Evidence from LFB Assistant Commissioner Andrew Brown on Policy Note 539 (fire survival guidance), reassessment procedures, compliance with national guidance, and the brigade's response procedures following the Lakanal House review.
00:00:28 hmm would you ask mr brown to come back in please okay
00:00:43 right mr brown ready to carry on yes thank you sir good thank you very much yes mr kennedy thanks sir good afternoon again mr brown good afternoon we were looking uh before the break at the latino control report could we go back
00:00:55 latino control report could we go back to that and paragraph 295 again which we find h0m quadruple zero double one two four four slash fifty
00:01:11 now obviously the report was published a few months before the exchange with richard dexter that we were looking at before lunch can we look um under the heading assessment and reassessment of the call
00:01:22 assessment and reassessment of the call caller again and in particular the fourth line which and the sentence which starts with the word moving to what it says there is moving to protect advice with the intent of keeping the
00:01:34 advice with the intent of keeping the caller safe may not always be the best solution and the calls should be continually reassessed there may be a tendency to limit reassessment due to the protect ethos now we know that the reassess guidance
00:01:47 now we know that the reassess guidance in pm539 was not revised before the grenfell tower fire are you able to help us as to why pn 539 and the reassess or rather the
00:01:58 pn 539 and the reassess or rather the reassessed guidance was not reviewed and revised before the grenfell fire
00:02:05 i can only offer an opinion if you can't speak to a fact then well um
00:02:13 well um tell us what you want to tell us and then we'll see where it takes us my opinion is that the the belief was that the reassessed terminology in there that we looked at
00:02:25 terminology in there that we looked at earlier
00:02:26 earlier was considered sufficient and brigade staff be they control or operational staff would always have in their mind about the need to reassess
00:02:39 their mind about the need to reassess be it continually or otherwise so it was implicit in it would be my opinion yeah thank you
00:02:45 thank you now if we can stay with this page and just look at the top
00:02:49 top really i've got in mind paragraphs 293 and 294
00:02:57 293 the paragraph entitled expectations that callers would be rescued and stay put advice
00:03:03 advice below that in 294 escape alternative escape routes did you ask anyone from control to review pn 539 and the rifts against
00:03:14 review pn 539 and the rifts against these other conclusions which are set out in the control report
00:03:20 not specifically my my understanding was these would be part of the general review
00:03:27 review and caught up in the generality yes can we turn to a separate issue which is uh
00:03:37 uh non-compliance with national guidance and sense of failure to warn against providing false reassurance or apparent non-compliance if i can put it more neutrally can we return to your comments of january 2013 on the
00:03:48 comments of january 2013 on the lindridge review which we find at lfb trouble zero eight five eight five four four slash thirteen
00:04:04 thank you and on page 13 we see action 10 dealt with and below that against the review process findings box it says this
00:04:16 it says this pn539 has been reviewed as a result of this action and does not contradict fsc 1093
00:04:24 1093 looking at the corresponding comment box on the far right hand side the deputy commissioner asked this but does it comply and you respond in bold and in red this
00:04:37 and you respond in bold and in red this yes it does and on that basis this action has been discharged on what basis did you assure the deputy commissioner that pn539 was
00:04:49 the deputy commissioner that pn539 was in fact compliant can i just read the reminder of the comment please of course
00:05:00 so
00:05:13 the basis on which i constructed that comment
00:05:17 comment was on
00:05:19 was on assurances that i had on two fronts one from the lack of the health ball that scott attended in the discussions with scott hayward but then also following
00:05:29 following my
00:05:30 my uh instruction to richard in terms of satisfying himself and the positive reaction i got from both of those was the basis on which i made that statement
00:05:41 statement if we can stay in this particular paragraph of the review process findings if we could go four lines down it says this whilst it could be argued that pn539
00:05:55 whilst it could be argued that pn539 does not contain all of the information the national guidance it should be noted that the format of the national guidance the detail is in the form
00:06:03 the form of a training package does not lend itself to a methodical approach can you help us as to why national guidance did not lend itself to the
00:06:14 guidance did not lend itself to the methodical approach
00:06:18 well understanding was that national guidance particularly 1093 was some
00:06:25 was some best part of 20 years prior to when we were making these comments and the methodical approach that we'd moved to
00:06:35 to in our approach for fire survival guidance calls in the london fire brigade it had somewhat moved on from what this guidance was saying now in the corresponding comment box
00:06:47 now in the corresponding comment box that rita dexter asked and we can't find a way to rise above that and you replied possibly textually yes and we are
00:06:58 yes and we are what way
00:06:59 what way which you didn't necessarily reveal to rita dexter here had you found to rise above the
00:07:05 above the methodical deficiencies of the national guidance
00:07:09 guidance that was purely on two fronts firstly the training we were giving to staff the fact that we were moving towards
00:07:19 towards command unit training as a result policy note 790 which was one of the other recommendations in here and also the resource information reference information files that
00:07:30 that staff were instructed to follow routinely with all fire survival guidance calls after lacking all and those files that have been revised
00:07:43 now you see in the bottom of this box the question what is the conclusion here have we discharged the action in word and spirit or not
00:07:55 and spirit or not now on my reading that appears to be another comment from rita dexter is that right
00:08:03 right and that your reply follows this time in emboldened orange
00:08:11 i i don't know whether that is rita or myself looking at the attached actions it would seem logical that is but but i don't know for sure whether that is rita's comment and my response let's
00:08:23 is rita's comment and my response let's assume it is uh you replied my view is that yes it is discharged in word and spirit question mark now assuming that question mark um is a mistake
00:08:34 is a mistake so far as you are concerned was it your view that pn539 complied with the letter of 1093 and achieved its purpose that's to say to enable cross to assess a situation and to give appropriate advice
00:08:47 situation and to give appropriate advice on that basis yes now can we explore that a little further and could we start with page 16 of the version of pn539 that was in then in force which we can
00:08:58 that was in then in force which we can find at lfb double zero double one double three nine four forward slash sixteen
00:09:09 appendix 3 again and if we could look at the middle of this page
00:09:15 this page and the third bullet point which says this provide reassurance to the caller that help and assistance is forthcoming and then if we can go again to the
00:09:26 and then if we can go again to the fourth line from the bottom which we looked at before lunch which says reassure the caller now
00:09:36 now if we can now go to fsc 1093 which you can find at lfb quadruple zero three six one seven
00:09:50 looking at page one and paragraph two the last sentence of the latter says this additionally in circumstances such as
00:10:01 additionally in circumstances 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
00:10:14 in some circumstances and if we can also turn to lfb double00118948
00:10:27 now this is the training note which is properly called keeping people safe i think sometimes it's called making people safe in in correspondence but if we can turn to page six
00:10:42 we see in the right hand column the second paragraph says this if that could be amplified attempt should be made to reassure the caller without promoting a false sense of security
00:10:55 false sense of security now bearing in mind that keeping people safe was intended to supplement 1093
00:11:01 1093 would you accept that pn539 did not warn against the dangers of reassuring the caller
00:11:08 caller would you like to go back and see pm539 uh yes please if we go back to that uh which is at lfb double zero double one double three nine four forward slash
00:11:21 double three nine four forward slash sixteen
00:11:30 and what i was looking at before the third bullet point on the page and going further down four lines from the bottom reassurance so just looking at those
00:11:41 just looking at those bearing in mind 1093 and keeping people safe would you accept that pm 539 did not warn against the dangers of reassuring the caller if i can give a caveated answer to that
00:11:54 if i can give a caveated answer to that i would accept that it isn't explicit in terms of making it clear of the dangers of reassurance as in 1093 however the caveat i would add to that
00:12:06 however the caveat i would add to that is
00:12:07 is that the the reference information file and the training that control staff got i think made it clear that there's
00:12:17 there's a selection of phrases that one can use in terms of talking to the caller some of which would be reassurance and if used in the wrong
00:12:28 reassurance and if used in the wrong situation could be dangerous but the training that control staff get is you know only use those phrases as in when applicable and particularly after leckanel
00:12:40 looking back at the the unqualified assurance that you appear to have given rita dexter would you accept that essentially the pm539 complied both the
00:12:52 essentially the pm539 complied both the letter and spirit of the government guidance in particular 1093. that unqualified assurance was misplaced
00:12:59 misplaced i suppose
00:13:02 i suppose in
00:13:03 in looking at this in reflection the the phrase word and spirit was probably stretching it probably in word was was an incorrect uh
00:13:13 uh you a
00:13:14 you a choice of words but in spirit i would i would still maintain that in spirit yes it did mate can i now turn to a separate distinct topic which is pm 539 and the relevant
00:13:27 topic which is pm 539 and the relevant equality impact assessment now if we
00:13:32 now if we look at the version of pn539 which was reviewed as current on the 28th of march 2014
00:13:40 2014 and which was the version in force on the 14th of june 2017 that can be found at lfb
00:13:47 at lfb quadruple zero zero seven three seven
00:13:58 and if we turn to page twenty two
00:14:05 you see just coming down from the top there's a heading audit trail and we can see the content of that box shows that the policy was amended on a number of
00:14:16 policy was amended on a number of occasions between june 2010 and april 2017. is that a fair reading of what's set out there yes
00:14:28 what's set out there yes now if we can look at the heading assessments which i think is at the top of the page and has been lopped off thank you
00:14:36 thank you and the table immediately below that we see the initials eia they stand for quality impact assessment is that right that's correct and the date next to that is the 17th of september 2008 is that
00:14:48 is the 17th of september 2008 is that right that's right yes now you were the policy owner of pn539 do you accept that in your capacity as policy owner it was your responsibility
00:14:59 policy owner it was your responsibility to ensure that an eia was carried out to confirm that amendments of the policy did not discriminate against anyone and indeed promoted equality were necessary absolutely yes it was my
00:15:10 were necessary absolutely yes it was my responsibility are you able to help us therefore as to why no equality impact assessment was carried out completed after the 17th of september 2008.
00:15:22 september 2008. yes uh if if i can just briefly explain when
00:15:28 when when all the various notes in the fire brigade were transferred to policy notes in a way to try to rationalize all the different instruction policies we had in london fire brigade which would have
00:15:40 london fire brigade which would have been around the 2008 equality's impact assessment was carried out on all of them at that point and thereafter they weren't root inequalities impact assessment wasn't
00:15:51 inequalities impact assessment wasn't routinely carried out every time the policy was renewed or refreshed it was as and when something was included that was felt that an eia would be
00:16:03 that was felt that an eia would be necessary
00:16:05 necessary and
00:16:06 and i don't believe that we determined an eia to be necessary at the three-year review in 2010 or 2013. certainly looking back now
00:16:19 or 2013. certainly looking back now some
00:16:21 nine years later yes
00:16:24 yes probably an eia should have been carried out at some point can you help us though as to why it wasn't
00:16:31 wasn't given the whole document was reviewed on the 3rd of september 2010 because
00:16:38 because because nothing was included at that time that felt an eia was necessary can i move on to a separate issue now which is pre-inquest action 14
00:16:51 which is pre-inquest action 14 and that concerned the review of policy 790.
00:16:54 790. um i think as we go through this 790 in its previous guys was pn155 it's working title yes now the development of pn 790 uh
00:17:06 yes now the development of pn 790 uh described
00:17:07 described uh the two-way exchange of critical information between control and the instant ground when fsg calls were incoming that's correct and
00:17:16 and the first thing i'd like to discuss with you as with all these actions is to establish the extent of your involvement and role with particular actions
00:17:25 actions now joe smith said this in a witness statement and we can go to it it's lfb double zero one two one two one nine forward slash two
00:17:44 six and looking at paragraph 69 she said this i had some involvement in the development of pn 790 with patrick utting after the latin house fire
00:17:57 utting after the latin house fire i reviewed pn 790 from a control perspective to ensure that the words and descriptions were accurate i also recommended that a change of advice given to residents in high-rise
00:18:09 advice given to residents in high-rise buildings could occur and needed to be included in the policy this work was carried out in 2011 before i was seconded to see foe pn 790 was not at that time a shared
00:18:22 pn 790 was not at that time a shared policy between operational firefighters and control now as the allocated lead officer for this particular action did you ask joe smith to carry out this work
00:18:34 smith to carry out this work no i always would have gone through scott hayward i would have had any objection with joe doing it but i wouldn't have bypassed scott and gone straight to jail i didn't bypass scotland and go straight to jail what
00:18:46 scotland and go straight to jail what was the nature and extent of your involvement in the development of pn790 i had no direct involvement in the drafting
00:18:56 drafting although the command units that were a key part of this triangulation between control the fire ground and the cooler
00:19:07 control the fire ground and the cooler were a key part of that and i was managing those so i had a particular interest in this obviously because all of my various responsibilities fitted under it at one point or other
00:19:19 point or other just following on from that point miss joe smith says in the final sentence of this paragraph that pn 790 was not at least at that time a shared policy between
00:19:31 shared policy between ops and control now if we look at the version of the policy issued on the 23rd of february 2012 and reviewed as current on the 17th of april 2014
00:19:42 of april 2014 and we can find that we don't need to go to it but it was owned by and i quote the head of instant command policy and the operations review team
00:19:54 on that description of ownership it would appear to be shared ownership that applies to that policy is that a fair and accurate reading
00:20:05 reading no i i don't think it is because i i think what joe is referring to is obviously shared between firefighters and control and the owners that you've described are
00:20:17 described are operational so i think that's what she's referring to
00:20:21 to but for as a point of all that i don't agree with what she's saying but i think that's what she's referring to so just to clear matters up did you understand the policy to be shared or
00:20:33 understand the policy to be shared or not the authorship uh wasn't although control were heavily involved in a consultation but the delivery of the policy and what the policy talked about was absolutely
00:20:44 the policy talked about was absolutely shared
00:20:46 shared i have to say i find it slightly um
00:20:50 um odd to have this concept of a policy being owned by one bit of the organization and not by another bit particularly where they're both um affected by its content
00:21:02 affected by its content does that strike you as being odd as well uh
00:21:07 uh not really sir maybe it's because i was so close to it that it didn't appear odd but
00:21:12 but but the the the ownership really is about
00:21:16 about who manages the updating of the policy so in terms of making sure it's kept current and reviewed every three years that doesn't mean to say it's only that group of staff that the
00:21:28 it's only that group of staff that the policy applies to and at the end of the day someone has to own it and then it's deciding who's best suited to own it and i i think
00:21:39 to own it and i i think that some people some members of staff look too much into who owns it and on that basis make a decision in their own mind that that therefore doesn't apply to me and that and that's completely
00:21:50 to me and that and that's completely incorrect
00:21:53 incorrect right thank you now can we go to a separate document which is lfb triple zero double three two double six
00:22:10 now this is a
00:22:12 this is a email chain and if we go to page two
00:22:18 and we see the initiating email sent by pat hutting on the 11th of february 2011 under which he sent you and others a draft of pn790
00:22:30 draft of pn790 as you say then described as pn155 when it was in development and that it was sent to you as part of the
00:22:39 the informal management consultation process was this the first time you'd seen a properly worked up draft of pn790 i believe so yes
00:22:52 did you uh review it and by review i mean scrutinize
00:22:59 no i my normal practice and i can't imagine be any different with this would be to pass it to my deputy assistant commissioners and also control for their
00:23:11 commissioners and also control for their view of it and then to feedback to me essentially to those who are better placed and closer to the detail to provide the detailed review that it required yes and
00:23:22 detailed review that it required yes and they may in turn consult some of their borough commanders for you know their their very er
00:23:28 er up close advice and following on from that answer if we can scroll up we see that you forwarded the policy to scott hayward and joe smith who's then stevards as well as som turner and you
00:23:41 stevards as well as som turner and you said as we can see here you are presumably already happy with this as you have inputted into it was that your understanding of that they had in fact contributed to this draft
00:23:52 had in fact contributed to this draft before it was circulated yeah absolutely i knew via scott that there was a close consultation going on in the development of this policy had they fed up to you the the substance of the
00:24:04 the the substance of the the drafting queries and extent of the development of the policy that they were evaluating no but they had shared with me some of
00:24:15 no but they had shared with me some of the
00:24:17 the exercises that were being put into place to test
00:24:21 to test the uh accuracy and and effectiveness of the policy were you aware though of the overall direction of travel in which the draft was
00:24:30 draft was oh yeah absolutely in terms of the you know the triangulation of uh information and the issues that come out at lac and i was absolutely yeah well aware of that if we
00:24:41 absolutely yeah well aware of that if we scroll up again please we see an email from joe smith and she said this dave i've worked closely on producing this document patrick that's utting
00:24:52 patrick that's utting to ensure it aligns with our documentation we'll get to see and discuss any suggested revisions from the consultation before published so i'm very happy with the policy so far is it fair to say on the basis of your
00:25:04 is it fair to say on the basis of your evidence thus far that given that assurance you are happy uh to effectively sign off on what had been produced by that stage yeah subject to what
00:25:14 what other
00:25:15 other information i received from my adaptations and commissioners yes and you had no separate views of your own to communicate to pat hutting at this stage no
00:25:26 can we go to another email chain lfb trouble zero quadruple three two
00:25:43 you see as her for every email chain and this inquiry the starting one is always at the bottom of the page and we see an email date of the 13th of april 2011 from michelle is it kaneka
00:25:54 april 2011 from michelle is it kaneka kaniki i think sent to assistant commissioners including you a further draft of pn790 still then described as 155 and she asked the following
00:26:05 asked the following please provide any comments or feedback you care to offer on this draft to myself
00:26:11 myself or before
00:26:12 or before on or before wednesday the 4th of may please also assess the impact of this new procedure on your department and advise what if any activities further work will need to be undertaken before
00:26:23 work will need to be undertaken before this procedure is implemented for example does this new procedure require change such as current training provision service delivery resources or further or future strategic planning
00:26:35 further or future strategic planning now if we go to the top of the page you forward this to assistant commissioner cotton as she then was
00:26:41 then was on the 14th of april copying in various others you asked assistant commissioner cotton who then was head of operational assurance to please arrange for comments
00:26:52 assurance to please arrange for comments for me from your team and asked other recipients as per a recent agreement comments to me if you wish please why were you asking assistant
00:27:03 why were you asking assistant commissioner cotton and her team for comments
00:27:06 comments uh because uh danny cotton had responsibility for the operational review team and as as
00:27:14 and as as as i imagine the inquiry has heard the operation review team would attend incidents in an audit monitoring capacity so they were a really useful group of staff in terms of seeing things
00:27:26 group of staff in terms of seeing things that were happening on the fire ground and could give an independent view so i wanted their view as to the potential success or not of this policy
00:27:37 potential success or not of this policy what was the recent agreement you were referring to there
00:27:44 i think that was as a result of discussion because the ccs were at that time my deputy assistant commissioners for the four areas and uh we discussed it at a principal
00:27:55 and uh we discussed it at a principal management board meeting and i'll be i've mentioned to them that i'd want further comments from them did you scrutinize this most recent iteration of the policy in draft
00:28:07 iteration of the policy in draft i don't believe so no did you carry out or ask someone else to carry out the task of assessing the impact of the new procedure on control and advise what if any activities for the work would be needed
00:28:19 activities for the work would be needed as
00:28:21 as miss kanuki asked
00:28:23 asked i discussed with scott how how it would work in practice not from the point of view of should we or shouldn't we adopt this policy because it was a
00:28:35 adopt this policy because it was a recommendation we'd highlighted for ourselves it was necessary and not from the point of view of do we need more staff but it was from the point of view that how would this work
00:28:46 point of view that how would this work in practice do you remember further training requirements being discussed with you by mr hayward or indeed anyone else in relation to control following from the implementation of this draft policy
00:28:58 implementation of this draft policy not further training requirements the the issue for control was of course twofold one is the fire survival guidance which there was training already in train for and then
00:29:11 training already in train for and then secondly there was the issues of passing the information that will be gathered uh from
00:29:18 uh from fire survival guidance through the command unit to the fire ground so it was those two issues that we discussed thank you i'm now going to move on to a separate distinct topic which is consideration of stay put an instance
00:29:31 consideration of stay put an instance where there are a large number of fsg calls being received now if we can first of all go to what was the february 2011 draft of
00:29:42 what was the february 2011 draft of policy 155 as it then was and we can find that at lfb trouble zero eight three double five nine
00:29:59 there it is we can see from the top it's draft 155 and it's date february 2011. could we go to page four within this document
00:30:08 document and paragraph 7.10 please
00:30:13 that provision reads in exceptional circumstances nic incident commander may consider informing control that their advice to fsg callers should be altered eg to attempt to leave their property
00:30:27 eg to attempt to leave their property were you specifically aware of that provision
00:30:33 yes
00:30:36 and had that specific provision been brought to your attention by anyone or is it something you were lighted upon as part of your reading of the document here's the letter
00:30:47 did you consider whether control staff would need guidance on that particular provision whether via policy such as pn 539 or rifs or by training
00:31:04 my expect yes my expectation would be that
00:31:07 that that this would find its way into all three of those uh
00:31:13 uh all three of those documentation and or a link to 790 in it where this mentions but yes it should be it should certainly in terms of training
00:31:24 it should certainly in terms of training and rifts be reflected can i press you on that was it in reality your assumption that that would be done or did you actively consider what changes were necessary either to
00:31:35 what changes were necessary either to policy or to the rifts or to training no i didn't actively consider what what they may be it was my assumption that those working on this would have made
00:31:46 those working on this would have made that link across to the relevant documents
00:31:49 documents does it follow from that answer that you didn't consider whether these changes or rather control room staff required guidance on what information they should be gathering so as to assist the
00:32:00 be gathering so as to assist the incident commander to determine whether a partial or total evacuation was necessary
00:32:07 necessary well
00:32:08 well this policy at the at the back has a control information form that details that very information so my expectation is that
00:32:20 is that that information already exists in terms of being laid out what control staff should do and then in the training that would go ahead jointly between command units control
00:32:31 jointly between command units control etc that did go ahead that would be included in that so that would be covered off there so you didn't think that any further information beyond that identified
00:32:42 identified that was necessary
00:32:47 not in addition to what i've already laid out now
00:32:51 did you consider what advice would have to be given to the caller if the incident commander did change stay put advice and the decision was made to
00:33:02 put advice and the decision was made to evacuate
00:33:06 i didn't i didn't consider exactly what difference that advice would be at that moment in time however in subsequent discussions and
00:33:19 however in subsequent discussions and looking at various exercises in the outcome of exercises uh it's it was a it was a thought process that i had then
00:33:30 it was a thought process that i had then thereafter the results of those exercises that triggered you to think what further information and what further advice needs to be given yeah not in so much that i thought actually there's something missing but then
00:33:42 there's something missing but then obviously started to focus in my mind on what that would be can we look at paragraph 7.11 in this draft which says this the incident commander should consider
00:33:54 the incident commander should consider the early ordering of an additional cu to assist in managing the fsg calls especially if control is dealing with multiple fsg calls
00:34:05 multiple fsg calls other personnel may be required to manage information if a large number of fsg calls have been received control has experience of handling up to five
00:34:15 five fsg calls relating to a single incident again were you specifically aware of that provision
00:34:25 that i was i was aware of it because i read it it wasn't brought to my attention
00:34:31 attention can you help us with what precisely was meant by the phrase a large number of fsg calls
00:34:39 was there a threshold in mind no no there wasn't i think there's there's obviously single multiple and and large and multiple
00:34:50 and large and multiple dictionary definition is more than one so therefore in my mind multiple is two plus
00:34:55 plus and large
00:34:56 and large one one imagines that we're talking about five but that's only because five's mentioned and five was at lacanal i think it's it it's not particularly helpful that we use generic phrases like
00:35:08 helpful that we use generic phrases like that but then in saying that i don't see what it would add if we were specific in terms of two one five etcetera i'm not quite sure what else that brings to the policy
00:35:19 policy i suppose the only advantage would be it gives a specific threshold to concentrate the minds of uh not only the incident commander but control room officers as to whether
00:35:30 control room officers as to whether withdrawal of stay put needs to be considered and if so the nature and extent of evacuation it does but i would i would say to that that it's it's always
00:35:41 that it's it's always potentially dangerous to give parameters such as that because every incident is is different and every fire is different and buildings are different when you put them together the
00:35:52 when you put them together the circumstances are different so to put an unnecessary unnecessary threshold on something that five fsg's mean something it might mean something in a certain circumstances but it might
00:36:04 in a certain circumstances but it might be
00:36:05 be well within capabilities on a different one so
00:36:08 one so we rely very much on professional judgment which is why i guess the phrases there are quite generic did you consider whether pn 790 should
00:36:19 did you consider whether pn 790 should include some form of strategy or guidance for control room staff so that they would know how best to respond to multiple fsgs for example five
00:36:32 no because
00:36:39 in my view this is this is a a scale issue of normal business so
00:36:45 so not normal business in terms of we get lots of fire survival guidance calls that's clearly not the case but
00:36:52 but control uh can become very busy in in a very short space of time and it used to handling lots of different incidents at
00:37:03 handling lots of different incidents at one time
00:37:05 one time so it's not unusual for a 20 pump fire and a 12 pump fire to be gone at the same time or lots of four or six pump fires which are very resource intensive
00:37:17 resource intensive and control are used to managing that so in terms of fire survival guidance calls it's a different proposition but it's the same knowledge skills and experience that they use on a on a daily
00:37:29 experience that they use on a on a daily basis in terms of being able to multitask and i think when you gave evidence in october he referred to a fire at a merit hotel in poplar yes i think the date of that was 11th of
00:37:40 think the date of that was 11th of november 2010. now can we go to lfb trouble zero double three one nine six forward slash three
00:37:56 here we see roughly a third of the way down
00:37:59 down this page
00:38:00 this page that andy hickman emailed you on the 12th of november 2010 at 13 13 hours as well as scott haywood and others about the fire in poplar and he said
00:38:12 about the fire in poplar and he said this scott dave with regard to last night's
00:38:16 night's 10 pump fire as i'm sure you've been made aware this was a particularly challenging incident for control given the number and nature of fire survival calls they handled some of which went
00:38:27 calls they handled some of which went over for went on for over an hour despite the pressures the way information was passed the fire ground enabling searching and in some cases rescues to be undertaken seemed
00:38:38 cases rescues to be undertaken seemed excellent
00:38:39 excellent can you explain why it was a particularly challenging incident
00:38:47 i wasn't at the incident but i did speak with andy after i think it was challenging because the nature of the fire itself was
00:39:02 was was not not so
00:39:06 not so extensive as one way it might imagine from the way this incident has turned out ie 10 pumps and a number of fire survival guidance calls so there was i think there was issues in terms of
00:39:17 think there was issues in terms of locating the fire and the smoke travel through the corridors had been quite extensive and because it was a hotel there's always the issue about knowing
00:39:28 there's always the issue about knowing exactly
00:39:29 exactly who is where and and having someone knowing the residents there because they're a transient group of people now we know
00:39:38 we know although there's some debate about it there were at least eight fsg calls on the night and certainly an amount that exceeded
00:39:45 exceeded the five that happened at lachnal did the number of fsg calls following the poplifier at the poplifier prompt any discussion about control's
00:39:56 prompt any discussion about control's capacity to handle that volume of fsg calls no why not
00:40:05 because i think that they they handled them
00:40:09 them superbly well and so whilst andy says it was challenging it's
00:40:16 it's i'm
00:40:17 i'm certainly it was a busy night for control and and they did very well as i would expect them to do but i'm not quite sure they saw it as challenging as maybe andy saw it who who i wasn't there
00:40:28 maybe andy saw it who who i wasn't there and wasn't uh experienced in the way control operates so i think they saw it as a busy day at the office did it prompt any consideration of the need to plan at least or to train
00:40:40 plan at least or to train uh in relation to an incident that involved say for example eight fire survival guidance course
00:40:46 i think at this time we were already developing the 34 actions from lack of all house and we obviously had the issue of policy
00:40:59 we obviously had the issue of policy note 790 in mind so in our view we were working towards this and the transfer of information and we'd already started the programme of training on fire survival
00:41:11 programme of training on fire survival guidance calls as a result of lack and also
00:41:14 also i think in our mind we were this just reinforced the work we were already doing
00:41:19 doing is that
00:41:20 is that after the event rationalization of the thought process or was it something you consciously considered at the time
00:41:29 uh it's not after the it's an after the event i guess because it never it never come to me at the time that we needed to do it and i'm trying to think of why
00:41:40 do it and i'm trying to think of why that might have been can we go to lfb trouble zero trouble three nine seven apologies it's another email chain
00:41:54 and if we can go to look at the bottom of the first page there's an email sent on the 13th of july 2011 timed at zero nine zero eight hours uh pat utting emailed your staff
00:42:06 hours uh pat utting emailed your staff officer
00:42:07 officer david chandler i think also goes under the name of barney is that right that's correct
00:42:11 correct um with a further draft of pn790 still described as 155 and he says this could you run this past mr brown please there have been a few changes since he
00:42:22 there have been a few changes since he last saw it following the testing of this policy at an eight pump exercise the main change is a two-tier mobilization essentially one fire survival guidance call will attract a person's reported
00:42:34 call will attract a person's reported attendance two or more or fsg call at a high-rise building will attract the pr attendance and they dedicated pl cu and sm so
00:42:47 dedicated pl cu and sm so just for the avoidance of that for people who are unfamiliar pr stands for what persons reported pl
00:42:54 pl uh pump leader command unit and station manager thank you now david chandler responded
00:43:00 responded and if we can de-amplify at the top of the page
00:43:04 the page leave it with me and i'll get back to you asap
00:43:08 did mr chandler run the policy past you can you remember uh i believe he did yes um did you or were you content with the draft in the state that was put before
00:43:19 draft in the state that was put before you at this time i was content with the addition of recognizing extra fire survival guidance calls and and putting extra mobilization on yes and did you consider whether the
00:43:32 on yes and did you consider whether the two-tier mobilization based on one fsg call and two or more fsg core system was an adequate way of responding to a large number of fsg calls
00:43:44 number of fsg calls i considered it appropriate for that
00:43:48 that that point in terms of one for persons reported a second attendance for more it wouldn't be appropriate if there were extensive fire survival guidance calls
00:44:01 extensive fire survival guidance calls but then
00:44:03 but then as i said earlier we we rely on a professional judgment of officers to order or more our resources as they see fit dependent on the circumstances at the time so i thought
00:44:14 circumstances at the time so i thought that was that was a good predetermined attendance approach to get things moving to take the heat off the incident commander in terms of thinking about
00:44:25 about resources at that early stage can we now turn on to the lindrich review itself we've glanced at it occasionally dated the january 2013
00:44:36 january 2013 if we can go to lfb trouble zero double three nine four three four six
00:44:50 now uh group manager lindridge considered action 14 and we can see it roughly midway down that page and he said this
00:44:59 said this control staff perceive pn 790 as an operational policy for frontline personnel
00:45:06 personnel specific observations made as a result of this view have been fed back to the ac opr that's you and will be considered in a forthcoming forthcoming review of control fsg policy
00:45:19 forthcoming review of control fsg policy can you remember now what those specific observations were yes i i think they really were just around
00:45:28 around dave lindbridge talking to control staff and it's as as we were discussing not that long ago this morning the fact that control staff
00:45:40 control staff appeared to view this as an operational policy so i don't think it was anything more specific than than the his opening sentence really and can you help us as to what the forthcoming review of fsg
00:45:52 to what the forthcoming review of fsg policy
00:45:53 policy was referring to here
00:45:58 that would have it's not clear what it would be no that that
00:46:05 that i think he's referring to uh policy note 539 and the fact that he was up for its three yearly review could we now go to lfb trouble zero
00:46:16 could we now go to lfb trouble zero double three nine four three four slash thirteen
00:46:25 and if we can see at the bottom of page 13 in the review process findings box for action 14. mr lindridge said this pn
00:46:34 pn 790 was authored by representatives from instant over the page management sorry was authored by representatives from incident management policy and
00:46:45 from incident management policy and control
00:46:47 control the procedures describes two-way exchange of fsg information this was tested in an exercise at stratford 16th of june 2011. with feedback shared with the authors
00:46:58 the authors overall it was a success but did identify that fsg is resource intensive at control do you know who'd concluded that fsg was resource intensive at control
00:47:11 resource intensive at control not not who the specific person was i imagine it was observations from hutting who was
00:47:17 who was there at these exercises now can we in this context go back to the latino control report which is a hom quadruple zero double one two four forward slash
00:47:30 zero double one two four forward slash four nine
00:47:46 thank you and if we could look at paragraph 287
00:47:51 we see his headed workload and if we could go to the third line of this paragraph which says this control resources were dedicated to dealing with three fsg calls at the same
00:48:04 dealing with three fsg calls at the same time during the period 1635-1750
00:48:09 this will have made overall call handling more complex given the need for a supervisor or another control officer to be available to support the control officer dealing with the fsg call
00:48:20 officer dealing with the fsg call and increase both workloads and the personal pressure on the staff involved in his statement cc simmons said during my many years service i've experienced other major incidents
00:48:33 experienced other major incidents involving similar levels of focus commitment and volume of work however the unfolding and deteriorating circumstances experienced by the trapped persons who are communicating with the
00:48:44 persons who are communicating with the control room created an intensity that i've never previously experienced and placed my staff and i a in a unique situation
00:48:54 situation now given that particular assessment did you take any action to ensure that the level resource in control could meet the challenges posed by fsg calls
00:49:05 the challenges posed by fsg calls particularly incidents where there were multiple fsg calls i i'm well aware of this paragraph and i never took any
00:49:16 never took any specific action in terms of do i need more staffing etc we'd carried out a shift review
00:49:27 out a shift review that was
00:49:29 that was i think in place at this time where we'd reallocated resources to match the busier times of the day statistically when fire calls are received but i was also comfortable on two other
00:49:42 but i was also comfortable on two other issues really one is the what we call the the buddy or fallback arrangements if you like using other control centers and we had we had specific arrangements in place with
00:49:53 specific arrangements in place with staffordshire and northwest fire control that fell out of the national fire control project as well as mutual aid arrangements with surrounding brigades
00:50:05 brigades plus also the fact that we could have arrangements within the control room in terms of thinking about how the support from
00:50:16 thinking about how the support from supervisors and control officers manifested itself so in lacanal there was one call that went on for a long period of time and was was very
00:50:28 long period of time and was was very traumatic and demanding but then another call another two calls were very quick so it could well be that resources could be rationalized if there were some
00:50:39 be rationalized if there were some simultaneous calls within the control room before we went to the buddy arrangements with other control centers that gave us to a degree unlimited support
00:50:50 support well thank you can we now turn whilst looking at action 14 exercise fluorine which was an exercise that was held on the 20th of december 2012 so a few weeks
00:51:03 the 20th of december 2012 so a few weeks or so after the latino control report was published could we go to lfb double zero one double two eight two seven
00:51:21 now this is what's described as a facilitator briefing for the exercise can we go to page three
00:51:34 where the exercise objectives are set out and we can see that it was an exercise to test the effectiveness of pn790
00:51:44 of pn790 and presumably you were aware of exercise flooring is that right yes did you attend the briefing following the exercise i attended one exercise i can't remember
00:51:55 i attended one exercise i can't remember which one it was though i'm afraid now looking at these objectives do you agree that the emphasis of the excise was on the transfer and recording
00:52:06 excise was on the transfer and recording of fsg information and not the handling of fsg calls
00:52:21 yeah i can see why you'd say i think the first bullet point information gathered by control officers from fire survival callers deeply implies fire survival guidance cause but it's not explicit
00:52:33 it's not explicit now it's not clear whether it deeply implies it call handling doesn't appear to be a phrase or indeed there's no synonym for it in its objectives would you accept that well i i accept that but you can't
00:52:45 well i i accept that but you can't gather information from fire survival callers without call handling so the aim of the excise does not seem to involve handling a build up of fsg calls
00:52:56 involve handling a build up of fsg calls would you agree with that
00:53:01 no it doesn't deal with a build up now and it doesn't appear to consider
00:53:08 consider uh the provision that pn790 we looked at earlier that an incident commander may be put in a position where he has to revoke stay put and take consequential steps would you agree with that it wasn't covered
00:53:23 it doesn't appear so now can we go to page two which is headed y
00:53:32 and the first bullet point we see there is lachnal
00:53:37 what was the point or purpose of the exercise insofar as it related or concerned lachna
00:53:48 well because policy note 790 was a as a result of a direct
00:53:54 direct self-appointed action as a result of lack of house i think it was quite rightly thought useful to explain to the attendees
00:54:05 useful to explain to the attendees uh that lachenal house has prompted us to to think about this triangulation of information could we go to page six please
00:54:18 we see that that fourth bullet point that the scenario was to include three fsg call concerning four persons can you help us was there a particular
00:54:30 can you help us was there a particular thought process as to why three fsgs was considered the optimal scenario for these purposes i think it was to reflect lack and all because whilst there were five
00:54:41 because whilst there were five fsg calls at leckenhall there was only ever three simultaneous calls so i think this was to reflect the fact that uh of those three simultaneous calls at leckenhall
00:54:53 leckenhall bearing in mind the
00:54:57 the emotion and the force of cc simmons's
00:55:02 simmons's uh statement that we refer to was quoted expressly in the lack of control room do you know whether any active consideration was given to including a a significantly greater number of fsg
00:55:13 significantly greater number of fsg caused by which i mean more than five so as to properly and effectively stress test the adequacy of the arrangement set out under pn790
00:55:27 no i don't think it was but i am aware that we did with this exercise i believe there was there was a background exercise going on in control that simulated
00:55:38 simulated uh
00:55:39 uh the the the pressures that that harry simmons was referring to so
00:55:45 so the background exercise in control wasn't just about three survival guidance calls gone simultaneously there were
00:55:52 were they were simulating other incidents going on nothing whatsoever to do with this to put pressure on the control room so that that pressure would have been felt regardless of whether it was
00:56:03 felt regardless of whether it was through this one incident or other as a combination of can we leave these briefing notes and go to an email correspondence that you had with group manager lindridge
00:56:14 with group manager lindridge we can find that at lfb00118958
00:56:28 now we see that on the 9th of january 2013 group manager lindridge emailed you a summary of the discussion that had taken place that day about exercise flooring
00:56:40 about exercise flooring now group manager lindridge set out certain observations in respect of pn539 pn 790 and the riffs and if we can look at pn 790 which is
00:56:52 and if we can look at pn 790 which is the second subject heading in the email and the third bullet point where he says this
00:56:59 this provide detail around the use of secondary comms networks and the need to avoid multiple simultaneous lines of communications now did that point refer to
00:57:10 now did that point refer to information exchange about fsg calls between control and the instant ground can you remember
00:57:21 i believe so yes can you help us and if your memory doesn't allow an answer please say so but what aspect of the exercise had led to this particular conclusion can you
00:57:32 to this particular conclusion can you remember
00:57:33 remember i think it was that there was there was there was difficulty in communicating between control and the
00:57:45 communicating between control and the command units because of the the number of transmissions that needed to go on and i seem to remember that the solution
00:57:57 and i seem to remember that the solution for this
00:57:59 for this was a dedicated hotline
00:58:03 hotline put in the control room that could could be used by the command unit to avoid the overload of information can we look further down in this email
00:58:15 can we look further down in this email we see the further i think it's the final subheading exercise documentation and mr lindrich said this the exercise should be implemented into a regular
00:58:27 should be implemented into a regular training program
00:58:30 now what was discussed can you remember now about the need for a regular training program uh they were they were discussions that i had
00:58:42 i had with scott or richard rather sorry it had been written at this time wouldn't it well richard scott i think richard might been away at that time so i discussed with them about arranging
00:58:53 so i discussed with them about arranging these
00:58:55 these and i had a responsible officer in central operations managing command unit so they fell within my area of responsibility and then later on when
00:59:07 and then later on when tom george was appointed ac one of the deliberate decisions i made was that he would be responsible for command units as well as control to help bring these together even further
00:59:20 bring these together even further are you able to help us as to whether the particular recommendation regarding training was in fact implemented there were certainly regular exercises they started in 2013
00:59:34 they started in 2013 and then apart from the impact of vision in 15 they they carried on and then really ramped up in 2016 i seem to remember
00:59:43 remember can i now turn to a separate topic which is the nature and extent of assistant commissioner chandler's involvement yes now
00:59:51 yes now if we can go to lfb trouble zero two eight nine four two
01:00:07 now we can see that you emailed ac chanted on the fourth of april 2013. and if we go broadly two thirds down page one there's the heading brigade
01:00:19 page one there's the heading brigade control
01:00:21 control where you say this please go through every point on the lachmal action plan and the audit and pull them together in one spreadsheet and satisfy yourself that everything has been completed
01:00:33 been completed now here the action plan i think refers to pre-inquest actions rather than those directly arising from the coroner's recommendations is that right yes does the word audit refer to the
01:00:45 does the word audit refer to the lindridge review of january 2013
01:00:50 yes what had prompted this email to be sent by you at the start of april 2013.
01:01:00 so richard had just returned from extended period of leave and
01:01:07 and that had obviously been a period where scott had started reporting back to me in that intervening period and given
01:01:17 and given the issues that we discussed earlier on this morning i wanted a second opinion so i wanted richard to
01:01:25 to look at this and just double check for me that everything was working in the way i was told it was working and also it was to
01:01:35 it was to get richard back into the thick of it because he'd been away for four or five months thank you could we go to lfb trouble zero six zero seven zero one
01:01:53 can we look at the second email on that page which is uh mr chandler's response to you
01:02:00 to you where he set out in blue the summary conclusions of his review of the lachnal pre-inquest actions could we go to page two and look at the heading that concerned item 14
01:02:15 under the heading fsg policy for communication with the fireground he wrote this yes this is now in place it was last amended in may 2013 and is due for
01:02:26 amended in may 2013 and is due for review in february 2015. i would have a question if this should be an operational assurance policy or a mobilizing policy although this policy is in place and the
01:02:37 although this policy is in place and the interaction between control ort and operational crews is improving there is still further progress to be made did you just did you discuss that
01:02:48 did you just did you discuss that particular action with mr chandler yes can you remember now the gist or the thrust of that discussion uh yes
01:02:57 uh yes it was very much as we said earlier so richard in his interactions with control it had picked up on the point that dave lindrich had that control were feeling that it was
01:03:08 that control were feeling that it was operationally focused and my response to that is
01:03:12 that is it's it's it's it's a non-issue who writes to policy it applies to operations and control equally because without either of them the policy won't
01:03:23 without either of them the policy won't work and so it's just for us to embed that in continuation training with control to drive that point home were there any other particular points in relation to which mr chandler felt the
01:03:35 relation to which mr chandler felt the progress needed to be made
01:03:40 not in terms of things not working well but in terms of yes we'd started doing the training the familiarization training and we needed to carry on with that and most
01:03:52 needed to carry on with that and most probably start to ramp it up and then also include regularly station managers now looking at the first recommended action concerning action 14
01:04:03 action concerning action 14 mr chandler said this focus to be made on the future integrated control training courses recommended in rule 43 response to the coroner
01:04:13 coroner towards improving and harmonizing the language used between control and the fire ground now looking at that particular recommendation do you agree that the intended focus of
01:04:24 do you agree that the intended focus of the proposed integrated training was on information exchange between control and the fire ground and not on the handling of fsg calls
01:04:36 yes given that did you consider to what extent
01:04:42 extent the handling of fsg calls should form part of the proposed integrated training
01:04:56 no but
01:04:58 but only because
01:05:01 i didn't see from the result of what richard was saying here that he was
01:05:07 he was he was proposing or suggesting there were any issues that he'd found with the hand in the fire survival guidance calls as a result of him looking at policy note 790.
01:05:18 note 790. could we go to lfb double zero double one double zero three zero
01:05:32 now on the 28th of august 2013 dave archer whose assistant commissioner cotton's personal assistant sent you and director reason a copy of the rule 43 action plan in advance of a
01:05:44 the rule 43 action plan in advance of a meeting that was to follow the next day now
01:05:49 now we can find the attachment at lfb0011031
01:06:04 now this document was a consolidated action plan arising from the coroner's recommendations made following shirley towers as well as the lachnal inquests did you read it
01:06:15 did you read it yes
01:06:17 yes if we can turn to page 11.
01:06:23 we see at the bottom of page item 14 is addressed
01:06:29 and it flowed from the shirley towers inquest that quotes consider the training and supervision required for control staff to enable relevant information to be captured and passed to operational
01:06:40 captured and passed to operational firefighters is that right yes
01:06:44 yes that was then divided into three separate lfb actions the first of which was to review lfb policy and procedure is that
01:06:56 review lfb policy and procedure is that right
01:06:58 yes and that was assigned to ac mobilizing who i think was ac chandler at this time until he left in october 2013 is that right
01:07:09 left in october 2013 is that right that's correct now in the fourth column you see
01:07:15 you see there is a an update on the third of june i should say the fifth column an update on the third of june 2013 and if we scroll down to page 12.
01:07:31 we see in the last substantive paragraph on that page under that column it says this although policy 790 outlines
01:07:42 although policy 790 outlines communications between control and the fire ground there are still a number of issues that appear to cause a disconnect in relation to communication between control and the fire ground
01:07:53 control and the fire ground this can be classified into four key areas one
01:07:56 areas one competence issues of the control room staff
01:07:59 staff two training see item 13. now pausing there what were the competence issues concerning control staff
01:08:13 i'm not quite sure exactly what what he's referring to here if you can't remember or can't assist i'll leave it there yeah can we go back in this document to page 10.
01:08:27 bottom of this page we see item 13 another which flows from shirley towers and it said this review the training given to control staff in relation to
01:08:38 given to control staff in relation to recent
01:08:40 recent gra so generic risk assessments including
01:08:43 including gra 3.2
01:08:46 gra 3.2 that too was assigned to ac mobilizing who was ac chandler is that correct that's correct and now we see in the far right column another update given on the 3rd of june
01:08:59 another update given on the 3rd of june 2013
01:09:00 2013 and if we can look in the second paragraph
01:09:03 paragraph which is
01:09:04 which is in the very bottom right of the page it says this
01:09:08 says this none of the subsections dealt with a recommendation to train control staff in information provided within gras further investigation has shown
01:09:19 further investigation has shown organizationally we would not use gras as a training subject the gra's populate lfb policy and therefore training would be based around the policy not gra
01:09:32 the policy not gra currently the high-rise firefighting policy is not an integral part of controlled training the training undertaken within control covers only the mobilizing aspect of a
01:09:44 covers only the mobilizing aspect of a high-rise incident and not the wider implications below that is a yet further update dated the 4th of july 2013 it said this
01:09:55 the 4th of july 2013 it said this discussion is currently underway with our training provider on how the recommendations made to the coroner in the lachnal rule 43 recommendations will be delivered the hfrs
01:10:07 be delivered the hfrs if you just help us what that stands for hfrs
01:10:12 oh hampshire fire and rescue service thank you issue is integral in these training issues and will be included within these discussions a lot of material there but there's a
01:10:24 a lot of material there but there's a short question are you able to help us as to what the outcome was of these deliberations
01:10:37 no i'm afraid i can't was it decided that control staff would receive training on the substance of gra 3.2 insofar as it affected their roles
01:10:51 3.2 insofar as it affected their roles well on that i can help so [Music]
01:10:55 [Music] so so this summary beforehand is absolutely right in terms of the way we operated
01:11:02 operated uh that control wouldn't have been asked to or any any manager in control wouldn't have been asked to look through gra 3.2 because organisationally we already had and incorporated it within
01:11:14 incorporated it within uh policy note 633 high rise so any training for control that was necessary for what they needed to do would have fallen out of policy note 633
01:11:26 would have fallen out of policy note 633 in terms of going back to the original question uh the training provider
01:11:34 i'm sorry i can't recall exactly what fell out of those discussions don't worry
01:11:38 worry can we go on to a separate email now lfb trouble zero nine two four zero seven
01:11:56 now you sent director reason an email the next day following on from dave archer's email and you said thanks for this morning does this revised version work for you
01:12:09 does this revised version work for you and you attach the consolidated rule 43 action plan with your revisions and if we can look at the substance of those revisions or at least some of them they can be found at lfb 00
01:12:21 they can be found at lfb 00 four zero eight forward slash eleven
01:12:36 now we can see
01:12:40 that you've been vigorously exercising the track change facility here and that you deleted most of the entry against item 14a including the four key areas causing
01:12:53 including the four key areas causing a disconnect between control and the fire ground under pn790 can you help us as to why you deleted all of that material this would be the the second
01:13:06 this would be the the second uh comment box would it yes well i'm looking at the uh
01:13:12 uh look at the first comment box the top and the second one as well but particularly the second one
01:13:30 um
01:13:35 well i think the second one
01:13:39 basically the way i operated was was trying to be consent and concise where possible so for stylistic rather than substantive yes i think the second one is trying to
01:13:51 yes i think the second one is trying to be
01:13:51 be more concise and to the point and
01:13:55 and and certainly that looks although i haven't just read everything in that top box but
01:14:00 box but but it would it would to my eye it would have been just to try to be to the point the downside though of brevity
01:14:11 the downside though of brevity has been removing some of the substance and flavor of some of the concerns that have arisen which would have been useful for a reader to have known when assessing the
01:14:23 reader to have known when assessing the effectiveness of the completed actions would you accept that criticism all right i accept that there's the potential for that of course i would say two things firstly that certainly wasn't
01:14:34 two things firstly that certainly wasn't the intention and secondly when we discuss these uh these documents it wasn't a case of just what's written and then move on there
01:14:45 what's written and then move on there would have been discussion at the board about it so so i'm confident that whilst there might have been a briefer action update that doesn't mean to say
01:14:56 action update that doesn't mean to say that we didn't discuss it in more depth when we met as a group now
01:15:02 now can we go to lfb trouble zero four double zero two nine
01:15:17 as you can see these are minutes of a meeting of the operational directorates coordination board held on the 3rd of september 2013 could we turn to page 3 and item 7 in
01:15:29 could we turn to page 3 and item 7 in particular we can see the bottom of that page this item considered the rule 43 monitoring report amongst other matters and if we can turn
01:15:41 amongst other matters and if we can turn over the page again and look at the first line
01:15:46 we see that specific issues were raised during the discussion the report including
01:15:50 including item 13 which is the third point there and it says this ac slash mob so i think that's ac for mobilizing is it yes
01:16:01 ac for mobilizing is it yes advise that control use their judgment when dealing with high compartment buildings though it was acknowledged that this is a complex matter which requires further con consideration
01:16:13 consideration what complexity is required further consideration can you remember
01:16:21 well the the the complexities are that
01:16:26 that fire survival guidance obviously in a higher eyes is is different to that in a normal dwelling and so
01:16:37 and so so therefore the fire survival guidance needs to be you know specifically modified and therefore the complexities are that staff handling those calls need to have
01:16:50 staff handling those calls need to have a you know an excellent grip on the surroundings and the risks and the dangers that are impacting on the caller so it makes it
01:17:01 impacting on the caller so it makes it far more complex in a higher rise than it does in a normal house can i now turn to the lindrich review of november 2013 and if we go to lfb at trouble zero eight three nine seven
01:17:14 at trouble zero eight three nine seven eight forward slash four
01:17:26 and here we see in the lower half email on the 15th of november 2013 you emailed scott haywood and you said this i've just met with dave lindrich to
01:17:38 i've just met with dave lindrich to discuss whether there are any outstanding pieces in the latino action plan as a result i've asked dave to discuss with you that's dave lindbridge to discuss with you the following issues
01:17:50 to discuss with you the following issues to ensure any outstanding issues are completed
01:17:54 completed action 14
01:17:56 action 14 is mentioned further down the page and you said this creation of policy for for communications from control to the fire ground
01:18:04 ground it seems there might be some specific observations made as a result of day's review that need to be considered in future reviews of fsg policy we need to confirm what these
01:18:15 we need to confirm what these observations are has a review of fsg being completed whether these observations have been considered if not then why not
01:18:26 considered if not then why not what were the specific observations you thought he might have [Music]
01:18:35 i seem to recall that they they are the the same observations that we've discussed already in terms of transfer of information
01:18:47 transfer of information the the potential for an overflow if you like through
01:18:53 through poor radio discipline too much information being passed or received and not in an orderly fashion i think i'm not not having the facility to be able to do it i think it was around that
01:19:05 was around that now mr lindrich in january 2013 had reported that his observations were due to be considered as part of a forthcoming fsg review
01:19:16 forthcoming fsg review now it appear from this email that the fsg review remained in prospect rather than being a concluded fact is that right uh
01:19:26 uh it would appear so yes the fsg
01:19:30 the fsg sorry the
01:19:31 sorry the 539
01:19:32 539 i think was due for a scheduled review that year so if november 13 then it was slightly uh overdue um sir it's 20 past three um it is a
01:19:44 um sir it's 20 past three um it is a convenient point if it's convenient for you yes the witness thank you well i think it's time we had a break mr brown so we'll stop there uh we'll resume please 25 to four and again please don't discuss your
01:19:56 and again please don't discuss your evidence while you're out of the room thank you sir thank you very much would you like to go to the usher please
01:20:10 thank you very much 25 to 4.
01:37:53 would you ask mr brown to come back in please
01:38:07 all right mr brown yes thank you sir when we go then yes mr canine thanks sir um could we now turn to gra 3.2 and in particular how that fed into the arrangements policy arrangements at control
01:38:18 control could we turn to lfb trouble zero nine three six one six
01:38:31 now we see on the 10th of may 2012 michelle kaniki emailed you the latest draft of gra 3.2 and we can see in the second paragraph she said this the attached high-rise gra has already been
01:38:44 attached high-rise gra has already been through regional consultation and a number of amendments accepted highlighted in track changes due to the inevitable amendments resulting from the regional consultation process
01:38:55 process it felt prudent to wait until the national consultation second round prior to issuing this revised document for internal consultation am i right
01:39:06 am i right that lfb control had not given or hadn't contributed to the draft before this point i.e
01:39:13 point i.e may 2012. that's correct in the third paragraph she wrote this please review this document with a view to identifying impact on lfb procedures
01:39:24 to identifying impact on lfb procedures especially those areas where changes to the main text have been highlighted using track changes as well as any other comments observations and amendments felt necessary did you review in a sense of scrutinize
01:39:35 did you review in a sense of scrutinize this document not personally i sent this to staff as i would in normal circumstances for their comments were you aware of the particular
01:39:46 were you aware of the particular provisions concerning fsg calls no not not prior to sending it out to staff now the we have been unable to find any
01:39:57 now the we have been unable to find any emails in which you forwarded this email to anyone in control did you ask anyone at control to review the substance of gra 3.2 in this particular draft
01:40:09 particular draft i couldn't i couldn't honestly put my hand on my heart and say i did all i would say is my normal practice was to send it out to pom and the four area decks and the deck
01:40:22 pom and the four area decks and the deck in central operations that would be minimal practice and i don't see why i would have done any different in this circumstance but i couldn't give you a guarantee that i did we can't find anything so i want to see to give you an
01:40:33 anything so i want to see to give you an opportunity to confirm whether or not but there we go now if we can look at gra 3.2 and go to lfb quadruple zero one two double five
01:40:52 this is the version that was uh finally published in february 2014 um i assume you've read the general eric risk assessment in its final form is that right yes
01:41:04 final form is that right yes and could we go to page 20
01:41:10 and if we look at the second paragraph on that page it says this fire and rescue authorities must also have effective arrangements in place to handle fire survival guidance calls from residents and others when they believe
01:41:23 residents and others when they believe they are unable to leave the building due to disability poor mobility illness or the effects of fire now after gra 3.2 was published in february 2014 did you take any steps
01:41:36 february 2014 did you take any steps effective steps to ensure that control had effective arrangements for such residents
01:41:44 no but i was satisfied that that they already had these arrangements not notwithstanding the discussions we've had earlier on today in terms of
01:41:55 we've had earlier on today in terms of policy
01:41:56 policy but i was satisfied that a questioning that control officers do would
01:42:02 would naturally bring out these issues did you specifically ask yourself that question having read this paragraph as to whether the arrangements that were in place were effective to assist those who
01:42:15 place were effective to assist those who had disability permeability illness i didn't read it stop and think consider and then move on [Music]
01:42:25 [Music] but it was a natural process in my mind that yes we we do already deal with this looking at the fourth paragraph on this page it sets out what fsg called arrangements should include
01:42:36 arrangements should include and we see the third bullet point for example
01:42:40 example it anticipates a re-evaluation process
01:42:44 process did you flag that particular provision once gra 3.2 had been publicized or published rather with control
01:42:54 no however
01:42:56 however again my view is that the reassess ticks this reevaluation box
01:43:06 box can we go on to page 30 within the document
01:43:13 as you see at the bottom of the page the specific provisions governing fsg starts here and extends over the page now after gra 3.2 was published did you
01:43:24 now after gra 3.2 was published did you consider asking anyone in control to review the document to ensure that pn790 pn539
01:43:32 pn539 and the rifs were consistent with the detailed provisions of the gra
01:43:40 i never asked that specific question but going back to my answer a few minutes ago in terms of the consultation
01:43:50 i i do think my normal well my no my normal practice was to send it out to officers so i do believe i would have sent it to control so i would have taken that as read
01:44:01 that as read but again as i said i can't for sure say but i didn't i didn't specifically ask that question could we now move on to a separate topic which is training and latino issues and the associated pre-inquest actions
01:44:14 the associated pre-inquest actions now
01:44:15 now the first of the topics i'd like to discuss with you is the identification and provision of training and to start that off could we go to a paragraph in mr hayward's first
01:44:27 paragraph in mr hayward's first statement which we can find at
01:44:33 nine lfb0055191 forward slash seventeen
01:44:46 and if we could look at paragraph 48 in particular mr hayward said this control senior management reviews the training need for staff on an ongoing basis to identify new themes and ensure
01:44:58 basis to identify new themes and ensure that ost
01:45:00 that ost creates training packages for these jessip
01:45:04 jessip which we know mtfa is that marauding terrorist firearms yes and deliver these to all staff was that how you understood that the training needs of control staff would be
01:45:15 training needs of control staff would be identified and met one of them yes did you have did you yourself have any involvement in this process
01:45:24 not in the not in the process of identifying training needs specifically no unless a training need become uh
01:45:34 uh i become conscious of a particular need because of a particular event or a particular meeting did you yourself monitor whether the training needs of
01:45:45 monitor whether the training needs of control had been effectively identified and effectively met or did you delegate that function to mr hayward and his managers
01:45:54 managers i would have i would have delegated that function
01:45:57 function to mr hayward but then i would have also kept a watching brief on the brigade-wide performance to see if there was any implications for control could we stay in this statement but turn
01:46:09 could we stay in this statement but turn to page 18. and look at paragraph 52 and mr hayward says this due to the need to ensure that control is able to continue to carry carrying
01:46:22 is able to continue to carry carrying out its day-to-day functions most training by necessity is delivered to staff who are on watch this means that if there is a significant incident or a sudden increase in calls the staff including
01:46:34 increase in calls the staff including the ost might be recalled to their positions in the control room to answer and handle 999 emergency calls 53
01:46:44 53 as was intended when the new shift system was implemented implemented in 2011 trainer-led training took place within the short shift in the period between april 2011 and
01:46:56 in the period between april 2011 and april 2014 there was a four hour overlap between the two shifts the effect of this was that i could release stuff from training whilst maintaining service delivery although
01:47:07 maintaining service delivery although this did depend on sickness another leave from april 2014 to date the early short shift start time was moved to 0 800 hours in order to support the sbm
01:47:19 800 hours in order to support the sbm function which meant that the overlap shift reduced to two hours by 1400 to 1600 hours now just to ensure that i've understood
01:47:30 now just to ensure that i've understood this correctly mr brown after april 2011 control training took place within the four hour shift overlap while staff were on watch is that a fair
01:47:41 while staff were on watch is that a fair understanding yes it is uh if i can just caveat that i was heavily involved in the shift change it was one of strategic issues and it was my
01:47:53 and it was my expectation that whilst that four hour period will be used for certain types of training it shouldn't be the only place that training takes place and and i
01:48:05 that training takes place and and i think that the the viewers has become the case that is only that four-hour period where training can take place my view was that once the short shift started at 10 o'clock then there could be some all-day
01:48:17 o'clock then there could be some all-day training that could start to take place were you aware that the early shift moved in april 2014 no i wasn't and uh and i wasn't particularly impressed when i found out it moved can you remember
01:48:29 i found out it moved can you remember when you find out that it had been moved uh i can't remember exactly when but it it came up and uh in in my meeting with scott that had already happened and uh and i remember my reaction was
01:48:42 and uh and i remember my reaction was well i i why wasn't i consulted on it and b
01:48:46 and b i'm really not happy about it because it's unpicking what we we haven't long implemented i spent a lot of time and effort in getting this new shift in with the consequential reduction in training
01:48:57 the consequential reduction in training time well reduction in that four hour period yes yeah it was done for good reason i understand why but nevertheless it wasn't something that i was consulted on um could we turn to inq
01:49:09 um could we turn to inq trouble zero one four nine four five
01:49:23 now i'm assuming you're familiar with the fire service manual even if isn't if it isn't a document that you consulted on a daily basis is that a fair assumption yes and it was published in 1998 is that right i believe so yes now
01:49:36 1998 is that right i believe so yes now if we can go to page 129 in this document hopefully we should find appendix one control staff training competence promotion there we go and we can see in the right hand column
01:49:48 can see in the right hand column it says this in the first substantive paragraph
01:49:51 paragraph trainee for control personnel has always been hindered by the small number of staff available and the need to maintain cover in the control center training is usually watch related and
01:50:02 training is usually watch related and carried out at the normal place of work this ensures the maximum number of personnel available for these reasons brigade should consider the provision of a training officer and or watch training days away
01:50:14 officer and or watch training days away from control first of all were you previously aware of that particular requirement yes
01:50:21 yes did you ever ever suggest to mr hayward that he consider uh facilitating training days away from control uh to ensure that training was not interrupted by service demands
01:50:35 not interrupted by service demands these were issues that we we discussed at length
01:50:39 at length and uh and there's there's good reason for there's challenges for watch training days away from control and one of them is terms conditions of control officers which i don't believe
01:50:52 control officers which i don't believe support us in being able to compel people to come in on their off-duty days so for a variety of reasons including the ability to be able to staff the
01:51:05 the ability to be able to staff the control room should there be an incident we always fell back on the provision of providing on watch training all be in a separate
01:51:17 on watch training all be in a separate room so when when we moved to merton there were separate training rooms so all intents and purposes it appeared completely away from the control and this alarm sounded
01:51:29 thank you can we now turn to the next topic which is the planning of training now presumably you would accept that as a basic requirement control should have a structured training plan yes
01:51:42 a structured training plan yes now
01:51:44 now can we bearing in that mind scott hayward said in evidence that there was never a formal written plan for delivering training to control staff were you aware of that admission
01:51:57 were you aware of that admission it was never an all-encompassing plan there was a delivery plan for the operational support team but there was never an all-encompassing plan for staff on watches there was however individual
01:52:09 on watches there was however individual plans for specific pieces of training but it nevertheless it was something that i wanted and i spoke with richard chandler about achieving it in 2013 i think well we'll come on to that one the
01:52:22 think well we'll come on to that one the points that rose out of mr hayward's evidence was that to his knowledge you had no recollection you had never asked him to produce the overarching
01:52:33 overarching training plan does that accord with your recollection uh well i certainly asked richard to deal with it whether i subsequently asked scott
01:52:45 whether i subsequently asked scott after richard left i i wouldn't have i wouldn't have let it drop so now i think it's unlikely that scott and i never had a discussion on an overarching training plan um could we now look at the audit of
01:52:57 um could we now look at the audit of control training that was carried out by station manager kelly in he reported in august 2010 uh that can be found at lfb double zero one zero nine zero nine two
01:53:18 now if we can go to page 7 in that document in particular paragraphs 47-49
01:53:29 those paragraphs say this 47 it appears that adequate long-term planning of the regularly delivered elements of the bctd curriculum has not been carried out
01:53:41 been carried out this may account for the fact that the delivery of fire survival continuation training to observed candidates fell outside the parameters of recommendations found in the emergency call handling techniques and for
01:53:52 call handling techniques and for survival guidance training document ie 12 monthly 48
01:53:58 48 however brigade control principal management has stated that once the current tranche of fire survival training is completed it is planned for all staff to receive a full course every 24 months with 12 monthly interim
01:54:11 24 months with 12 monthly interim training being delivered by a computer-based training solution notwithstanding the above it is vitally important that adequate training planning systems are implemented for all
01:54:22 planning systems are implemented for all courses including appropriate training records that support the cyclical training planning process and if we look at paragraph 50 it sets out recommendations
01:54:33 out recommendations the one at the bottom of the page is implement adequate training planning and recording systems now
01:54:41 now we can see against the first line of paragraph 47 that you commented in the following terms is this still the case post lack no
01:54:52 case post lack no now that question implies that it shouldn't have been the case is that an accurate reading of your comment yes against the recommendation to implement adequate training planning
01:55:05 adequate training planning you commented doesn't para 48 do this can we take it from your comment that in your view the proposal for biannual fsg training program without
01:55:17 biannual fsg training program without more constituted an adequate training planning system but bearing in mind this whole document was about fire survival guidance so in itself
01:55:28 itself it was focused on a particular element then the
01:55:33 then the my comments are related just to that so so yes i am i am suggesting that the biennial training of fire survival guidance are a full day half day full day half day would meet
01:55:46 half day full day half day would meet that however
01:55:49 this recommendation 50 in terms of a all-encompassing training plan then no paragraph 48 wouldn't have met that did you discuss this recommendation looking at paragraph 50 with scott
01:56:01 looking at paragraph 50 with scott hayward yes and can you remember what steps effective or otherwise did mr hayward take to implement that recommendation well the recommendation in relation to fire survival guidance
01:56:14 in relation to fire survival guidance training at this time there was a a robust plan the the first tranche of fire survival gardens training i think run from the summer through to
01:56:25 through to september time i think and then and then carried on in the half day the following year et cetera it was it was thereafter that it it started to unravel to a degree
01:56:39 you say unravel um what do you mean by that and what were the consequences well
01:56:46 well so what i mean by that it was it was intended to do a full day in 2010 then a half day in 11 et cetera then in 2012 should have been a full day and
01:56:58 should have been a full day and and i found out uh some time after that that hadn't been the case and uh at that point uh
01:57:07 uh there was discussions about role play and
01:57:11 and and
01:57:12 and four hours versus all day etc and was making some discoveries in terms of what had gone on wasn't
01:57:20 wasn't what i had expected so that's what i mean by unraveling thank you we'll come on to your intervention uh in due course okay thank you um before we do so can we go
01:57:31 thank you um before we do so can we go to your second witness statement which can be found at lfb trouble zero eight four zero two zero forward slash two zero
01:57:45 and if we look at paragraph 55 you say this at paragraph 30 of my statement dated 29th of january 2019 i refer to brigade policy note 164
01:57:57 i refer to brigade policy note 164 training pn 164 and
01:58:01 and it pausing there pn164 the proper title i think is training control control staff new entrant is that right yes this iteration of pn 164 was current as
01:58:13 this iteration of pn 164 was current as at january 2009. there are sections within pn 164 that address the systems in place for continuation training section 2 and refresher training section 3.
01:58:25 refresher training section 3. i've also reviewed pn164 that was current at the time i left the brigade in march 2017 i have nothing further to add to the information provided in pn 164 in
01:58:37 information provided in pn 164 in response to this request now if we look at the two versions of 164 that you've exhibited to your statement the first was issued in september 94 and amended in january 2009
01:58:49 september 94 and amended in january 2009 and the second was reviewed as current in may 2015.
01:58:55 2015. now
01:58:56 now we don't need to go to the documents yet but is it right that as head of service delivery of mobilizing you were the owner of pn164 yes and certainly when
01:59:07 owner of pn164 yes and certainly when station master sorry station manager kelly carried out his audit in august 2010
01:59:14 2010 yes
01:59:16 yes now there is no requirement and you can take it from me in either version of pn164 um for a training plan to be produced
01:59:26 produced were you aware of the absence of such a provision
01:59:34 yes i guess i was yes and
01:59:37 and presumably you were prepared to tolerate that omission if so why
01:59:44 because because just just because it doesn't say something in policy that as far as i'm concerned that doesn't mean i can't request it for good managerial reasons
01:59:57 request it for good managerial reasons and if if someone would have said to me well i'm not going to do that because that's not in policy then i think we've had a very very robust discussion about it so
02:00:07 it so so in in not everything is going to be written in policy it's just good managerial practice so i didn't really see it as a particular issue whether it was in or not but it said
02:00:18 but it said just to come back on that the existence of a training plan is the basic building block of effective training would you agree with that yes yes
02:00:28 yes yes and
02:00:29 and given that the provision would be a sentence or maybe slightly more than one sentence it was hardly an onerous in inclusion or incorporation within pn164 was it no no
02:00:40 incorporation within pn164 was it no no absolutely and there's no there's no good reason why it shouldn't be in there i guess the point i'm just trying to make is i don't see his absence as getting in the way of producing one but i'll take your point
02:00:52 producing one but i'll take your point it would have been helpful to have had it in there and maybe reinforce the message to control as well yes can we look at the audit trail um on the most recent version of the policy by
02:01:04 the most recent version of the policy by which i mean may 2015 which can be found lfb trouble zero eight four zero five four forward slash eleven
02:01:24 and we see from the history
02:01:27 history of the documents evolution that the policy was last updated i think on the 11th of november 2010. is that correct
02:01:43 so insight was last sorry you can say that it was sorry that it was updated oh yes yes misled you sorry on the 11th of november
02:01:52 november now given that date did you give any consideration to ensuring that when pn 64 was reviewed and updated in november 2010 it took into account the substance of
02:02:05 it took into account the substance of mr kelly's recommendations made in his report of august 2010
02:02:11 no i don't think i did can you help us as to why not
02:02:22 if you can't remember well no no the reason i'm posing is because if if it had been a naturally occurring scheduled three yearly review
02:02:35 scheduled three yearly review then
02:02:36 then that would i would just remind the relevant people that you need to be reviewed and i was just trying to work out my mind with the 2010 was a natural one because if it is a natural one it's
02:02:47 one because if it is a natural one it's probably more likely why i admitted to put it in [Music]
02:02:53 [Music] but but
02:02:54 but but it didn't occur to me at the time natural view or not to say we need to amend policy to include that because as i say my view was that a training plan
02:03:05 i say my view was that a training plan should be produced in any case so i think
02:03:08 i think it's something that i've obviously overlooked thank you can we turn to lfb double zero one zero six one four six
02:03:28 we see here that uh mr hayward emailed you a document entitled lack of control action sheet um first of all had you asked him to prepare a
02:03:37 prepare a an action sheet yes this would have been following one of our meetings what had prompted that had it been the lindridge review uh yeah so this was this was very much
02:03:48 uh yeah so this was this was very much what was going on at the time and i wanted to see exactly what scott was doing about it particularly because richard wasn't available at this moment could we go to that action sheet which
02:03:59 could we go to that action sheet which is lfb double zero one zero six one four seven
02:04:13 and if we look at the bottom of page one it says in the second column reading from the left two year training matrix including all control training fsg refresher then
02:04:25 control training fsg refresher then reading across in the third column it says matrix being created by the ost and then finally in the far right column under the heading outcomes it says this
02:04:36 heading outcomes it says this senior managers with ost have revised systems for the release of staff for training delivery to be implemented shortly the two yearly matrix will form the backbone to this
02:04:47 matrix will form the backbone to this plan completion date end of january 2013 but the plan will evolve as a living document projecting training for the future on a rolling basis
02:04:59 future on a rolling basis now were you surprised concerned or annoyed
02:05:04 annoyed to see that more than two years after the recommendation had been made by mr kelly a plan was still not in place for control training yes
02:05:14 yes all three well one in particular of those emotions uh
02:05:20 uh not not surprised because we've been having these discussions and i think scott here is referring specifically to uh fire survival guidance so
02:05:31 so whenever i used to chase for a plan i would i would seem to be sent various component parts of plans rather
02:05:42 various component parts of plans rather than one all-encompassing plan and so this was this was his plan just for fire survival guidance calls uh and whilst whilst this plan notwithstanding what i said a short
02:05:53 notwithstanding what i said a short while ago
02:05:55 while ago uh was working it still wasn't dealing with my
02:05:59 with my overall approach to training i was after following on from that and your reference to mr chandler can we go to lfb
02:06:07 lfb 0028 942
02:06:19 we've been to this a number of occasions now you emailed mr chandra on the 4th of april 2013. if we turn to the top of page 2.
02:06:30 you can see the first substantive bullet point there where you say on a wider training issue can you talk me through the training plan for control why did you make that particular request of mr chandler at this time i.e april
02:06:43 of mr chandler at this time i.e april 2013
02:06:45 2013 uh again because this this was part of a range of things that i uh
02:06:52 uh i had in mind for when richard returned things that were building up and and this was one of them because i still wasn't getting to where i wanted to be in terms of the training plan and i knew
02:07:03 in terms of the training plan and i knew i'd spoken to richard about it previously before he he left not left his extended leave period and
02:07:12 and so i wanted to remind him it was something that was overdue what was his response
02:07:22 i can't remember his email response but we met regularly and he told me i think it's in hand did you receive the uh oft promised matrix or not no
02:07:36 oft promised matrix or not no did you ask for that matrix i i did and and and i think rich's response was i'm on to it
02:07:44 on to it but i'm just back after a period of time leave it with me and so i left it with him
02:07:50 him and uh
02:07:51 and uh to see where he come back with that is april 2013. can we go to lfb trouble zero three two eight two six
02:08:10 this is tom george's report entitled review of brigade control you can see dated july 2016 so certainly more than three years after the email exchange with mr chandler
02:08:22 the email exchange with mr chandler now we'll come back to this review in more detail in probably on monday but for the time being can we go to page 22 and paragraph 47
02:08:44 sort of came and went
02:08:57 uh if we can go think if we go there we go um if we look at paragraph 47 some staff feel that they are not adequately developed in role or receive development to progress to a
02:09:09 or receive development to progress to a higher role the review has identified that maintenance of skills training is ad hoc not planned in a robust manner and often not recorded on individuals training records itrs and then if we can
02:09:22 training records itrs and then if we can go over to page 12
02:09:26 which is the recommendation of paragraph 49c at the top of the page it says this each om operations manager is to ensure that an appropriate robust annual watch training plan is in place
02:09:38 annual watch training plan is in place for their watch agreed by their som and available to all watch members and managers
02:09:43 managers all training must be recorded on an individual's itr the pom somms should work with colleagues from the brigades information management team to introduce an i.t
02:09:55 management team to introduce an i.t solution to this similar to training diaries used by station staff what was your response to the finding that training was ad hoc and still not
02:10:06 that training was ad hoc and still not planned in a robust manner
02:10:10 frustration did you discuss both your frustration and the substance of the finding with mr hayward
02:10:19 no because
02:10:21 because at this point tom was in place and as i said earlier one of the reasons i wanted tom george in there is because i wanted another ac on site to look more
02:10:33 i wanted another ac on site to look more closely in a way that i just wasn't finding the time to do so so it was
02:10:40 so it was i was disappointedly unsurprised but yet frustrated as well nevertheless uh i was very tempted to talk directly to scott but that would mean
02:10:51 to scott but that would mean i
02:10:52 i use the management chain and i was very i've always been very keen on following the line management chain i think it's it's bad management not to so so i made it clear to tom uh
02:11:03 so i made it clear to tom uh what he needed to do although to be fair to him he knew what he needed to do because he'd identified himself yes yeah taking the step back it's six years by this stage after mr
02:11:14 it's six years by this stage after mr kelly's audit from august 2010 or near as dammit six years
02:11:22 in 2016 what was your view of the reason why
02:11:27 why training was still not planned in a robust way and persisted being provided on an ad hoc basis what was the root cause
02:11:37 well the root cause was was firstly the fact that we weren't we didn't have iit support in the same way we controlled didn't have it support
02:11:49 way we controlled didn't have it support in the way that station-based staff did that was partly to do with the shift system in terms of the way it was recognized but that wasn't a
02:12:01 recognized but that wasn't a an excuse
02:12:03 an excuse it was also partly because control were just
02:12:07 just used to using spreadsheets and but what they also did do was they as i mentioned earlier they did keep coming up with individual training plans for specific pieces of training so
02:12:20 plans for specific pieces of training so that defy survival guidance training plan they had the national control center training plan there the rmc training plan so they had individual ones but it it
02:12:31 but it it in i think they kept falling into traffic thinking well we've got all the component parts and so therefore there it is but my view no that's that's not what it is and uh and it was it was kind of a constant
02:12:42 and it was it was kind of a constant battle to try to get them to understand what it was that we really needed and then of course there was a vision training which was absolutely immense and then everything else got put to one
02:12:54 and then everything else got put to one side whilst we dealt with it we have not found that the matrix was ever provided to you does that accord with your understanding yes
02:13:04 yes could we go to your first witness statement lfb trouble zero three two one double six forward slash fifteen
02:13:19 now if we look at paragraph 40 where you say this
02:13:22 say this i retired from the lfb before any the recommendations set out in ac george's review report were implemented the responsibility for those recommendations passed from me to the
02:13:33 recommendations passed from me to the then ac tom george now director of operations
02:13:40 can you help us as to why you yourself didn't take urgent action on receipt of the
02:13:46 the george recommendation in july 2016 to ensure robust training plans were put in place
02:13:57 i think because
02:13:59 because i i i had taken one step back or up whichever way you wish to describe it in terms of becoming direct to operations and and the link
02:14:10 direct to operations and and the link between me and control was now elongated because because tom was managing control and
02:14:18 and for me to
02:14:20 for me to to lean in and take instant action particularly around there still was the issues going on with training with vision
02:14:27 vision it's just not the way i did business so tom had been brought in and given the specific role of of brigade control with a few other add-ons
02:14:39 brigade control with a few other add-ons but nevertheless had the luxurious position of being able to concentrate and be based there in a way that i never could
02:14:47 could so i really just just underlined the issue with tom although he knew it himself anyway that this needed to be done rather than me just stepping in over him and doing it
02:15:00 just stepping in over him and doing it which i think just would have been bad management mr brown thank you um sir i've reached a point where i should be moving on to a fresh topic which is the
02:15:12 moving on to a fresh topic which is the complex one of training and record keeping yes i will not get that topic completed in quarter of an hour and if i start now i shall leave mr brown hanging in mid-question which i think is
02:15:24 hanging in mid-question which i think is unfair on mr brown um we are very well placed the entirety of monday has been allocated to mr brown's evidence oh really the whole of the whole of monday um
02:15:35 the whole of monday um i'm absolutely confident that his evidence will be done and dusted within that day
02:15:39 that day and so um
02:15:41 and so um at this point i don't think there's any prejudice for us pulling up stumps now um mr it's been a long day anyway and we can complete mr brown's evidence in properly on monday right well thank you
02:15:53 properly on monday right well thank you um well you've heard what mr kennedy has said i think the option is to plow on for another 10 or 15 minutes and reach a bad point at which to stop or to break a bit early which may not be
02:16:04 break a bit early which may not be entirely uncontinual i don't know um but it does mean that uh i frame i have to ask you to come back to continue your evidence on monday morning but i think that was programmed wasn't it it was uh yes right so uh on
02:16:17 wasn't it it was uh yes right so uh on the basis that as you've heard mr kenya say you'll finish on monday sometime i don't know when i think it would be sensible to stop now okay thank you so we'll break that we'll resume please at
02:16:29 we'll break that we'll resume please at 10 o'clock on monday morning and as i said to you before please don't talk to anyone about your evidence or anything relating to it over the weekend okay thank you sir all
02:16:40 over the weekend okay thank you sir all right thank you very much would you give the usher then please
02:16:53 all right let's get here well um we should finish this witness on monday then we shall one way or another we will very good thank you very much um we'll stop there and resume at 10
02:17:05 we'll stop there and resume at 10 o'clock on monday morning thank you very much
02:17:17 you