the debrief, so I would have expected to be informed had there been anything.

02:31:53 Yes, Mr. Chairman. Is that a convenient moment?

02:31:56 moment? Yes, I think it is. Thank you very much. Well, it's uh time we stop for the day, Miss Smith. I'm afraid I'm going to have to ask you to come back again on Monday of next week to continue your evidence, but I think you were probably expecting

02:32:08 but I think you were probably expecting to do that. I was. Thank Um, and we'll resume there for 10:00 on Monday, please. And over the weekend, please don't talk to anyone about your evidence or anything relating to it. No.

02:32:19 to it. No. All right. Thank you very much. Would you like to give the usher then, please?

02:32:33 Thank you very much. 10:00 on Monday, please. Thank you.