Evidence session examining the London Fire Brigade's response to the Grenfell Tower fire, including operational decisions, command structure, and lessons learned.
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00:00:00 Thank you.
00:00:29 Good morning everyone. Welcome to today's hearing. Today we're going to continue hearing
00:00:34 evidence from Ms Dani Cotton, formerly the Commissioner of the London Fire Brigade.
00:00:39 So would you ask Ms Cotton to come back in please?
00:00:41 Good morning Ms Cotton.
00:00:54 Good morning sir.
00:00:55 All ready to carry on?
00:00:55 Yes sir.
00:00:56 Good, thank you very much. Yes Mr. Chairman.
00:00:58 Mr. Chairman, good morning to you. Good morning members of the panel. Good morning to you Ms Cotton.
00:01:01 Good morning.
00:01:02 Now yesterday when we broke we were looking at an article at INQ 3014890. Can we please have that up?
00:01:12 There it is. And just to remind everybody of its title, Fatalities Will Happen Sooner or Later
00:01:19 warns fire safety expert after Dubai blaze resurrects fears over flammable cladding.
00:01:24 And if I can just remind you of the last paragraph on page one, if you scroll down the screen you can
00:01:30 see it. I'll repeat it to you because we looked at it yesterday. Tall British buildings have been
00:01:35 required to comply with British safety standards BS 476 which meets the class naught standard
00:01:41 stipulating no surface spread of flames since regulations were changed in the aftermath of the
00:01:47 1973 Summerland holiday park fire on the Isle of Man which killed 50 people and injured eight
00:01:53 seriously. Now you got this article as I know, as we know from the emails that we saw yesterday afternoon.
00:02:03 We've heard from other witnesses particularly Rita Dexter and Dan Daley, AC Dan Daley, that even
00:02:09 notwithstanding the UK regulatory regime the LFB had by this time encountered a great deal of
00:02:17 compartmentation breaches and a great deal of enforcement activity as a result focused around
00:02:24 compartmentation problems or focused on those problems. Were you aware of that at this time?
00:02:30 I became aware I wasn't I'd never worked in the fire safety part of London fire brigade but later
00:02:40 on in my career I became aware of some of those. When was that? I'm not sure I would have been
00:02:46 familiar with operational incidents where there had been compartmentation breaches as an operational
00:02:53 officer but not so much the enforcement side of things probably until I was the director and then
00:03:01 the commissioner. So 2016 or so? Yes. Do you accept that the LFB as a body knew that the assumption
00:03:12 that in the case of any given building the building regulations had been complied with
00:03:16 was an unsafe assumption? I think as from my knowledge at the time I was not aware that I
00:03:28 don't think that would have been made as an assumption. I think that there was still the
00:03:35 belief that the regulatory environment in the United Kingdom was designed to prevent such
00:03:41 breaches happening but I know that you know we were aware there were exceptions to that where
00:03:46 breaches did occur. Indeed and you must have been aware that the LFB as the enforcement body for
00:03:54 responsible persons in London came across perhaps came across with great frequency failures of
00:04:04 compartmentation in the building. Quite apart from any fires? No I was not aware that they came across that regularly.
00:04:12 Were you aware that from 2009 after Lacknell there were concerns within the LFB about potential
00:04:20 weaknesses in the regulatory system specifically the building regulations and the RRO? No I was not aware.
00:04:27 Did you ever discover that fact? No I don't think so. The area and the directorates that I worked in
00:04:34 were not connected with fire safety. You say not connected with fire safety it sounds would this be
00:04:41 right that you were completely disconnected from fire safety? I would say that and definitely whilst
00:04:49 doing the work that I have to prepare to come here that it's become quite evident that the fire
00:04:57 safety department in London Fire Brigade was not as well connected to the rest of the organisation
00:05:03 as it could or should have been. Is that an understatement? I think it was not as well
00:05:08 connected I think information was not shared and I think that it was probably not given the prominence
00:05:14 it should have been. Now the risk that a building may fail to comply with the regulatory regime is
00:05:26 one thing. What about the risk that highly insulated materials themselves may fail was that a risk
00:05:32 known to you in your capacities from 2012 to 2017? No it wasn't. Do you accept that it was the job
00:05:45 of operational assurance to put these two pieces of the puzzle together namely the risk that a
00:05:52 building may not comply with the regulatory regime and the risk that materials on a building may fail
00:06:00 and assist fire spread was a very real risk. That would not have come into the operational
00:06:08 assurance arena under any circumstance we didn't have dealings with the fire safety aspects it
00:06:17 might have come to our attention through ODCB you will have seen the membership of ODCB contain
00:06:23 the assistant commissioner for fire safety and also obviously Dave Brown who's in charge of fire
00:06:29 safety but no that wouldn't have been something that operational assurance would have been dealing
00:06:35 with. I'd like to know why that is given what operational assurance did as you've told us namely
00:06:43 to ensure the safety and safe operations and effective operations of firefighters on the
00:06:50 incident ground and members of the public. So the question is why wasn't it something to do with
00:06:56 operational assurance given that firefighters may come to a fire in a building which has either
00:07:02 failed or is about to fail and is not compliant with the building regulations? Because I think
00:07:10 there was a problem in the realization and understanding that there could be such a
00:07:17 significant failure of building regulations that was never brought to my attention so therefore we
00:07:24 would not have known that and I think there for it would have been very difficult to have drawn
00:07:30 that to conclusion that I would have known and therefore could have shared with firefighters.
00:07:35 Obviously firefighter safety was one of my main focuses and priorities so had that been something
00:07:43 that had been brought to my attention it would have been something we would have addressed but
00:07:48 it was not. We saw yesterday that it was within the operational assurance department that the
00:07:56 highly insulated buildings CBT package originated. Yes and as I explained yesterday that was as a
00:08:04 result of a firefighter fatality fire which is why it was of such great interest to the operational
00:08:10 assurance department and as I explained yesterday it was under a very different circumstance of
00:08:17 highly insulated buildings that that was the attention we were bringing to firefighters because
00:08:22 it clearly was a risk because it had translated into fatalities. Yes but surely the operational
00:08:27 assurance department wasn't interested only in firefighter fatalities and only interested in
00:08:32 incidents that had happened. Is it not the case that the operational assurance department should
00:08:39 have because it was part of its role been interested in examining all the risks presented by highly
00:08:46 insulated buildings on the incident ground. I think the problem here and I think that it wasn't
00:08:52 one that just London Fire Brigade suffered from I think the UK Fire Service as a whole still did
00:09:00 not have the knowledge contained in one place to identify the specific risk and the potential for
00:09:07 the hazard that could cause. I think there was nowhere that was sharing that information and I
00:09:12 think that should have been something that a central body should have been able to identify
00:09:17 all the pieces of information that I have now seen as part of my preparing to come here and
00:09:24 made that something that was shared through the UK Fire Service but it wasn't something that we had
00:09:31 shared with us in operational assurance. Now you got this article or rather you got the link to
00:09:39 this article through the email we've seen. We saw it yesterday afternoon. Looking at the first page
00:09:44 it's quite a striking image isn't it? Yes it is. Did you read this article in full do you think? Yes
00:09:51 I did. Yes. Let's turn to page four and on page four after the article there are some comments
00:10:01 left by individuals starting with Alan Brinson at the top of your screen and he highlights the
00:10:10 fact that fatalities had previously occurred at a similar fire in Roubaix in 2012 and also in as it
00:10:19 seems in Dijon in France in 2010 and then there are two comments below that and if you scroll down
00:10:25 please you can see the one left by Dane Owen who is at Omega Fire. Now he says this this article
00:10:34 seems to lack a grasp of regulations and the fundamental issue here it is this nothing to do
00:10:40 with class nor the surface spread of flame typically these facades achieve that requirement
00:10:45 as the outer skin is aluminium or other non combustible material therefore the fire will
00:10:50 not spread on the surface of the cladding. This is often confused by architects and specifiers
00:10:55 as the products often have a class naught rating and is then misunderstood as being compliant for
00:11:00 use in high-rise schemes. The issue is the flammable core of the insulation inside the cladding. This
00:11:06 is covered in the UK by clause 12.7 of the approved document which states the in buildings with a
00:11:14 story 18 meters or more above ground level any insulation product filler material etc. used in
00:11:21 the external wall construction should be of limited combustibility. The permitted products
00:11:25 or method of testing to pass the required standards are then referenced in the appendix. Although
00:11:30 this issue is prevalent in the Middle East and has been highlighted by recent fires there sorry
00:11:34 highlight of a by recent fires there are also large schemes still being incorrectly specified
00:11:40 and constructed in the UK due to this fundamental misunderstanding of the regulations. Now reading
00:11:50 that what did you read that at the time? No I read the article I didn't read the comments
00:11:54 underneath. You read the article you didn't read the comments underneath we saw the message that
00:12:00 came from Tony Biles who specifically picked up clause 12.7 yesterday we saw that if we want we
00:12:08 can go back to the email and we saw your response to it that is what would you accept he is responding
00:12:17 to not the article where we see no reference to 12.7 but the comment which has may have been left
00:12:23 by Dane Owen. Did you not go back to the article and have a look at it and see what it was that
00:12:29 Tony Biles was talking about? No because I understood that Tony Biles comment was as I
00:12:36 explained yesterday not one that he was making reference to understanding that because I knew
00:12:43 he was an understanding fire safety so no I didn't and I didn't read the comments underneath it.
00:12:48 If we go back to the email then let me show you the reference at LFB00024217 I just want to see if
00:13:07 I can pursue this a little more in your email of the 7th of January 2016 at 1509 you say in
00:13:13 response to Tony Biles who says always new clause 12.7 would be used somewhere by someone you say
00:13:19 I'm surprised it's taken them so long to reference such a key piece of information and we looked at
00:13:24 that yesterday together now I've shown you the comment which contains specific reference to 12.7
00:13:31 are you able to explain what you mean by or what you meant by I'm surprised it's taken them so long
00:13:38 to reference such a key piece of information? Yes as I explained yesterday I was responding
00:13:44 to Tony Biles flipping comment there is no response to the comment he's making about 12.7
00:13:51 that's what I explained yesterday though that's the sum of it and now I've shown you the full
00:13:56 document and the article rather the comment in which 12.7 appears specifically you still
00:14:04 stand by that answer to you? Yes that's the truth that was the answer that was the response at the
00:14:08 time that's all there was to it. Nonetheless having read that comment now as I've shown you
00:14:13 do you accept that you and other members of your directorate were on notice of the fact that
00:14:18 developers in the UK were routinely misunderstanding the building regulations and approved document B
00:14:24 and 12.7 specifically and conflating surface spread of flame with the requirements that the
00:14:30 products needed to be of limited combustibility? Other colleagues in fire safety may have had that
00:14:36 knowledge but as I said the people referenced in that email are not fire safety officers and had
00:14:42 not worked in the fire safety arena. Right why didn't you read the comments? I have no idea I
00:14:48 just read the article the articles of the interest to me I quite often find with many articles that
00:14:53 people write many many comments underneath that aren't relevant and I also am not a qualified fire
00:15:01 safety officer so lots of those would have been technical architectural details the interest to
00:15:07 me was around the actual article itself and the spread of the fire and the fact that it was made
00:15:12 reference to it shouldn't happen in the United Kingdom because of the building regulations we
00:15:17 have here. Right did you seek to explore that question with the fire safety department? No I
00:15:22 knew the fire safety department were aware of the fire because any noticeable fire is something of
00:15:28 interest to operational officers and the fire safety department contains a number of senior
00:15:33 operational officers. The senior officer in the fire safety department at this time was I think
00:15:42 Dan Daly? I think it would have. Or was it Neil Orbell at this point? Potentially Neil Orbell I
00:15:48 think but I couldn't recall it was either Neil Orbell or Dan Daly. Either way was there anything
00:15:52 stopping you simply pinging this on to them and asking them whether or not this could happen here
00:16:00 in the light of their specific knowledge? I think as I said previously that I had had conversations
00:16:06 at ODCB and other places where we had talked about fires overseas where there had been examples like
00:16:15 this and we had had the conversation about building regulations and standards being very
00:16:20 different in the United Kingdom. I mean did you regard this simply as a fire safety matter and
00:16:30 something for them and and really nothing to do with your department? No not at all that's why
00:16:35 we had a professional conversation because any fire is of interest to the fire service so it
00:16:42 wouldn't simply be a matter for fire safety. Yes you said a specific conversation did that
00:16:47 conversation not inform you that there were not infrequent breaches of building regulations by
00:16:55 developers or by owners of buildings regularly enforced by the LFB which involved failure of
00:17:03 compartmentation and fires such as this so that thinking that it couldn't happen here was an
00:17:10 unsafe assumption? As I said I was not aware of the amount of fire safety breaches and prosecutions
00:17:17 that London Fire Brigades had experienced. Did you actually have a conversation or discussion
00:17:22 with anybody in the fire safety department about this fire based on this article? No I didn't. Why
00:17:27 is that? Because I knew that colleagues were aware of these fires because of conversations I'd had
00:17:34 at ODCB. Which colleagues? Fire safety and other senior colleagues in operational policy because
00:17:41 all the members of ODCB would have been part of those conversations. Having seen the article did
00:17:48 you do anything about it? As I explained I had a conversation with professional colleagues where
00:17:53 we discussed the fact that building regulations were very different overseas to the United Kingdom.
00:17:58 Who told you that the building regulations overseas were very different to those in the
00:18:04 United Kingdom? It said so at the bottom of the article. Well it did and you just said you had a
00:18:08 conversation with professional colleagues where you discussed that. Who were the professional
00:18:12 colleagues you had that discussion with? Other senior officers I can't remember the exact list.
00:18:16 Graham Ellis was definitely one as was Lee Drawbridge but colleagues from other departments
00:18:20 as well I think operational policy. Right did you have a discussion with any professional
00:18:26 colleagues on this article from the fire service department? I'm sorry could you repeat the fire
00:18:34 service department? Fire safety department? No you've asked that no I didn't. You didn't why is that?
00:18:38 Because as I said we'd had conversations at ODCB about it. Yes but ODCB hasn't got people on it
00:18:48 from the fire safety department. The assistant commissioner for fire safety was a standing
00:18:51 member of ODCB. So well that's interesting so because we've not seen any discussion at ODCB
00:18:59 level involving that officer on this topic. No so it wouldn't have been a discussion that was
00:19:06 necessarily minuted it would have been a professional discussion amongst colleagues around fires in other
00:19:12 countries but the standing members of ODCB contained all of the assistant commissioners
00:19:19 from the relevant departments policy fire safety resilience operational assurance and that's the
00:19:26 basis where we would have conversations not the whole subject of that meeting was always minuted.
00:19:31 To the best of your recollection did any officer from the fire safety department at any time give
00:19:39 you an assurance that the fire that happened in Dubai the subject of this article couldn't happen
00:19:46 here because of our regulatory regime? No. No and given that were you not interested yourself to
00:19:55 find out the answer to that question rather than simply taking it from as a quotation from the
00:20:00 article? At that time it was something that wasn't brought to my attention so no. It wasn't brought
00:20:07 to your attention as you say but was it not something that you were interested in getting
00:20:11 to the bottom of so that you could be sure that this was not a risk that your firefighters were
00:20:17 going to be facing? I knew that we had a very professional fire safety department containing
00:20:23 not only operational officers but fire engineers and I would have expected if they had that
00:20:29 knowledge they would have raised that and brought that to the attention of all operational colleagues.
00:20:34 Right so in a nutshell does it come to this you got the article you read it you didn't read the
00:20:43 comments and you waited to see if the fire safety department said anything to you about it and if
00:20:50 they didn't then all was well? Yes. Now let's look in a little bit more detail at the institutional
00:21:09 knowledge of the brigade on widespread compartmentation failure. We heard some evidence
00:21:14 about this at module 5 and Dan Daly told us that much of the LFB's RRO enforcement activity was as
00:21:22 he said predicated on compartmentation because it's a significant risk where we find it's been
00:21:27 breached that's what he said and he told us about a report which I'd like to show you at LFB 00120301.
00:21:35 It's entitled fire resistant compartmentation flats and it was written by the head of regulatory
00:21:49 enforcement in fire safety Andy Jack and indeed I should just tell you this document is an exhibit
00:21:54 to Andy Jack's witness statement to the inquiry. He has told us in writing in that statement that
00:22:01 this was written in August 2016 and for a bit more background AC Daly told us that the report
00:22:09 may have gone to the directorate management board DMB and possibly the CMB or the commissioners
00:22:16 group that's what he told us at day well he told us that I'm not sure exactly when we can find that
00:22:24 out. My question is did you see a subsequent version of this report? Not that I recall I would not
00:22:30 have attended their directorate management or performance management board. Right now let's
00:22:35 look at the document page 2 and at page 2 you can see that the bottom paragraph there is something
00:22:45 there is a headline the compartmentation issue and a text underneath that which says this the
00:22:53 compartmentation between flats is of vital importance to prevent the spread of fire through
00:22:57 a building containing multiple dwellings and is essential if an evacuation strategy based on
00:23:03 defend in place is to be used in the building in the absence of adequate fire-resistant
00:23:07 compartmentation fire and or the products of combustion are liable to spread into other
00:23:12 dwellings in the block and or the means of escape in the absence of an early warning of fire persons
00:23:18 in those premises may be overcome or prevented from making a safe escape this assumes an even
00:23:24 greater significance in in premises occupied by vulnerable persons who may need assistance to make
00:23:29 an escape or otherwise be slow to do so due to infirmity or lack of awareness of danger for
00:23:35 example in sheltered housing blocks and if you go to page 3 turn to that page it says this the
00:23:42 ongoing experience of the authorities inspectors is that fire risk assessments rarely consider
00:23:47 compartmentation in areas of the building away from the means of escape and rarely consider
00:23:53 services that run through flats for example soil pipes and ventilation consequently scant
00:23:59 factual basis is available to justify or validate use of a stay put emergency plan now AC Daily told
00:24:10 us and it's day 184 page 70 line 10 to 71 line 19 for the reference that the point being made by
00:24:19 this report was that stay put as an evacuation strategy should only be relied on where it can
00:24:25 be established that a building's compartmentation is effective and that the LFB had concerns at
00:24:31 the time the fire risk assessors were not able to assess the compartmentation of the building
00:24:35 as a whole that was his evidence now would I be right in thinking that when you became
00:24:41 commissioner in 2017 you became aware of that problem no I was not made aware of that problem
00:24:47 you were not no I wasn't had you been a way made aware of it previously no I hadn't been
00:24:52 had you ever been made aware of that problem no I hadn't been can you explain why that is I don't
00:25:01 know because nobody shared that information with me you were the commissioner come January
00:25:05 2017 I was and nobody told you that stay put an evac you as an evacuation strategy should only
00:25:13 be relied on where it could be established that the building's compartmentation was effective no
00:25:18 nobody told me do you find that surprising I do now knowing seeing that but nobody told me this
00:25:24 at the time the report then goes on to cite examples of fire safety breaches that have
00:25:30 compromised compartmentation and I'll just show you one or two if we stick with page three is
00:25:35 cotton you can see lower down in the second paragraph first bullet point a number of examples
00:25:40 the first one is common communal ventilation system at lacanel which allowed products of
00:25:45 combustion to percolate from flat to flat and then if you go to page eight I'll show you these
00:25:53 together and then ask the question if you look at the top of page eight the report goes on to
00:25:57 record in the conclusions part which starts on page seven as follows there are significant
00:26:04 examples of compartmentation issues posing high levels of risk to the public more examples are
00:26:09 very likely to be discovered and so rectified as a result of fire risk assessment before fires
00:26:15 occur pushing the boundaries of the RRFSO to ensure that this happens is in the interests of
00:26:21 public safety now during your tenure as Commissioner what was the LFB strategy for resolving that
00:26:30 widespread concern do you know no I don't you don't know I don't you know whether there was a
00:26:35 strategy I'm unaware right now against that background and given the LFB's knowledge as
00:26:43 I've shown you namely significant examples of compartmentation issues posing high levels of
00:26:49 risk as this report says can you explain why no action was taken to inform local crews that
00:26:56 compartmentation issues were abundant they might impact their operations and posed a high risk for
00:27:02 crews and members of the public alike I don't know why that information wasn't shared again do
00:27:10 you find that surprising I do find surprising that a part of London Fire Brigade had information that
00:27:17 could impact on operational crews ability to deal with an operational incident and that wasn't shared
00:27:22 yes well I mean can you shed some light on what it was about this organization the LFB that meant
00:27:28 that that information was so tightly held and not disseminated to the people who mattered I don't
00:27:34 know it's become evident in my reading papers to prepare for this that I think that sometimes the
00:27:40 work of the fire safety team was in almost a silo situation and was not as well connected to
00:27:47 the operational colleagues as it should have been but I can't answer as to why I say I didn't work
00:27:53 in that directorate and do I take it from that answer that that's the that is also the reason why
00:28:00 no action was taken to expand LFBs operational training on compartmentation issues I would
00:28:07 imagine so but I say I'm unaware can you and given your last two answers one suspects what I know
00:28:23 what you'll say but let's give you an opportunity to answer it why did the LFB not send a very clear
00:28:28 message to crews telling them of the LFBs growing concern at latest by 2016 that a stay put evacuation
00:28:37 strategy may be undermined or inappropriate in any number of buildings in front of them and that
00:28:43 they may be they may be required to evacuate residents in challenging environments I don't know
00:28:49 the answer to that let's go to CLG 1 3 0 is 9016 this is a letter dated the 3rd of April 2017 to
00:29:09 Gavin Barwell as he then was MP who was the Minister of State for Housing Planning and Minister for
00:29:17 London within the DCLG as it then was and if you look at page 2 we can see that the letter came
00:29:24 from you yes it did yes it's copied to Brandon Lewis who was Minister for Policing and the Fire
00:29:31 Service and let's just see what you say you say in the third paragraph down well there has been a
00:29:45 focus on the quality of construction in schools and hospitals due to some high-profile building
00:29:49 failures we have mounting evidence of issues of concern within residential buildings and in
00:29:55 particular blocks of flats in a purpose-built block of flats each flat should be separated by
00:30:00 a minimum of 60 minutes fire-resistant construction from the rest of the building compartmentation
00:30:05 should also be provided between flats to the escape routes around communal rooms and facilities
00:30:10 concealed voids common service rises and from other occupancy types residential buildings are
00:30:16 designed to have a stay put policy whereby only the residents within the flat of fire origin
00:30:21 evacuate in the event of fire all other residents can safely remain within the building unless
00:30:27 directly affected by heat or smoke or directed to leave by the attending firefighters the standard
00:30:33 of compartmentation is therefore critical as it limits fire spread within the building to protect
00:30:39 other residents from the effects of fire it also assists in protecting firefighters by
00:30:43 preventing unseen or unusual fire spread when compartmentation is missing or incorrectly
00:30:50 installed it can potentially place residents at significant risk with the Lacknell house fire
00:30:55 in 2009 in which six people died there were compartmentation breaches which allowed fire
00:31:00 and smoke to spread through the building contrary to the functional requirements of the building
00:31:04 regulations and in direct conflict with the evacuation strategy for the building we're
00:31:08 deeply concerned that since the beginning of 2017 LFB has identified on average at least one
00:31:14 residential property or development in London with significant compartmentation deficiencies
00:31:20 per month these usually come to our attention after a fire or by a person responsible for the
00:31:27 property seeking our advice it is safe to assume that there are many other cases that do not come
00:31:32 to our attention yet are placing the residents of those properties in significant risk from
00:31:37 fire spread within the building and then if you turn
00:31:52 to the last page please you see there's a paragraph about wider issues which I don't
00:32:00 think I need to read to you the last sentence I should it says this we are also concerned
00:32:06 about contractor competency and how this influences compartmentation deficiencies and therefore
00:32:11 occupant safety in respect of fire whilst raised in the context of flats the issues above also
00:32:17 occur in a variety of building types and occupancy such as schools and hospitals I very much hope
00:32:22 that we can meet to discuss how we can work together to make London a safer place to live and I look
00:32:26 forward to hearing from you now first you agree this letter doesn't actually convey what the
00:32:33 wanted from the department what was it I believe that in this letter was put together by Dan Daly
00:32:44 and his team in fire safety the concern was around the the approved inspectors it says and
00:32:53 around building standards and that they to put pressure on the responsible people for building
00:33:02 and regulation and inspection of buildings to ensure this couldn't happen
00:33:09 did you meet Gavin Barwell so could you remind me the date of the letter please yes it's the
00:33:13 third of April 2017 I think we did I'm sorry I had many many meetings with external people I
00:33:22 can't remember specifically but I'm I'm pretty sure that Dan Daly and I and someone else from
00:33:28 his fire safety team maybe Andy Jack did meet with him right at all events it looks as if would
00:33:34 this be right that certainly by the third of April 2017 you as the signatory of this letter
00:33:40 were well aware of the problems discussed in it yes at that point the fire safety well and
00:33:46 Dan Daly had brought this to my attention as an issue yes yes but by this time of course you were
00:33:50 commissioner and not in charge of operational assurance I was yes when this came to your
00:33:55 attention and before signing the letter you read it did you think to direct or investigate I should
00:34:06 say what training was being given to frontline responders about the risks posed by compartmentation
00:34:13 failure and the consequent knock-on effect to the validity of a state policy in any given building
00:34:20 so I was aware from my previous membership of ODCB that following any operational incident our
00:34:28 fire investigation team would complete a report that would contain details of the fire the cause
00:34:37 of the fire and any issues that had come about that would be fed into the diat process and any
00:34:46 areas or trends as we've said before would have been identified so if there had been increasing
00:34:51 risks which would have been identified by fire investigation reports that would have been fed in
00:34:57 and I would have assumed that that would have then been taken forward into a training program
00:35:04 but no at that time I did not check that personally
00:35:08 now you told us earlier this morning that you'd never been made aware of the problem namely
00:35:23 that state put as an evacuation strategy should only be relied on where it could be established
00:35:29 that a building's compartmentation was effective and the LFP had concerns from 2016
00:35:34 I mean looking at this letter that can't be right can it you did know that at least by early April 2017
00:35:42 what I said was that I wasn't aware that London Fire Brigade had so many issues with prosecution
00:35:48 around breaches I was clearly aware from this letter that there had been issues in the built
00:35:55 environment because that's why the Assistant Commissioner for Fire Safety wanted us to meet
00:36:01 with Gavin Barwell I wasn't aware of the detail of that or the volume of that
00:36:07 right well let's then go back over things a little bit looking at the topics covered by this letter
00:36:13 to which you put your signature when did you first become aware of the problems identified in it
00:36:19 I think shortly before this letter Dan Daley would have
00:36:23 met with me and had a conversation with me about it so you knew nothing about any of this until
00:36:29 what early April late March I don't recall when I would have had other knowledge but I definitely
00:36:35 I mean I can only say that I would definitely know it then because I can see that I'd
00:36:39 read and signed a letter so I can't remember right and when this was first brought to your
00:36:44 attention do you remember what your reaction was no not specifically at that time I had only been
00:36:51 in post for a very short time there were as you can imagine a huge number of things that came to
00:36:58 my attention and a huge variety in roles and responsibilities that the London Fire Commissioner
00:37:04 had and this was one of those so it was an exceptionally busy time we were also as you
00:37:10 aware dealing with large-scale terrorist incidents that have taken place in London so I it was
00:37:18 exceptionally busy time and I can't recall the specifics of each piece of information I'm sorry
00:37:23 when it was first brought to your attention did you not think to yourself or did you not ask
00:37:28 yourself why it hadn't been brought to your attention at any earlier time 2015 particularly
00:37:34 2016 when you were director of operation operational assurance I would have assumed that this had been
00:37:41 brought to the attention of the director of operations and the deputy commissioner
00:37:45 at that time so no I wouldn't have thought why it hadn't been brought to my attention when you make
00:37:50 an assumption you say I would have assumed that this would have been brought to the attention of
00:37:53 the director of operations did you not ask why you didn't know about it until April late March
00:38:00 perhaps 2017 no I didn't I mean why is that this is a major challenge isn't it to the efficacy
00:38:09 and fire safety of high-rise residential buildings in London you had occupied a senior position in
00:38:16 operational assurance and then safety until you were appointed commissioner did you not want to
00:38:21 know why it was you didn't know anything about this if that's the case no because I say we had
00:38:28 professional operational colleagues in that directorate who would have been aware of that
00:38:32 information so I don't know why they didn't share that information right and can I just ask you then
00:38:38 given that you knew these of these problems in April 2017 what steps did you take or did you
00:38:45 take any steps to instigate any training any refresher training to make sure that frontline
00:38:53 responders knew that when they went to a fire in a high-rise building these were the risks they had
00:38:58 to be aware of I didn't take any steps personally at that point this information would have been
00:39:05 shared through both the directorate management board and with odcb and that's where those steps
00:39:13 would have been taken as the commissioner no I didn't take any steps personally why is that
00:39:18 as I explained it was an exceptionally busy time I was new to the role I was trying to
00:39:25 um get effectively get my head around the huge numbers and areas of responsibility that I had
00:39:31 so um I was very busy with dealing with a large number of key issues yes but this issue was
00:39:39 sufficiently important wasn't it for you to write to the minister and copied to the other
00:39:46 relevant minister this was a big issue otherwise you wouldn't have sought to trouble central
00:39:51 government with it so why wasn't this top of your agenda or close to it um because I said there were
00:39:56 a number of other risk critical things such as terrorist attacks taking place in London that
00:40:02 were also competing priorities this isn't the only letter you wrote at the time is it uh let's go to
00:40:08 lfb triple zero eight nine zero six four
00:40:18 now this is a letter that is addressed to ben gummer mp house of commons
00:40:27 and if you go please to the third page you can see that it isn't signed it looks as if it's a draft
00:40:36 do you remember this document no I don't you don't
00:40:42 uh let's just look then at the third paragraph down we go back to page one please housing
00:40:52 uh the title is conservative party manifesto uh and it opens I'm writing to you regarding
00:40:58 the conservative party manifesto for the 2017 general election so this I think we can take it
00:41:04 I think we can take it was ahead of the general election on the best of my recollection the eighth
00:41:10 of june that year I know this will be published very soon but hope there may be still may be an
00:41:15 opportunity for you to consider three proposals from the london fire brigade lfb for inclusion
00:41:20 in the manifesto that will improve fire safety in our homes schools and places of work but now I
00:41:26 set out three key measures that I would urge you to include in the manifesto and would of course be
00:41:30 happy to provide further information on any of these issues and then housing
00:41:36 uh we have mounting evidence of issues of concern over the quality of construction of some residential
00:41:43 buildings and in particular blocks of flats in a purpose-built block of flats each flat should be
00:41:48 separated by a minimum of 60 minutes fire resisting construction from the rest of the building
00:41:53 residential buildings are designed to have a stay put policy where only the residents within the
00:41:58 flat of fire origin evacuate in the event of fire all other residents can safely remain within
00:42:03 the building unless directly affected by heat or smoke or directed to leave by the attending
00:42:09 firefighters the standard of compartmentation is therefore critical as it limits fire spread within
00:42:15 the building to protect other residents from the effects of fire it also assists in protecting
00:42:21 firefighters by preventing unseen or unusual fire spread and then there's the paragraph
00:42:27 uh which is identical to the paragraph in the letter you signed on the 3rd of April 2017 and
00:42:34 then below that in bold in the box it says this what we are calling for we are keen to ensure the
00:42:40 quality of housing and a key safeguard our building regulations building regulations ensure that plans
00:42:46 are approved by local authority building control LABC or private approved inspectors we are concerned
00:42:54 that LABC power to take enforcement action expires after 12 months of a building being completed
00:43:00 and power to prosecute expires after two years these deadlines limit LABC powers and can leave
00:43:06 a legacy of problems which can massively impact the safety of residents in a fire we want the
00:43:11 deadlines to be extended to a more appropriate period to be decided through consultation with
00:43:16 key stakeholders do you remember seeing this this this letter in draft form
00:43:24 no i don't recall seeing it is this did you ever have you ever seen this document before
00:43:29 no i don't think i have i don't recall seeing it right do you remember having any discussion
00:43:34 about writing to ben gummer on these issues uh no this would be the conversation between dan
00:43:40 daily and probably helen newton right do you remember any discussion about a problem with
00:43:49 enforcement of building regulations and time limits available to the LABC for prosecution
00:43:54 no i don't remember that right
00:44:02 can i then turn to a different topic which is the 2016 review of brigade control by AC
00:44:09 Tom George who has given evidence and he produced as you may know a report on the 22nd of July 2016
00:44:17 which contained a number of observations and recommendations and he explains in his statement
00:44:24 that steps were being taken by other senior officers in control to implement the recommendations in
00:44:30 his report now he also told us that he presented an updated report to the lfb's corporate management
00:44:37 board in February 2017 not long after you were appointed interim commissioner do you remember
00:44:43 that report i do yes you remember it being presented to the cmb i do yes yes
00:44:50 do you know why the report had not been presented to the cmb in July 2016
00:44:57 no i'm unaware the report had been commissioned by and obviously presented to director Dave Brown
00:45:05 in his directorate why that wasn't then taken to the commissioner's board
00:45:10 i don't know it was something that i was quite keen seeing the outcome of right
00:45:19 you say you were quite keen to see the outcome of it how did you learn about it
00:45:23 Dave Brown had told us at the commissioner's board that AC Tom George was being commissioned
00:45:29 to do that piece of work and you asked him for it did you i spoke to Dave Brown and asked
00:45:39 if we were going to see the outcome of the report and he said we were
00:45:42 and then when by the time i became commissioner i asked again about it and it was then presented
00:45:47 to the commissioner's board did you specifically ask him to present it formally to the commissioner's
00:45:52 board i asked Dave Brown if he would be bringing it yes right when did you first read it
00:45:59 probably prior to that meeting i see when you did read it did you have any particular concerns
00:46:05 about its findings or about control more generally i had concerns about control i had become aware of
00:46:13 the fact that control were i'll say not you know they were feeling that they
00:46:21 were isolated from the mainstream part of london fire brigade i had actually visited control on
00:46:27 number of occasions as part of the program they were doing of staff engagement to hear some of
00:46:36 their concerns so i was aware that there were issues and so that's why i was pleased that
00:46:42 the report had been commissioned to look deeper into the issues in control and did you ask Dave
00:46:51 why you hadn't presented it to the cmb before february 2017 no that would have been a decision
00:46:57 between himself and the then commissioner on dobson yes maybe but were you not interested
00:47:02 to know what the reason was i knew the report had been through a number of different
00:47:11 sort of evaluations of it i suppose so no i didn't know why it hadn't been presented
00:47:16 and i think it's right that you asked that a further update be provided to the cmb
00:47:21 six months thence i did yes why did you want an update in such a short space of time
00:47:27 because i wanted to ensure that the areas that have been identified were being addressed
00:47:31 did you have any particular concerns arising out of your review of that report or
00:47:35 from discussing its findings at the cmb i was concerned that i thought there were a number
00:47:40 of areas that needed focus and work on and that i wanted to ensure that the action plan was being
00:47:46 implemented can i just go back then to the letter to ben gummer the draft document we looked at
00:47:53 earlier you said you hadn't seen it before let's have it on the screen lfb 00089064
00:48:01 i said i didn't recall seeing it i'm not sure whether i had i don't recall having seen it
00:48:05 you don't recall having seen it well let's just let's just get to the bottom of that if we can
00:48:09 can we have that on the screen can we also have on the screen at the same time please
00:48:12 lfb 00089063
00:48:20 this is an email from helen newton to you do you see i do yes and subject for clearance to sign
00:48:29 letter repartee manifestos and it says hi danny despite the unexpected nature of the general
00:48:34 election we have identified an opportunity to urge the three main political parties represented
00:48:39 in london to include some of our key asks in the party manifestos we understand that the parties
00:48:45 are still seeking policy ideas although time is of the essence and it goes on i've heard from
00:48:51 several labor mps this week etc uh and in the middle of paragraph it in the middle of the
00:48:57 middle paragraph it says the key asks are on building regs sprinklers in schools and the
00:49:02 single recall register are all issues on which we've been campaigning and it's signed off by
00:49:07 helen newton who's the public affairs manager for the lfb as you can just about see on your screen
00:49:15 you don't doubt do you that this draft did at least come across your desk and quite possibly
00:49:21 as i said at the time it was exceptionally busy it was quite common that i would have
00:49:29 in the region of 20 to 30 letters a week right that would require my signing so yes as i said
00:49:36 i don't recall but the issue around the total recalls campaign was something we've been doing
00:49:43 a lot of significant work on and the fire safety team helen newton had been particularly focused so
00:49:48 i was very aware of that in the next paragraph it says please find attached three letters which
00:49:54 are the same wording but addressed to each party lead and then in bold underlined could you let me
00:49:58 know as soon as possible if you are happy to approve and sign these as i'll need to get them
00:50:03 out very quickly do you remember whether you did sign them and send them out i don't know as i say
00:50:09 my my inbox would have been managed and dealt with by my staff officer and my pa team so i would
00:50:16 imagine they would have printed them for me to sign at all events you don't remember a specific
00:50:22 problem with a letter like that such that you would call helen newton and say i'm sorry
00:50:27 i'm not prepared to sign that or have a further discussion about it i wouldn't imagine so helen
00:50:32 newton would have done a lot of background work with dan daily on these issues and they were both
00:50:38 being very proactive in these matters so can we proceed on the assumption that although you may
00:50:44 not be able to remember it now at the time you saw the letter you would have read it and and signed
00:50:51 it off as asked by helen newton i would imagine so i say i can't recall but i would imagine so
00:50:55 right and when you say i would imagine say is that because you don't remember taking one of these
00:51:01 letters out of the pile you had and saying i'm sorry i can't sign that i need to have a discussion
00:51:06 about it um i think i probably would have had a discussion about it anyway but i don't recall
00:51:11 specifically any issue with this letter right now i just got one or two final questions for you miss
00:51:16 cotton on the 14th of june 2017 you attended the grenfell tower fire as commissioner of the london
00:51:23 fire brigade and indeed as monitoring officer i did yes and in september 2018 you attended phase
00:51:30 one of this inquiry to give evidence about the night in question over three years later have you
00:51:38 having had the time to reflect not only on the events of that night but on the years
00:51:42 that preceded it is it your view that the grenfell tower fire was a one-off fire completely
00:51:49 unpredicted completely unpredictable for which the lfb could never reasonably be prepared
00:51:55 um i think that having had the time to reflect and the understanding of the knowledge london fire
00:52:00 brigade had um my view is that we had a lot of organizational knowledge um i still think that
00:52:09 even now the knowledge held by london and the uk fire service would not have anticipated such
00:52:16 a catastrophic failure of any building with so many breaches but yes we did have knowledge of
00:52:22 various aspects of that and i think that that has become evident by the documents that i've read
00:52:29 and reflecting on the evidence that you have given to the inquiry over the last two and a bit days
00:52:35 are you able now to identify anything that you could or should have done during your time at
00:52:40 the lfb which would have better equipped the incident commanders at the fire on the 14th of june
00:52:47 at the fire on the 14th of june at grenfell tower i think that organizationally um there was
00:52:53 information that we could have shared that could have been um translated into training for um all
00:53:00 members of london fire brigade um that may well have assisted them yes thank you um i've now come
00:53:09 miss cotton to my prepared questions there may be some further questions that i have skipped over or
00:53:14 happened to ask you which i may need to go back to and there may be further questions that others
00:53:19 may wish me to ask so i'm going to ask the chairman for a little bit of time for that in the usual way
00:53:23 as we do yes well as i think you know miss cotton when council gets to the end of his prepared
00:53:30 questions uh we always have a break to give him a chance to check that he hasn't left something out
00:53:35 and to give other people who are following the proceedings but not from this room a chance to
00:53:40 suggest questions that perhaps we should have put you so we'll have a break now i think we'll
00:53:46 we'll come back at quarter past 11 and at that point we'll see whether there are any more questions
00:53:52 that we need to ask you yes sir thank you and as before when you're out of the room please don't
00:53:57 discuss your evidence or anything to do with it with anyone no sir thank you all right thank you very much
00:54:10 uh right miss millick well i thought we could be a little bit more generous on the timing of the break
00:54:16 this time uh yes and that'll give you plenty of time to deal with anything that crops up it should
00:54:21 given the overnight break we've had but if i need a little bit longer well of course you only have
00:54:25 to tell the usher to come and warn us very good thank you very much thank you very much
00:54:28 quarter past 11 please
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01:15:40 would you ask us cotton to come back in please
01:15:53 right miss cotton well we'll see now if there are any more questions for you thank you sir
01:15:56 thank you yes mr millick yes mr chairman thank you one or two um can i ask you please to be shown
01:16:02 lfb double one sorry double zero double one eight two three seven lfb double zero double one eight
01:16:08 two three seven
01:16:12 this is an hse document health and safety executive entitled striking the balance
01:16:18 between operational and health and safety duties in the fire and rescue service and you'll see it
01:16:25 has two authors one of whom it was the chair judith hackett now the date of this was in fact
01:16:33 march 2010 if you go to page two please
01:16:39 you could see that there was some guidance here and some principles
01:16:46 if you look at that you can see that
01:16:53 if you look at page two you can see the principles set out there under principles
01:16:57 particular challenges for fire and rescue authorities as employers
01:17:00 now first i should ask you have you ever seen this document before yes i have you have when
01:17:05 did you first see this document do you think um i'm not sure but i remember having um conversations
01:17:12 high level ones with dr asian bevin who was the head of health and safety and he had also worked
01:17:18 for the health and safety executive were you commissioner at that stage or were you in one
01:17:23 of your former roles no in my former roles which role assistant commissioner operational assurance
01:17:29 i see a coa so you saw that before 2016 then yes yes i see and if you look at the guidance
01:17:39 under principles you can see the application of health and safety law is challenging for
01:17:43 foreign rescue and it sets out some reasons why that is it then sets out the health and safety
01:17:50 duties and if you go to page four you can see some guidance behind the principles on page four
01:18:00 and this is what the hse inspectors would consider you see those were you aware of
01:18:06 the primary duties which it is said in this document hse inspectors would consider page four
01:18:15 so i can't sir no i have to wait for it to come up
01:18:18 up
01:18:24 thank you so there you can see at the top of your screen it says the primary duties under health and
01:18:31 safety law are on employers hse inspectors when inspecting or investigating an individual fire and
01:18:37 rescue authority using hsc's own procedures including the work related death protocols
01:18:42 we'll consider and then there's a list of of bullet points you see that okay yes were you
01:18:46 familiar with those at the time not familiar with them i think i'd seen them but i wasn't
01:18:50 familiar with the detail because as i said i had dr asian bevin was my professional expert in health
01:18:57 and safety right so you just explained to me did you when you got this document and you saw it
01:19:05 did you ingest the detail and make sure you were well aware of these these principles and these
01:19:11 things that would be considered i didn't receive formally receive the document i was aware of the
01:19:16 document right did you ever have cause to refer to it no i didn't right can i ask you please to
01:19:26 be shown cwj six zeros 22 this is another hsc document the management of health and safety in
01:19:41 the gb fire and rescue service of october 2010 have you ever seen this before i don't recall
01:19:50 having seen this no right it's a 24 page document if we go to page 23 please we can see that
01:19:59 there are some key recommendations set out in summary in part five of this document
01:20:05 and you can see that in paragraph one all fire and rescue services should and there's a list of
01:20:14 things they should do including having effective processes to assess competence as the third
01:20:20 bullet point down much of this is about about training and maintenance of accurate records of
01:20:27 training etc two is about the production of national guidance or minimum common practice
01:20:34 minimum standards and three fire and rescue services should ensure the training framework
01:20:40 for the maintenance of core skills is able to equip firefighters to competently deal with all
01:20:45 reasonably foreseeable risks at incidents quality assure the delivery and effectiveness of core
01:20:50 skills training across all duty systems and roles and ensure training records are complete and
01:20:55 effective and it continues under four and five on training and five good practice on incident
01:21:03 command training and six is about risk critical information being provided to an incident commander
01:21:10 being accurate timely and suitable and it goes on over the page to page 24 in similar vein
01:21:20 seven all services should ensure that the first bullet point they provide adequate training for
01:21:25 staff gathering and assessing risk critical information a system in place to actively collect
01:21:30 relevant risk critical information they monitor the effectiveness of these arrangements risk
01:21:35 critical information is kept up to date and is in a suitable format and incident commanders
01:21:40 are able to assess access the information to inform their command decisions
01:21:47 were you aware of those recommendations that i've shown you no i wasn't you weren't
01:21:55 at any stage even as as as commissioner i don't believe so no can you explain why that is given
01:22:02 your role originally as a coa i would imagine it would be something that dr adrian brevon is the
01:22:09 professional lead for health and safety and prior to that
01:22:14 brenda weir who led on health and safety would have been informed of but i was not made aware of
01:22:19 right it's old isn't it that you weren't made aware of it given your role as a coa surely that
01:22:25 would be well this kind of document would be exactly the sort of thing that you would
01:22:28 expect to have on your desk or is that wrong i wasn't made aware so no i don't believe so
01:22:35 well um that reasons from the outcome i mean do you accept that you should have been made aware
01:22:39 of this document it should have been imprinted on your heart i think that i had a health and
01:22:44 safety professional i said who had worked for the hse working for me so therefore
01:22:49 i would be as not a health and safety professional myself dependent on having that professional
01:22:55 expertise during your time as a coa do you remember whether there was an audit
01:23:03 or quality assurance conducted independently to ensure that the lfb was actually compliant with
01:23:09 the expectation contained in this document and indeed the first one i showed you
01:23:13 i don't recall if there was you don't recall if there was i don't recall if there was do you
01:23:19 mean by that you have no recollection of there ever being one or you don't remember one way or
01:23:23 the other i don't remember one way or the other right as a coa you you it would be unusual
01:23:30 wouldn't it not to know about a third party independent audit of compliance um we had
01:23:36 external mopak who provided audit facilities london fire brigade they may well have undertaken that
01:23:42 the mopak recommendations um were discussed at commissioner's board
01:23:46 whether that took place um prior to me being there i i'm not aware
01:23:55 yes thank you very much um miss cotton i have no further questions for you it remains for me to
01:24:00 thank you very much for coming to the inquiry in phase two and assisting us with our investigations
01:24:04 we're extremely grateful to you thank you yes miss cotton and i'd like to add my thanks on
01:24:09 behalf of not just myself but obviously the other members of the panel you've given evidence for
01:24:14 quite a long time it's very helpful to us to hear directly from those involved in these sort of
01:24:19 matters so we really are very grateful to you for coming along and telling us what you know
01:24:24 thank you so thank you very much indeed and you're now free to go thank you very much
01:24:28 thank you i'd like to give the usher
01:24:39 right mr millet now we have another witness i think but not quite yet we do not quite yet
01:24:45 former commissioner ron dobson who will be examined by andrew kinia queens council
01:24:50 i am told that he will be ready or at least here in about an hour um well we'll start him at two
01:24:57 o'clock would probably be a probably best the most convenient course wouldn't it very well yes
01:25:01 very well well we'll um break at that point we'll resume then at two o'clock when we shall look
01:25:08 forward to hearing evidence from former commissioner dobson thank you very much two o'clock please