Grenfell Tower Inquiry - Evidence from London Fire Brigade Head of Fire Safety on training, stay put policy, and awareness of cladding risks
00:26:04 would you ask mr daley to come back in please
00:26:19 all right mr daily ready to carry on yes absolutely good thank you yes mr village yes mr chairman thank you mr daley before the break for lunch you were telling us about the understanding of the purpose of the
00:26:30 understanding of the purpose of the inputs from dclg as you put it and you said that the learning was brought back for the felos to say that you might not usually get an external wall as part of
00:26:41 usually get an external wall as part of your consultation process but if you do these are the routes to compliance and these are the risks if you don't take them seriously i just want to understand if we can please a little bit more about the consultations you're referring to or
00:26:53 the consultations you're referring to or that process um that's a process of con statutory consultation is this right between the um or rather with the lfb by building control officers yes absolutely we
00:27:05 control officers yes absolutely we referred to it earlier today normally concerns itself with means of escape and facilities for firefighters yes as i mentioned earlier on occasions we are sometimes given a more complete bundle from building a troll body
00:27:17 bundle from building a troll body and where there are aspects that we might want to comment on we we do but it's not usual and just just sorry if i may in terms of the presentation
00:27:28 the presentation the the context of the day uh when it was presented by dclg was very much that you know the diagrams that you showed were produced as part of that package from dclg now and lfb products as such they were pulled together from
00:27:40 as such they were pulled together from that presentation um i think they they illustrate why we have the regulations in place that we do and the importance of them so it's not so much it doesn't represent learning if
00:27:51 so much it doesn't represent learning if you like it it's about what underpins the regulations and the need for them and so that was what was being brought back right um the consultation process that you're describing um you you say that it's firefighting
00:28:04 um you you say that it's firefighting um
00:28:06 um it means of escape and firefighting um installations effectively um
00:28:11 um those clearly fall within the scope of the
00:28:14 the uh the rro is the is is the normal delimitation ambit of of those consultations the scope of the rro itself generally they're the bits to which
00:28:25 generally they're the bits to which would be a statutory consultant yes i see
00:28:29 see i see
00:28:30 i see but so do we take it that this training so far as those consultations was concerned took fellows fellows a little bit further than the normal scope of the consultation yes i think so i think it's
00:28:42 consultation yes i think so i think it's it's areas of professional concern and interest that would be shared amongst a professional group right did anybody at that time think anybody in your department think
00:28:54 anybody in your department think that what was coming back from that 7th of july 2016 nhbc conference was of wider interest
00:29:05 was of wider interest to the brigade generally rather than to the interests only of felos and their consultation role
00:29:14 i think it's if anything it was taken as a reassurance if you like about what we were seeing internationally and reassurance of the conditions and the regulations in this
00:29:25 conditions and the regulations in this country
00:29:26 country i think the examples that were shown in that presentation of the two buildings in this country are very different from some of the international examples provided in so much as the bayesian stoke examples are
00:29:39 much as the bayesian stoke examples are steel framed building where the glazing failed and grenach has more in common with both lacking iron shepherd's cult in terms of the materials and the type of structure that was involved
00:29:51 reassurance in what way in smashers the regulations are there for a reason i think that was part of the presentation right because they are there to to underpin safe buildings in this country right
00:30:06 right um now of course i'm just thinking through the chronology this is july 2016 you've been head of fire safety some months you'd also i think we've established this morning seen some of
00:30:17 established this morning seen some of the communications between the lfb and dclg that had happened in 2011 12 and 13 between um for example commissioner dobson and
00:30:28 for example commissioner dobson and brandon lewis mp about the
00:30:32 about the um
00:30:33 um lack of clarity or perhaps ambiguity in respect of certain aspects of approved document b did that
00:30:40 did that did the fact of that correspondence trigger any views in your own mind about what about whether the dclg had um had satisfied itself
00:30:51 had um had satisfied itself or satisfied you about those problems and was presenting a approved document be as entirely clear and straightforward my understanding is at the conference
00:31:03 my understanding is at the conference there was
00:31:04 there was um discussion and so i wasn't there but this is part of the feedback what was that there was discussion around how people interpret the guidance and whether or not it was clear for everyone who has
00:31:15 it was clear for everyone who has intended to use that guidance i think that's that's been part of our concern i think it was a concern um shared at that conference i think it's a concern that's it's been shared more widely than that so in terms of
00:31:29 more widely than that so in terms of was was i satisfied i think the fact that when shepard's court happened very shortly after that um the actions that we took suggests that i i wasn't you know i still asked that question yes and we'll come to that
00:31:42 yes and we'll come to that now pretty much uh
00:31:45 uh but
00:31:46 but you remember i read to you paragraph seven of dave green's witness statement uh where he said that the purpose of the presentation was to cascade elements of the learning he'd received at the nhbc seminar to felos
00:31:58 seminar to felos was there a general practice within the fire engineering department of feeding learning from seminars such as the nhbc seminar back to lfb personnel
00:32:10 to lfb personnel there has been occasions uh one that i can think of would be around ventilation systems so ventilation systems in buildings range from very simple
00:32:21 range from very simple manual interventions to automatic systems and quite complex systems in more highly engineered buildings and
00:32:28 and it's entirely possible that operational crews would come into contact with those and would need some guidance as to what they should operate and not operate because lcs in some of those instances
00:32:40 because lcs in some of those instances it's finding the right person with the right experience to know how to to operate those buildings right and was any thought given at the time specifically mid-july 2016
00:32:51 specifically mid-july 2016 to cascading as it's as it said the elements of this learning that dave green had
00:32:57 green had obtained at the nhb seminar to personnel other than felos for example operational firefighters no i think it was shared with senior fire safety officers
00:33:09 shared with senior fire safety officers as well i think part of the intention was that here's the assurance we've had here's the examples internationally and let's be vigilant around what may be something that that because
00:33:21 what may be something that that because we we had some concerns and confidence issues around building control oversight in other areas around compartmentation the paper i referred to earlier i think it was part of that
00:33:32 i think it was part of that exercises to to see to what extent that reassurance was borne out or to what extent it may be called into question
00:33:40 question which may then lead to some of those questions from lindsay still around the canyon town development you mentioned earlier yes i mean when you say um let's be vigilant around what may be
00:33:52 let's be vigilant around what may be something
00:33:53 something etc
00:33:55 etc why wasn't any thought given to um
00:33:59 um getting the operational true crews informed even if not trained on what to be vigilant for
00:34:06 for given what these slides in this learning tell you so i think some of the some of the content is very technical in nature
00:34:15 nature i think we were moving forward with the pilots around operational crews undertaking some degree of regularly regulatory checks and part of that would be to share that
00:34:26 and part of that would be to share that information i don't think it's something that you can routinely assume crews would grasp or understand because it can be quite a complex area right
00:34:35 right now um we know that
00:34:39 that uh there was a later version of this presentation which post-dated the shepherds caught fire yes and that document was dated october 2016.
00:34:50 2016. um can we go please to uh lfb triple zero eight sorry triple zero three two nine one six
00:35:00 nfb triple zero three two nine one six
00:35:09 now this is a document called tool buildings facades and it's date it still bears the date 13th of july 2016. uh but as i understand it it was rolled
00:35:20 uh but as i understand it it was rolled out and we'll come to this in a bit more detail later but this was rolled out to a group of people in october 2016. if we just scroll through it go to page
00:35:33 if we just scroll through it go to page two page three page four two three
00:35:38 two three four
00:35:39 four and then if we go to page twenty five
00:35:44 uh you can see um there's diagram 40
00:35:49 and
00:35:53 if one scrolls down through through the rest of the document you'll see that there are various options taken from the um from the technical guidance note
00:36:05 technical guidance note but if you go please to page
00:36:10 21 you'll see the general conclusion i'll just read it to you general conclusion as a general principle the external envelope of the building
00:36:20 building brought bold should not contribute to the first bed along the facade new construction material and method of construction are being used in facades and with a limited understanding of their fire behavior straight performance
00:36:31 their fire behavior straight performance there is a need in bold to understand in bold first bullet point what products are being used in the facade system and their fire behavior and second bullet if they are used appropriately and meet the
00:36:43 they are used appropriately and meet the relevant guidance these could affect the way fires develop and spread in a building
00:36:49 building now as you probably know the first responding operational crews who attended the grenfell tower of fire were taken to this presentation at phase one of this inquiry and none of them
00:37:03 one of this inquiry and none of them could recall ever having seen it is that consistent with your understanding of who is likely to have seen this presentation or one like it yes um are you aware
00:37:15 um are you aware that it was ever delivered to operational personnel i don't believe it no could we go to lfbs um
00:37:23 um quadruple zero sorry if i may not to operational personnel other than those in the role of potentially senior fire safety officers who do carry an operational element just to be clear thank you
00:37:34 thank you right and that actually short circuits the next question i think but can you can you explain why it was never rolled out even in an information form to
00:37:45 to frontline firefighters let alone put into a training package i think to look at the context within which it's a risk that was relevant or or present
00:37:57 risk that was relevant or or present part of the work that fire safety does generally is to look for trends and issues that are emerging in the built environment that we would share with colleagues i think the um
00:38:09 the um there was learning shared post laca now there was an awareness of unusual fire spread we we reported on unusual fast bread and structural failings as part of a routine reporting
00:38:21 failings as part of a routine reporting mechanism
00:38:22 mechanism and i don't feel that's at the moment from what's what was presented here that this was presenting or suggesting a trend or theme that was emerging it was more as i say a document
00:38:33 emerging it was more as i say a document that reassured that the regulations were there to do their job clearly we know now from not just the tragedy of grenfell but equally from the work we've done since to look at the built environment and high-rise residential
00:38:45 environment and high-rise residential premises that is there is an issue that is down has been undetected for some time if you look at the second part of this slide there is a need to understand the two things that i've read out to you
00:38:56 the two things that i've read out to you yes with this conclusion this these could affect the way fires develop and spread in the building why wasn't that need to understand a need to and to understand on the part
00:39:07 a need to and to understand on the part of incident commanders attending an incident or and firefighters in their teams
00:39:12 teams i think in terms of what those two points are asking that's about technical information about the specification of building facades that is not evident from looking at a facade
00:39:23 from looking at a facade and the relevant guidance again is a technical element that would sit within fire safety to understand as part of that consultation process the risk being if those two issues are not properly understood
00:39:35 not properly understood then the diagrams and the sentence there below could be the issue that would arise was there a view taken following on from what you just said there was no need
00:39:47 there was no need for operational firefighters particularly incident commanders at watch manager level to understand anything on this slide no i don't think it's a case of no need i think what
00:39:59 it's a case of no need i think what we would need to do is understand the proportion of the or the size of the issue that would potentially face instant partners the incident commanders have a range of considerations when they turn up an incident and whilst we want to furnish them with
00:40:11 and whilst we want to furnish them with as much information as possible to be able to do that job well there is also the need to put some perspective around what that risk looks like and to what extent they could expect to encounter
00:40:22 extent they could expect to encounter that risk in the environment given the risk which is that these could affect the fire wave fires develop and spread in the building why wasn't that risk just in simple terms put on to every
00:40:35 just in simple terms put on to every single watch manager's radar within the brigade so that when they did turn up at a fire where the cladding was involved in any way they would know that this was something
00:40:46 they would know that this was something to do with the construction material and and method of construction or at least could be which would then inform their their plan so i think that there was information available to instant
00:40:57 was information available to instant commanders following lacking out i think the high-rise policy talked about fire spread but i think what we witnessed at grenfell is something very very different to what our experience and exposure
00:41:09 exposure was at the time what is different what was different about leaving aside scale yeah which i understand but what was different about the type of fire at grenfell and the
00:41:21 the type of fire at grenfell and the thing which this slide said needed to be understood so i think what we saw going for was extremely rapid fire spread that was beyond our experience if you like of
00:41:33 was beyond our experience if you like of what we had witnessed at other premises in the country i think it was underpinned by um
00:41:41 um to a degree faith in the regulatory system
00:41:44 system that we weren't using those materials in this country and i think this presentation outlines the reasons why they weren't used and the routes to compliance that manufacturers and those building buildings should be satisfying
00:41:56 building buildings should be satisfying themselves before using materials on a building was it was a conscious decision taken
00:42:01 taken not to percolate the
00:42:04 the information or the learning contained in this simple general conclusion slide down i say down maybe that is the right word to operational firefighters i don't think there was a conscious
00:42:15 i don't think there was a conscious decision but equally i'm satisfied that if there was because of the nature of the work we do if there was something um that was immediately relevant to the role of a firefighter that needed to be shared
00:42:26 firefighter that needed to be shared then it would be in the way i described earlier around some other aspects of emerging trends in the built environment things around fires in white goods for example being a good example of
00:42:37 example being a good example of fire safety investigative work and work with manufacturers in the wider sector that was
00:42:44 that was producing outcomes in the built environment that firefighters needed to be aware of and posing the risks to residents that we equally had a duty to communicate and educate them about well why weren't the lessons learnt in this
00:42:55 why weren't the lessons learnt in this slide in particular in this conclusion something that was immediately relevant to the role of a fighter a firefighter because i don't think what this what this presentation is talking about is something that that we had evidence
00:43:07 is something that that we had evidence of
00:43:08 of in this country i think that's that's the point i'm i'm making i mean you may take a different view and i'm sure you will forgive me mr daily but there's nothing in the general
00:43:19 daily but there's nothing in the general conclusion that says that this general principle and the need to understand need only arise overseas and you needn't worry about it because it never happens here there's nothing like that here is there
00:43:30 there's nothing like that here is there no i think when you take that conclusion in the context of the wider presentation i don't think you can simply look at one slide from a presentation that that presents the whole context
00:43:41 that presents the whole context of the information yes but you're delivering it to uh london-based firefighters who are very much uk-based uh in the context of earlier fires but critically the shepherds caught fire so
00:43:53 critically the shepherds caught fire so i asked again why wasn't this relevant uh to roll out to operational firefighters i don't think i've got another altitude in the one i've supplied okay um
00:44:03 um before we leave this topic and we may come back to it but can i ask you to look please at lfb404014
00:44:18 um and if you um look down this this is a a sort of spreadsheet really but a list of of of names
00:44:26 of names uh who were required attendees and then over to page two um some optional attendees at
00:44:35 at the presentation in october 2016. uh
00:44:39 uh just scanning on your eye down the list of names some of them are familiar uh we know about peter wolfenden and daniel egan who were actually on the fire ground on the 14th of june
00:44:50 fire ground on the 14th of june 2017
00:44:51 2017 there are others who are familiar from the documents some are completely unfamiliar in general who is this group i recognise those as middle managers
00:45:02 i recognise those as middle managers some of whom i believe are senior fire safety officers if not all
00:45:10 right thank you now i'm going to come i may come back to this topic in due course can i turn please next to lfb3024232
00:45:26 this is an email from staff officer
00:45:31 keely foster uh of the 6th of september 2016. so a month or so before the last slideshow we were looking at uh to ron dobson the then
00:45:43 uh to ron dobson the then commissioner in his last months of office i think uh 6th of september of 2016. and she attaches a presentation called highrise not high risk and
00:45:54 and you can see the second paragraph where she says in addition to this and not mentioned in this presentation currently do you think it should also include growing concerns over the clouding of buildings this article is
00:46:07 clouding of buildings this article is quite interesting and details external spread through cladding and insulation products and she attaches a link to to an article um let's let's look at that
00:46:18 an article um let's let's look at that uh
00:46:19 uh it's at inq three zeros one four eight nine one
00:46:26 and it's um it's an article contained uh on a website called
00:46:33 called highrise firefighting dot u dot co dot uk and and if you look at the domain name at the very bottom of the page you will see that that is uh indeed the um the the web site uh are
00:46:46 uh indeed the um the the web site uh are you familiar with that website right um
00:46:50 right um can we please look at the third paragraph on page one
00:46:55 uh uh and you'll see that underneath the pictures we've got carlton tower block one lead shirley towers hampshire and altair in the uae
00:47:07 altair in the uae uh and then if you look at the third paragraph below the pictures it says this also becoming more of an issue is external spread through cladding and insulation products a common practice in the uk when refurbishing high-rise
00:47:18 the uk when refurbishing high-rise buildings is to clad the outside of the blocks with polystyrene insulation sheets which are at least four inches thick they're then covered with mesh and rendered this gives them compliance with
00:47:29 rendered this gives them compliance with class one surface spread of flame and a low fire propagation to bs 476 part six 1989.
00:47:37 unfortunately once this thin render coat fails or is disrupted it exposes vast quantities of polystyrene installation of these insulation systems is a highly skilled process that required fire
00:47:48 skilled process that required fire breaks through the wall surface the guidance uk adb and bsa414 generalizes that the insulation material should be of quotes limited combustion uh quote quotes and that the cladding
00:48:01 uh quote quotes and that the cladding system will not permit excessive spread outside the building unfortunately there are already instances in the uk where fire has traveled up the outside of a high-rise building via a cloud insulation system in one instance
00:48:12 insulation system in one instance glasgow 2009 it traveled nine stories
00:48:19 uh now um
00:48:22 keeley foster is not i think am i right a fire engineer no she's not um and she wasn't based in the fire safety department is that right you know she was the commissioner's staff officer i believe at the time staff officer and
00:48:34 believe at the time staff officer and what was what did that role involve supporting the commissioner in his functions on a day-to-day basis right i see would you agree that this email suggests that awareness of the
00:48:46 email suggests that awareness of the risks of external fire spread with the res as as a result of cladding and insulation went beyond those individuals in the lfb with particular fire safety expertise
00:48:57 with particular fire safety expertise i think that's the timing of that email is after the shepherds caught fire yes the commissioner as you said earlier had raised concerns
00:49:08 as you said earlier had raised concerns around
00:49:08 around external walls previously yes and so it's something that the commissioner's office would have an understanding of certainly that time given mr dobson's rock
00:49:18 rock yes so can we take it from that that the risks identified on this website uh
00:49:26 uh percolated beyond the confines of the fire safety department your department yes i think it's fair to say that there will be people in the service who take a broader interest than maybe their core role
00:49:38 interest than maybe their core role right and in fact it went personally to the very top of the lfb as we see in this instance yes were you uh were you aware of whether there was at
00:49:49 were you aware of whether there was at the time any discussion with ron dobson himself about the quote growing concerns over the cladding of buildings as ms foster was suggesting was happening only in so much as the work we were undertaking around shepherd's court in
00:50:01 undertaking around shepherd's court in the investigation of that and the preparation of the slideshow i've just shown you yes but i think there was a pre-existing presentation that was being effectively updated to be used again yes
00:50:13 used again yes now um
00:50:15 now um can i then move ahead a year to june 2017 and show you lfb3024271
00:50:28 now um
00:50:33 this is a slideshow which bears that month
00:50:37 month june
00:50:38 june 2017. and it's prepared by dac kevin hughes
00:50:44 hughes uh who not only holds or held an mba but was also
00:50:47 was also i think
00:50:48 i think also had a degree in engineering and was a a fellow of the institute of fire engineers looking at his post nominals is that right he was a very very highly qualified fire engineer
00:50:59 engineer he was a qualified fire engineer all right
00:51:02 right we can call it we can quite a little bit i'm not you know i i don't know his ability to judge to what level all right
00:51:09 right uh we had those qualifications um
00:51:13 um very good now um the date of this is june 2017
00:51:18 june 2017 there is an email at lfb zero
00:51:25 and we'll come back to the come back to the contents of this document in a moment but i just want to show you this
00:51:31 you this this is an email that kevin hughes sends to you and others lindsay seal as you can see gareth and gareth steele the two individuals you mentioned earlier on the
00:51:42 individuals you mentioned earlier on the 30th of january 2017 so some six months before
00:51:47 before and it's it has the subject tall building conference sterol i've had several conversations regarding this event so i thought an email that pulls all of that together would be helpful the fourth tall building conference
00:51:59 the fourth tall building conference takes place at firex at the excel exhibition center in june each day we'll have a specific theme tuesday 20th of june design and fire engineering and tall buildings wednesday
00:52:11 engineering and tall buildings wednesday 21st management and insurance of fire risks and tall buildings thursday 22nd firefighting in tall buildings
00:52:20 and he then goes on to say russ the organizer has invited the lfb to contribute to the conference
00:52:29 can i just ask you this is this correct was this the same tall buildings conference for which kevin hughes went on to produce the presentation that we've just the first page of which we've just looked at yes it's awesome right
00:52:41 it's awesome right now we know that kevin hughes compiled the presentation before the grenfell tower fire happened because
00:52:48 because we can see that he sent it to lindsay seal and gareth steele asking for some feedback on it in may can we just look at that lfb double zero sorry lfb triple zero seven zero nine
00:53:00 sorry lfb triple zero seven zero nine four nine
00:53:14 and he
00:53:16 he sends that email simply saying subject tool buildings conference june 27
00:53:24 27 2017 would you provide some feedback please
00:53:28 please now it's right i think that mr hughes was head of fire engineering and specialist fire safety at the time this presentation was produced wasn't it wasn't it yes yes can we then go back to the presentation page six
00:53:40 page six that's lfb3024271 page six
00:53:45 page six this has the heading uh facade fires and i think that's a that's a photograph of shepard's court isn't it it is yes yes and it
00:53:57 and it says this um in the speaker notes the lfb commonly encounter facade fires just pausing there do you agree that by june 2017 that was true
00:54:09 that was true i wouldn't have categorized this commonly now so you you say that what mr hughes is saying there is incorrect is that right i wouldn't classify as common so are you saying that what mr hughes says there is incorrect yes i would yes right can you
00:54:22 incorrect yes i would yes right can you explain why mr hughes would have made given his role and given his experience would have made an error like that i'm not sure it was an area or whether it was his personal experience that he was referring to well he's talking about the brigades yes no i completely accept
00:54:34 the brigades yes no i completely accept that
00:54:35 that the terminology that he chose to use is not terminology that i would have chose to use what would you have chosen to use i would say that we have uh experience some experience uh recently of
00:54:47 uh recently of facade fires i'm not sure that i would quantify across the range of incidents that we attend that was not too common can we go to page seven
00:54:58 testing facade panel do you recognize the image of the blue burning panel from the testing of panels taken from the shepherd's court block of flats
00:55:08 flats yes it is yes and if you go to page nine
00:55:17 there is a photograph of a penthouse flat with a terrace
00:55:22 terrace and an arrow and the arrow if you look is pointing to what looks like fire damage
00:55:29 damage yes yes yes and the speaker notes say this here we see a close-up of the building the top of the penthouse flat on the 10th floor what is really interesting about this
00:55:41 what is really interesting about this is the fire actually started at the ground floor and progressed from the ground floor to 10 floors up all behind the cladding in a very short space of time
00:55:51 time do you recognize this incident i don't know you don't now if you go to page 11
00:56:00 h10 is a photograph of the uh point of ignition at street level we don't need to look at that but if you look at page 11 there's a picture of how the fire traveled
00:56:09 traveled and
00:56:11 and it it goes up and across as you can see from the
00:56:15 from the arrows on the photograph and
00:56:19 and it says the slide shows how the fire traveled from street level to the 10th floor
00:56:23 floor flammable building facades are a common challenge for the lfb again would you agree with that or do you disagree with that no i wouldn't agree with that so that's another error
00:56:34 agree with that so that's another error in mr hughes work is it i would say it's an area in terminology how would you put it i would say that we have some experience of it
00:56:43 of it right so the difference between you in these two respects is some experience as opposed to common challenge yes right
00:56:50 yes right either way it's something that the lfb would not regard as a one-off would that be fair yes nothing that's fair yeah all right now um if we go to line six
00:57:02 now um if we go to line six the speaker notes as follows um in residential buildings the fire is not confined to the flat of origin and our stay put limited evacuation strategy is compromised
00:57:14 is compromised we're just looking at that and we can look at other parts of it if you like but would you agree that this is a clear indication that your department the fire safety department was aware
00:57:25 the fire safety department was aware actually aware before the grenfell tower fire that stay put as a strategy may not be a suitable strategy for a high-rise block where there is non-compliant cladding
00:57:39 could you rephrase sorry could you ask the question again because i was considering rather than listening so i apologize that's all right um would you agree that here is a clear indication that the fire safety department was aware before the
00:57:50 safety department was aware before the grenfell tower fire that a stay put strategy may not be suitable for a high rise block that block which has non-compliant cladding i would say that
00:58:01 i would say that certainly my opinion at the time was that stay put is absolutely incumbent on compartmentation working that
00:58:11 that if we were to have an example where those compartments could be overwhelmed or overrun then that would compromise stay put also stay put isn't a fixed thing it's a
00:58:22 also stay put isn't a fixed thing it's a it's a movable uh piece of guidance that talks about if you're directly affected i'm sure sorry to go over our ground short inquiries done some of this before
00:58:31 before um but equally its incidents are dynamic and need to be reviewed as they progress to see if uh strategies and uh priorities maintain the same
00:58:42 the same so it may well be that the if a building's behavior is changing that then priorities need to change in line with that now what you've just told us
00:58:52 us uh
00:58:54 was that something that if i'd asked you this question in uh in the first half of june 2017 you'd have given me the same answer yes i think as an instant commander your role is to constantly review
00:59:05 role is to constantly review the dynamics of the incident the priorities and your performance against your
00:59:10 your uh goals as the incident commander to deliver your plan and that that doesn't rest with simply considering saving life it looks at the dynamics of the fire it looks at
00:59:21 at the dynamics of the fire it looks at your progress in terms of where you set out your objectives for managing that incident
00:59:28 incident but doesn't it follow from that that the incident commander needs to know what it is that he's looking at when considering what to do with stay put in a clad high rise i think the instant commander needs to
00:59:40 i think the instant commander needs to take account of everything that's in front of them yes he needs to know what's in front of him and they do need to know what's in front absolutely and let's look and see what this slide is telling you i've picked out two parts let me show you some of the rest of it
00:59:51 let me show you some of the rest of it if we pick up the third paragraph it says they that's flammable building facades calls unexpected fire spread sometimes unseen until it breaks out again in a different location and they
01:00:02 again in a different location and they often lead to fire breaking out on several floors these type of fires can really challenge the fire strategy of a tall building in residential buildings the fire is not confined to the flat of origin and our
01:00:13 confined to the flat of origin and our state but limited evacuation strategy is compromised large-scale evacuations in residential buildings especially those with single staircases cause a problem in terms of staircase capacity and obstruction to
01:00:25 staircase capacity and obstruction to firefighters and then there's something about commercial buildings the reason for highlighting this is to raise awareness of the problem i believe that the codes and fire engineering principles we use to design
01:00:37 engineering principles we use to design fire safety into buildings are excellent but
01:00:41 but farsad fires an uncontrolled spread of fire across the outside of tall buildings is a significant threat to the effectiveness of the many systems within the building this is a vulnerability that we can
01:00:52 this is a vulnerability that we can design out of buildings by ensuring the limited combustibility of facades and where any doubt exists at the design or specification stage we should be seeking independent testing of facade materials
01:01:03 independent testing of facade materials to provide assurance that they are of limited combustibility now some people may regard the the timing of what i've just read to you as
01:01:14 timing of what i've just read to you as uh prophetic in in many ways but my question for you is is what i've just read to you was what i've just read to you not considered to be something that all
01:01:25 considered to be something that all watch managers who are going to be likely to be attending as first responders at high rise fires in london should have known i think when you look at the words here i can completely agree that's that's an
01:01:37 i can completely agree that's that's an outcome that you'd like to see i think as the lead for fire safety i would have been looking to evidence examples of that and to put in place
01:01:48 examples of that and to put in place the appropriate awareness package i think there is an element of proportionality that has to come into
01:01:55 come into the extent to which this is an issue and the extent to which instant commanders should have it at the forefront of their mind now
01:02:01 mind now i see the words that have been chosen here they're not necessarily words i would have chosen myself but having said that i can't deny this is a presentation that was produced within the fire safety department and to what extent was there in fact any
01:02:12 and to what extent was there in fact any discussion about what i've just read to you on this page here
01:02:16 here between the fire safety department and the operational departments of the london fire brigade none to my knowledge can you explain why that is no and it's the first time i've seen this particular
01:02:27 the first time i've seen this particular presentation as well now i'm going to ask you uh next about the extent to which the lfb had regard to fires involving cladding systems which took place overseas
01:02:43 ac gary reason told us yesterday i think that in fact as a matter of practice the brigade never paid any attention to what happened abroad uh
01:02:54 uh i may have misquoted him but i don't think i've got the gist of what he said wrong first were you aware of any cladding fires in high-rise buildings overseas
01:03:05 at which point i mean i'll be playing sorry
01:03:08 sorry let's take from march 2016 onwards um i think i had some awareness but i i don't think i paid
01:03:18 a lot of attention to those issues in the role that i had previously and indeed your police witness statement says and i quote from page two there's no need to get back to it i also had a general awareness of some international incidents i cannot name
01:03:30 international incidents i cannot name any of these but i'm aware that some instances occurred yes now in your experience were incidents overseas seen as a learning opportunity for the lfb within your department my fire safety department of the
01:03:42 my fire safety department of the department at the time sorry to be the fire safety department from march 16 onwards i think when i came into fire safety i became aware that there were people that did take far more
01:03:53 take far more um
01:03:54 um notice of what was going on elsewhere in the world a more professional interest in protection matters than maybe elsewhere in the service and what did you take from that
01:04:05 and what did you take from that i think i took it as part of their professional interest their professional development that they held those issues of of interest and um
01:04:14 um let's say opportunities for development understanding and bettering their knowledge
01:04:21 right i may have misunderstood your answer but you say i became aware there were people that did take far more notice of what was going on elsewhere do you mean people in the lfb in the fire safety department i think right sorry i took up that role i think
01:04:33 right sorry i took up that role i think it was a department that was more attuned to now learning opportunities
01:04:39 yes and who were they who were the people in your fire safety department who had who are particularly attuned to overseas incidents so i would say um certainly the engineers i'd say
01:04:52 say um certainly the engineers i'd say um people that work to advise me um in terms of andy jack nick coombe people like that that have been around fire safety for a long time and would routinely take an
01:05:03 a long time and would routinely take an interest in incidents that looked like they were issues of protection interest now you say in your police statement and i think i'm afraid this time we do have to look at it that's right because it's a slightly longer passage if we go to it
01:05:15 a slightly longer passage if we go to it just met 307 7774 page three
01:05:30 uh you say at the very top of that page my underpinning assumption is that through building regulations in this country which control how things should be built and such things as the standards of materials used you cannot
01:05:42 standards of materials used you cannot always make any direct comparisons to what happens in other countries international incidents are of interest but they do not necessarily point to potential situations here without a more detailed analysis and understanding of
01:05:54 detailed analysis and understanding of those incidents how and why they occurred
01:05:58 occurred was that your clearly that was your view was that just your view or did you understand that that was the prevailing view across the brigade
01:06:11 whether it's across the brigade i don't know i think my my point here is that we are subject to different conditions different regulations um and so it does require us to to look
01:06:23 um and so it does require us to to look at
01:06:24 at what situations and what and what regulations applied and and were there opportunities for similar situations to rise in this country i think that's that's what i'm trying to
01:06:35 that's what i'm trying to convey
01:06:36 convey um
01:06:38 um i think that's probably true of of people that took interest as well was to try and understand whether the dynamics of
01:06:44 of a particular incident elsewhere held risk for us here in terms of what could be applied or couldn't be applied
01:06:52 applied now you call it an underpinning assumption was it just that an assumption or was that the view arrived at after a study of any of these international fires whether by you or by anybody else in your department only in
01:07:03 anybody else in your department only in that i had an awareness that we have different
01:07:05 different regulatory regimes across different countries right and so you cannot always make direct comparisons um you refer here to a more detailed analysis and understanding of those incidents did anybody in your department
01:07:16 incidents did anybody in your department ever carry out any such analysis to obtain any such understanding i've certainly seen documents shared
01:07:25 from professional journals that have looked at the investigations into international incidents yes but did anybody within the nfb do it did anybody have it's enrolled in no no
01:07:36 would it have fallen to the fire engineering and regulatory specialists in the first safety department to make comparisons between the different regulatory regimes in the uk and in other countries so as
01:07:48 in the uk and in other countries so as to be able to understand uh any differences that might might matter i think those individuals would have taken that um
01:07:57 um that opportunity to do that yes you did do you know whether they did i know examples where they have yes who did
01:08:06 who did i know that mr for example would have looked at incidents and what uh what was occurring in those places i know some of the engineers would take that interest too do you know which incidents nick coombe looked at
01:08:17 looked at uh no i couldn't name the top my head but i know these conversations that we would have had over time did it ever occur to you as head of fire safety from march 2016 to assign some of your regulatory or fire engineering personnel
01:08:29 regulatory or fire engineering personnel to look into these international incidents or perhaps some of them to see whether there were lessons to be learned anything in their regulatory regime which from which you could derive any
01:08:41 which from which you could derive any any comfort because of points of difference or or or the opposite of comfort because of similarities and trying to derive learning from them so the short answer is no i didn't ask for
01:08:52 the short answer is no i didn't ask for somebody to undertake that work but equally i knew i had a team of people that looked at those incidents and i knew there was a team people there that were keeping in touch on the regulations as they applied in
01:09:03 on the regulations as they applied in this country and doing the oversight work if you like on the building consultations that we um were consultants on right did was that work specifically commissioned or was it just done
01:09:14 was it just done um on an ad hoc basis by those who happen to be particularly interested in it
01:09:19 it i'd say it's possibly ad hoc i think maybe the people that lead that team would say it was more structured than that but it was something i was aware of that took place rather than something i asked somebody to do yes and do i take
01:09:30 asked somebody to do yes and do i take it that whatever work they did did not form into a formal report and make its way up to you no um
01:09:38 no um certainly not on this particular issue but if again i go back to the report around compartmentation that that
01:09:45 that that particular document drew on a lot of examples from around the country um to come to its conclusions yes yes and we'll come to that i think later um can i ask you about a particular fire
01:09:58 um can i ask you about a particular fire this is the torch tower fire in dubai in 2015. can we go please to lfb 302414
01:10:19 this is an email chain of the 22nd of february 2015. and the first email in the chain is the second and i want to show you is the second one on the page from peter cowell up to russ
01:10:30 the page from peter cowell up to russ timpson copied to neil orbell and
01:10:33 and others whose names are familiar including danny cotton and graham ellis uh highrise firing divides the subject importance hi
01:10:47 now you weren't copied into this email because it predates your arrival in the fire safety department by 14 months or so 13 months perhaps and but it does go to neil or bell
01:10:59 and but it does go to neil or bell did you see it as part or did you discuss it perhaps as part of the handover that you had with him in march and april 2016. no he didn't let's see how we go with it um peter
01:11:11 let's see how we go with it um peter carp says this dear russ you will not be aware of the above and i was wondering whether through the good offices of the international tool building fire safety network you could put me in touch with some relevant individuals who would have
01:11:23 some relevant individuals who would have been involved in and or might have first-hand knowledge of this incident although lfb has recently invested significant effort to improve our high-rise firefighting techniques
01:11:34 high-rise firefighting techniques and procedures we are never complacent and it is hard to imagine that an incident on this scale won't bring forward some quote lessons learned on quotes my focus would be any new issues associated with firefighting operations
01:11:46 associated with firefighting operations and in particular to identify whether this incident highlighted any command procedural or tactical issues which not already covered in the recently published uk dc clg cfra national generic risk
01:12:00 clg cfra national generic risk assessment and lfb's amended standard operating procedure the media the media reports indicate that weather very strong winds and falling debris were two major factors
01:12:11 falling debris were two major factors associated with ferocity and spread of this fire but i am conscious those dealing with this incident may in time be able to provide other relevant and useful information that may come of their incident debriefing and
01:12:22 their incident debriefing and investigation process in addition my colleague assistant commissioner neil orbell will be interested in any prevention or protection issues arising from this incident so i would also be grateful if you could
01:12:34 so i would also be grateful if you could bear this in mind when suggesting any contacts which you are able to offer now first who is russ timson i believe russ um runs the tall buildings conference that you referenced
01:12:45 buildings conference that you referenced earlier uh right and what is the international tool buildings fire safety network i think that is the organization that russ works or heads do you know what it does
01:12:57 works or heads do you know what it does or did
01:12:58 or did my understanding generally is is to share information
01:13:03 across the sector um not just with fire and rescue services but with um developers and so on right was it ever used by the lfb as an intelligence or learning source only instant as much as we supported the
01:13:15 only instant as much as we supported the tool buildings conference in the way that
01:13:17 that your previous emails and evidence has suggested
01:13:20 suggested right were you aware of a fire at a high-rise building in dubai called the torch in 2015 yourself even though you weren't yet head of the fire safety department i suspect i was but i can't honestly say
01:13:31 i suspect i was but i can't honestly say for certain that i did right were you aware whether the fire safety department was gathering information about international incidents at this time i wasn't now
01:13:41 did you ever discuss with assistant commissioner orbel whether lessons could be learnt from international incidents as part of your handover no do you know whether any other of the officers to whom this email was copied
01:13:53 officers to whom this email was copied had such discussions just from your knowledge
01:13:56 knowledge i don't have any knowledge of that did you ever have contact yourself with the international tool buildings fire safety network about high rise fires overseas once you became head of the fire safety department in march 2016. i'm going to ask you about another
01:14:08 i'm going to ask you about another incident the lacrosse tower fire in melbourne australia can we go please to lfb triple zero two four one nine six
01:14:23 now again this these predate uh your uh you're um taking over the governing governance of the first lady department in spring 2016. this is june
01:14:35 department in spring 2016. this is june 2015 it's an email from nicholas coombe to robert purcell uh and i want to look at the chain starting on page three please first this is an email from nick coomb
01:14:47 this is an email from nick coomb uh
01:14:51 to robert purcell on the 9th of june 2015
01:14:55 2015 subjects stay put please feel free to contact but contact me by to discuss stay put nick
01:15:06 the email subject has the subject stay put
01:15:12 and nick coombe gives his role as as you can see fsr management support audit and performance and fsr means i imagine fire safety regulation it does yes yes do you know what is the role of
01:15:24 know what is the role of a fire safety regulation management support audit and performance officer only in so much as that was the role um that mr was providing to my predecessor
01:15:35 predecessor and it was to oversee the performance outputs of the department and report those back and to
01:15:45 effectively support the assistant commissioner right in delivery of the department plan now we can see the subject is stay put and it's sent to robert purcell uh
01:15:58 and it's sent to robert purcell uh and we can see if you go in the second email at the top of that page uh you can see that rob purcell signs off as just at the very top of the page if you scroll down a little bit
01:16:11 so it comes onto the screen thank you the email above it is signed off by rob purcell he is the acting deputy chief officer
01:16:18 officer of the regional director northwest metro metropolitan fire and emergency services board albert street east melbourne v uh victoria in australia
01:16:30 v uh victoria in australia uh
01:16:31 uh now you aren't copied into these emails would i be writing saying you've not seen them before certainly didn't see them at the time or did you no i haven't seen these now um if we go to page two
01:16:42 seen these now um if we go to page two we can see rob purcell responds to nick cooper i've shown you the bottom of the email because we now know who mr pasel is and he responds also on the 9th of june 2015 and with a long email subject rhys stay put
01:16:55 subject rhys stay put nick thanks very much for the quick response i've been corresponding with emma regarding the lfb campaign know your plan and looking to understand the value and impact of the campaign and associated research that goes with it
01:17:08 and it goes with the brigade's position and if you look at the seventh paragraph down
01:17:14 down he says
01:17:16 he says uh
01:17:17 uh just two paragraphs above the bottom of your screen as you may be aware melvin recently experienced a significant high-rise apartment building fire caused by poor housekeeping and non-compliant cladding on the outside of the building
01:17:29 cladding on the outside of the building i've attached a link below but if it doesn't work search for la crosse building firm melbourne the apartments were also found to be overcrowded typically by transient international students and low-paid workers
01:17:41 students and low-paid workers fortunately the building was well protected by installed fire systems and all people were able to be evacuated quickly and without injury or i think i should say loss of life some apartments are still uninhabitable
01:17:52 some apartments are still uninhabitable today this type of fire is not isolated to melbourne as several fires have occurred across the world recently as a result of this cladding including in china and dubai and then rob purcell goes on to link
01:18:06 and then rob purcell goes on to link or provide a link to an abc news story now first
01:18:11 now first uh were you aware of the la crosse fire in melbourne in 2015 again i don't think i think i may have been aware of it but i don't think i knew much in terms of the detail of it
01:18:22 knew much in terms of the detail of it was nick coombe still with the fire safety department when you took over in march 2016 as its head he was yes he was he still is did you ever discuss this email or the lacrosse uh tower fire incident with nick coombe
01:18:34 uh tower fire incident with nick coombe or anybody else in the fire safety department you know or after march 2016. not in any daytona would you have considered the la crosse tariff to be of particular interest to the lfb
01:18:49 i don't i don't think so other than if they say in the same way that um mentioned earlier if there were lessons to be learnt because there was crossovers in terms of what we could see potentially occurring in this country
01:19:01 potentially occurring in this country then yes of course it would be i think it would be of in general interest from a protection point of view yes can we go to lfb3024
01:19:13 this is a report
01:19:15 report from the vic the vba the victorian building authority dated the 17th of february 2016. so a month only before you become head of head of fire safety at the lfb
01:19:26 head of fire safety at the lfb uh have you seen this document before i don't think so no right now we know that this document was in the nfb's possession because we have an email from russ timson to anthony spencer
01:19:38 timson to anthony spencer of the lfb on the 4th of march 2016 attaching it and that's lfb 3070422
01:19:47 3070422 i think we should have that up just for completeness sake
01:19:54 uh and you can see here's the email from russ timson to anthony spencer and anthony spencer i think is one of your engineers isn't he what i don't recognize the name you don't recognize the name
01:20:05 don't recognize the name right
01:20:06 right um
01:20:07 um and there's the email sending it to him it touches the report as you can you can
01:20:15 see three events in the report you might be interested in uh and the fourth one is melbourne australia reporting to high-rise facades following la crosse building fire in 2014. so this report is
01:20:28 building fire in 2014. so this report is in the in the lfb's possession in march 2016 i think we can agree that much yes yes
01:20:34 yes now um if we go to page two of the report please can we get back to it lfb three zeros two four two two zero page two
01:20:42 page two uh it describes the fire at the la crosse tower and in the third paragraph on that page it says uh this in the case of the la crosse building fire the metropolitan fire brigade mfb
01:20:53 fire brigade mfb identified it was the non-compliant use of the building's external cladding material that contributed most to the spread of fire and in the next paragraph the significance of the fire event associated with the non-compliant use of
01:21:05 associated with the non-compliant use of an external wall cladding material logically prompted the question how many buildings in melbourne have utilized external wall cladding material in a non-compliant manner now and then from that paragraph five
01:21:16 now and then from that paragraph five onwards it says the victorian building authority then initiated the external wall cladding audit the audit was designed to identify non-compliant use of external wall cladding materials in
01:21:27 of external wall cladding materials in residential high-rise buildings and then we can see at page seven of this document the findings of the audit and if we look at the third paragraph down from the top of that page it it says
01:21:39 it it says audit
01:21:40 audit finding the rate of non-compliance was 51
01:21:45 51 would you agree that for anyone from the lfe reading this report this ought to have prompted the question of whether it was possible that there were buildings in london
01:21:54 in london that also used external wall cladding in a non-compliant manner i think it would have prompted that question and i think at the time possibly the answer would have been that we hadn't seen the evidence of it
01:22:06 that we hadn't seen the evidence of it necessarily and that we had regulations that said it couldn't be used in buildings over that 18 meters do you know whether this report was passed on to anyone within the fire safety department
01:22:18 the fire safety department i don't know right you didn't see it presumably as part of your handover from ac orbele in march and april 2016. do you know of any action was that was taken within the fire safety department in response to the issues raised in this
01:22:30 in response to the issues raised in this report i'm not aware of any now all across far more generally no i'm not aware of any was that a missed opportunity for the lfb to learn from another country that it is possible for widespread
01:22:41 it is possible for widespread non-compliance with regulations to go unnoticed until there is a dangerous fire
01:22:47 fire without knowing what work was undertaken by the department i'm not sure i'm in the right place to comment on whether it was a missed opportunity it may well have been the experience of us that they did do some work around it but i'm not aware of
01:22:58 some work around it but i'm not aware of it
01:22:59 it i'm going to ask you about another fire this time in dubai again on new year's eve 2015 at a building called the address tower were you aware of that incident
01:23:10 were you aware of that incident uh i would have heard of that at the time yes yes did you learn about that incident after becoming head of the fire safety department in march 2016 or before i think i probably picked it up in general news yes
01:23:21 in general news yes uh can we go please to lfb 3024217
01:23:27 just help me with this if you wouldn't mind my interruption um
01:23:33 um you said a couple of times that you thought we had robust regulatory systems in this country which would prevent this sort of thing from happening
01:23:40 happening but you've seen from the uh report of the fire in victoria that they thought they had different perhaps but least robust systems
01:23:51 but least robust systems but the best part of 50 of buildings hadn't complied with them did it uh cross your mind that maybe the same was going on here that we had a robust system that people weren't complying with
01:24:03 complying with i think
01:24:04 i think well having not seen this report we wouldn't have crossed my mind from from this but i think certainly my experience at shepherd court and listening to
01:24:14 the wider concerns around building control oversight that i think we we were starting to to see certainly the report around compartmentation that i mentioned earlier that uh yes that would have been a
01:24:25 that uh yes that would have been a possibility to consider i think there were questions previously in letters that were referenced earlier i think are probably poking that same issue
01:24:34 issue all right thank you yes
01:24:40 yes can we go to lfb lfb3024217
01:24:46 which is an email run in january 2016 a week after the address tower fire
01:24:56 and uh if you go to the bottom email on page one you can see that
01:25:02 um the email chain starts with graham ellis writing to lee drawbridge and martin freeman
01:25:11 i think that's right uh and danny cotton as well as the cc fyi interesting article about flammable polyurethane and aluminium building cladding involved in the dubai fire
01:25:24 cladding involved in the dubai fire you see that yes now is it right that those officers uh
01:25:31 uh those officers were all at that time attached to the operational assurance department i believe they were yes so not in your department no no i mean as it then became two months later not only not in
01:25:43 became two months later not only not in the fire safety department uh not done fire safety now lee drawbridge was later promoted to deputy assistant commissioner dac and then moved to the fire safety department as head of fire safety delivery i think
01:25:54 as head of fire safety delivery i think yes yes when was that i think it was around june um 17 i think uh now the bottom email from graham
01:26:05 uh now the bottom email from graham ellis
01:26:06 ellis i've just read to you and he provides a link to an article on a site called ifsec global uh
01:26:15 uh and in the middle email if you go up the page please you can see um and this is the email time to 1507 on the 7th of january um tony biles
01:26:30 on the 7th of january um tony biles who is his group manager national resilience cb team
01:26:38 says always new clause 12.7 would be used somewhere by someone relied on it heavily throughout my career um
01:26:48 first tony biles and cbrn e team what is that the cb rne team so the cbrn is part of our um
01:26:59 so the cbrn is part of our um counterterrorism type arrangements right and it's also our response to hazardous material type incidents as well i think so it stands for chemical um biological radiological
01:27:11 for chemical um biological radiological and nuclear right now i mean we don't see that on the screen perhaps we should just if we can just scroll up you'll see it this email carries the cfoa national resilience badge if we just scroll up a little bit
01:27:25 if we just scroll up a little bit you can see it there um
01:27:28 um does that tell us but but tony barr's email address is far resilience and also tony biles met
01:27:36 met and also tony bars at londonfire.gov he seems to have a lot of emails across a lot of different entities
01:27:43 entities who was he do you know yes group manager in london fire brigade met him on a number of occasions right um
01:27:50 um as to the role he was performing particularly at this time he was working across
01:27:55 across partner groups as part of that role because it's formed from a multi-agency um background yes i see now um where he says 12.7 of course you're not copied in on this
01:28:06 of course you're not copied in on this email at all but um would you take it well is it the case that he was referring there to section 12.7 of approved document b i'm not sure that you don't i don't know
01:28:17 i'm not sure that you don't i don't know did you know that approved document b paragraph 12.7 is the requirement for insulation products used in external walls of buildings in excess of 18 meters to be of limited combustibility
01:28:28 meters to be of limited combustibility i know what you've just said that i would have referenced it or known it to be at 12.7 right do you know uh
01:28:35 uh why tony biles or in what context teddy bars would have as he puts it relied on it heavily throughout my career what's he talking about do you know i i don't but i suggest it's possibly a
01:28:46 i i don't but i suggest it's possibly a tongue-in-cheek comment right we may have to pursue that with another witness but the response at the top from danielle cotton who at this time is and
01:28:57 danielle cotton who at this time is and is still at this time director of safety and assurance uh says i'm surprised it's taken them so long to reference such a key piece of information i don't know whether she's referring to the article or to 12.7 can you help with
01:29:09 the article or to 12.7 can you help with that i'm sorry i can't you can't uh
01:29:13 uh standing back do you consider that this incident this type of incident is fire in dubai would be a learning opportunity for the nfb i think all all priors provide learning opportunities
01:29:24 priors provide learning opportunities but as i said i think in my police statement they need to be put into the context of further analysis to understand to what extent they may be an issue here and so far as this fire is concerned
01:29:35 and so far as this fire is concerned the the torch fire in dubai was any uh analysis undertaken by anybody in the fire safety department to your knowledge not to my knowledge right
01:29:46 not to my knowledge right and when you work with lee drawbridge in the first safety department did you ever discuss the address tower incident or other overseas fires involving chatting not that i can remember what about section 12.7 of approved document b did
01:29:58 section 12.7 of approved document b did you ever discuss that with lee brought draw yeah
01:30:01 draw yeah now before the grenfell tower of fire what was the attitude or the approach in the nfb that an incident such as the address fire couldn't happen in this country because of our regulations and
01:30:13 country because of our regulations and specifically because of section 12.7 of approved document b which is the requirement for limit materials of limited combustibility to be used in external wall constructions
01:30:24 be used in external wall constructions i don't know if it was a an overriding attitude i think it would have been a consideration for people in terms of their knowledge i think those that may be closer to some of the
01:30:35 those that may be closer to some of the um
01:30:37 um arrangements may have had their doubts i think there were doubts raised to say when i joined fire safety one of the documents that was sitting in the tray for me to address expressed doubts about compartmentation for example
01:30:48 compartmentation for example to your knowledge after march 2016 when you took over as head of fire safety or before that if you knew did anybody actually sit down with uh the findings from the
01:31:02 with uh the findings from the torch fire in dubai approved document b and whatever the governing building regulations in dubai were in order to see whether or not it is the case that it couldn't happen
01:31:13 it is the case that it couldn't happen here or whether there were actually learning points that could be derived from the from that file which might enable a better understanding of whether there were any weaknesses in approved document b not to my knowledge do you know why that is
01:31:24 know why that is no
01:31:25 no it's not my logic i'm not saying it didn't happen but i don't have any knowledge of it i see what you mean now um
01:31:35 is it fair to say that these actions all these incidents the address tower the torch tower both in dubai and the lacrosse tower in melbourne all came across the lfb's desk as it were in one form or another
01:31:47 as it were in one form or another but but little action little investigation was undertaken as a result i think i would agree the first part that's clearly coming to lfp's possession but as i said i can't
01:31:58 possession but as i said i can't quantify what action was taken because i wasn't there at the time but to my knowledge
01:32:03 knowledge and i'm not trying to be difficult here i think it is just in full context i don't want to suggest that nobody did work if they did but i don't have any knowledge of that uh but would this be fair that if anybody had done any important work with
01:32:15 anybody had done any important work with any important lessons which which had been drawn for most fires you would have known about it at least once you took over as head of uh head of fire safety in march 2016. no i think it's fair to say i would have expected to know and
01:32:26 say i would have expected to know and and if the learning was for the organization to have known before taking over fire safety
01:32:32 uh now i want to ask you about uh a conference
01:32:38 in the uae or rather about the uae in november 2016. um
01:32:45 um there was a conference called the united arab emirates fire safety delivery 2016 which i think was held by the lfb on the 16th and
01:32:53 16th and 17th of november 2016 with a number of attendees from the uae there do you remember that i have a vague recollection um
01:33:04 i have a vague recollection um were you there i don't think i was no i might have uh greeted
01:33:08 greeted a contingent when they arrived but i don't think obviously i think that actually maybe maybe correct can we go to lfb double zero one two zero three eight zero
01:33:29 and this is the um
01:33:33 um the timetable for the program for the for the conference fire safety delivery 2016 dates book for fire safety 16th and 17th november 2016
01:33:44 fire safety 16th and 17th november 2016 first day at union street the second day at plasto fast station community room and if you um look down to the bottom of page one
01:33:54 page one you'll see that
01:33:57 that the item third from bottom for day two so
01:34:03 so this is the one o'clock to three o'clock slot
01:34:06 slot uh in the day was entitled fire engineering high-rise external fire spread and theory of the shard
01:34:14 shard um to be given by james flynn and gareth steele do you know standing back a little bit why were the uae why was the uae chosen for the theme of
01:34:25 why was the uae chosen for the theme of the conference i believe it was a request from the uae um to attend lfp now i've seen the agenda i do have a better recollection
01:34:36 agenda i do have a better recollection of it and i do remember it not being a particularly successful venture i'm not quite sure that the people that we received were necessarily the people we thought we were going to
01:34:47 the people we thought we were going to receive right
01:34:52 did the fact that delegates of whatever quality or seniority from the uae wanted to attend the lfb not tell you something about what was happening in
01:35:03 something about what was happening in the uae from which the lfb themselves could learn i think maybe had there been a uh had it been a better experience than maybe there was i think it's safe to say that the um
01:35:15 that the um it wasn't an experience we were going to be rushing to repeat and i don't really say much more than that but it wasn't
01:35:21 it wasn't um
01:35:24 um it wasn't a meeting of joint professionals to share joint experience is probably the safest way i can categorize that that's a diplomatic answer i'm probably a little bit too diplomatic for my
01:35:35 a little bit too diplomatic for my insensitivities perhaps you could explain a bit more bluntly what you mean i don't think that the professional reception and agenda that was provided was met by equally professional individuals that
01:35:46 equally professional individuals that were there for the learning right um what role did the series of high-rise cladding fires such as the address and the torch play in the decision to hold this conference to start with or or was it was it just a
01:35:58 to start with or or was it was it just a response to a request it was a responsible request i mean i do know um we've had similar requests not just to fire safety but to london fire again generally from other fire services around the world okay um and uh
01:36:12 around the world okay um and uh i think it is just part of the the make up of london firewood attracts people to come and
01:36:17 come and uh
01:36:18 uh look to see how london works and and the challenges that london faces
01:36:23 faces was there at all a detailed discussion of materials used in cladding systems compliance with adb and current risks highlighted from the uae files at this conference i don't know
01:36:35 i don't know the detail of what was covered right
01:36:39 right can we then turn to lfb double zero one two zero three eight one
01:36:48 well this is a timetable for a three week course 15 days
01:36:55 15 days now we understand that this course was provided
01:36:57 provided by the lfb and babcock jointly as a as a collaboration exercise
01:37:05 and i think you could see that from what's on the screen do you agree with that
01:37:09 that yes um
01:37:12 yes um in the fourth column of the course timetable
01:37:15 timetable um you can see the activities for day four
01:37:18 four at beckton babcock to lead reflective learning flexible see and the guest speaker and case study incident command decision making and tactical planning
01:37:29 tactical planning high-rise firefighting incident command exercise
01:37:33 exercise 15
01:37:34 15 r simulation number two first bullet point uae based high-rise fire scenario now looking at column five there's another simulation um also first bullet
01:37:47 another simulation um also first bullet point uae-based high-rise fire scenario now we don't hold a copy of those training materials associated with this course
01:37:58 do you know whether any of those scenarios included external fast spreading cladding systems no i don't have any knowledge of of any of those scenarios you don't you don't know i have no knowledge of doceno
01:38:14 given that there had been a series of cladding fires in the uae in recent years before this conference does that explain to the best of your knowledge the presence in this program
01:38:25 presence in this program uh of a uae-based high-rise fire scenario
01:38:30 scenario i can only assume and it is an assumption looking at that that given the candidates were from that country was to try and provide um
01:38:38 um instant command thinking and support around the scenarios that they may have faced right does this tell us that
01:38:49 uh
01:38:51 does this tell us that the lfb had carried out some kind at least of close analysis of the uae fires or some uae fires
01:39:00 fires and had been able to put together a uae high rise fire scenario on the basis of what they knew i'm afraid based on having just seen this today
01:39:11 this today i can i don't know whether that's from lfb engagement or babcock or a collaborative piece i'm i would assume it's a collaborative piece and in that case the answer to your question were yes right
01:39:22 yes right now
01:39:27 the do you know who this training was delivered to i'm assuming it's part of the continue you just talked about right i see
01:39:37 i see do you know why these training materials weren't delivered to the nfb's own operational staff or were they no i have no idea whether they were actually got presented as part of
01:39:48 actually got presented as part of this visit or any time since mr chairman is that a convenient moment we're going to turn to a slightly different time yes i think it is uh we'll have a short break at this point mr daily we'll come back
01:39:59 mr daily we'll come back at 25 to 4 please and again don't discuss your evidence with anyone outside the room okay thank you very much
01:40:15 thank you thank you 25 to 4 please
01:58:10 would you ask mr daley to come back in please
01:58:23 right mr daily are you ready to carry on yes absolutely good thank you yes yes mr chairman thank you i want to ask you now some questions about learning lessons from other london fires particularly high-rise fires and i want
01:58:34 particularly high-rise fires and i want to begin uh with a topic namely the high-rise fire at mattingly on the cambridge road estate in kingston upon thames in july 2010. were you familiar with that incident no
01:58:46 were you familiar with that incident no i'm not not um now we've had a bundle of documents uh given to us by the nfb about that uh uh about that event uh lfb3028515
01:58:58 i wonder if i can just take you to it quickly and see how much you can help us with it
01:59:06 um
01:59:10 this is this is a data collection form for the event and you can see section 1 fahrenheit data collection to be updated at each
01:59:21 data collection to be updated at each inspection shaded fields and mandatory et cetera
01:59:25 et cetera and then you could see there's a file name
01:59:27 name and building name mattingly from peters road cambridge radio state kingston surrey
01:59:33 surrey uh and there are some details about the building
01:59:37 building and if you go to page 13 of this there's a general fire safety forum there
01:59:45 there uh
01:59:46 uh report details a 20 pump fire occurred in a 17-story purpose-built block of flats containing 60 flats on the upper 15 storeys the block comprised a single staircase a firefighting shaft and firefighting lift with the drm
01:59:58 firefighting lift with the drm dry rising main the fire started within flat 48 on the 12th floor spreading upwards to seriously damage the flats immediately above on the 13th 14th and 15th floors now um
02:00:09 now um just pausing there beer attack bureau veritas carried out a test of materials from the exterior of the building and then they produced a report of the 14th of september 2010 and that is in this
02:00:20 of september 2010 and that is in this same bundle at page 91 if we can just go to that please you can see the first page of it
02:00:29 and there it is and if we go within that report to page 92
02:00:35 92 paragraph 2.2 you can see that the report says
02:00:42 sd-03 fascia panel from flat 3 balcony two sections of white grp fascia panel no indication of flame retardant was found in the exterior gel coat or grp bulk the panel had no resistance to
02:00:54 bulk the panel had no resistance to ignition and once ignited it continued to burn and spread flame producing large amounts of dense black smoke the second duplicate sample for reference retention was not examined
02:01:05 and if you go to 2.3 below it goes on two pieces of white 18 millimeter thick expanded polystyrene bead board no flame no added flame retardant was found and the material had no resistance to
02:01:16 the material had no resistance to ignition continued to burn once ignited spread flame rapidly and shrank away from heat producing large volumes of dense black smoke the second duplicate sample for reference straight retention was not
02:01:27 reference straight retention was not examined
02:01:29 examined and the 2.5 talks about the upvc window frame and says in the second sentence black rubber seal straight gaskets had
02:01:40 black rubber seal straight gaskets had no resistance to ignition and once ignited to continue to burn and spread flame producing dense black smoke and the 2.6 castellated roof fascia panel
02:01:52 castellated roof fascia panel a white box profile was identified as grp with a smooth gel coat exposed surface and random glass reinforced core and rear surface the typical nominal thickness was 4 millimeters and no
02:02:03 thickness was 4 millimeters and no evidence was found of any flame retardant additive the panel had no resistance to ignition and once ignited it continued to burn and spread flame producing large volumes of dense black smoke the glass reinforcement tended to
02:02:16 smoke the glass reinforcement tended to keep the panel reasonably rigid whilst burning and the page 94 at paragraph 4.4 there's a comment on the castellated roof panels
02:02:28 which say that they remain part of the external envelope of the building that could provide a medium for fire spread and may therefore be a risk to health and safety it could have been ignited by a far starting in a top level flat or as in this case spreading to the top level
02:02:40 in this case spreading to the top level it could then spread fire around the roof edges where it could be difficult to control or extinguish one mechanism for danger would be from falling debris from this product spreading fire downwards and causing a
02:02:51 spreading fire downwards and causing a risk to health and safety of those escaping or firefighting below the large amounts of smoke produced by the burning of this product are also considered a risk to health and safety because of the overall amounts present and the wide
02:03:02 overall amounts present and the wide distribution of roof facial panels around the roof edge now just i've read you quite a bit of this
02:03:08 this although it's technical in some respects would you agree that it appears from these findings by bureau veritas that the materials used on the facade of the mattingly block in kingston in 2010 were not fire
02:03:20 in kingston in 2010 were not fire resistant and could allow fire to spread yes i think that's clear from the report yes and the same that could be said for polystyrene insulation the upvc window frames and the roof panels the castellated roof panels yes now um
02:03:33 castellated roof panels yes now um that that's clear from the reading and did you ever look at this document at the any stage i've never seen you stop you've never seen this document could we please go to double nfb triple zero two eight five
02:03:44 double nfb triple zero two eight five one five
02:03:45 one five uh page 64. same document run page 64. this is an email of the 23rd of july 2010 so
02:03:53 2010 so shortly after the fire but before the fire investigation report was produced and it's sent to stephen walker steve churrick and dave kennett with the subject marie mattingly external fire spread and
02:04:05 marie mattingly external fire spread and then there's an incident number and
02:04:08 and in the email in the first paragraph um mr ferkins who is fire engineering group
02:04:15 group um of the lfepa says this having viewed the cctv footage recently obtained by john elwell there appears to have been an unusual amount of smoke generated the smoke volume and
02:04:26 of smoke generated the smoke volume and color is similar on all four fire floors suggesting that it is predominantly coming from the building fabric rather than contents of individual occupancies i've left the dvd on steve turek's desk
02:04:37 i've left the dvd on steve turek's desk uh now he then goes on to say in the third paragraph the key issues seem to be
02:04:43 be one whether a similar occurrence could happen if a fire occurred on the lower floor it would affect more residents and may have a greater impact on the escape stair steve walker advises that the mattingly block is currently unoccupied
02:04:54 mattingly block is currently unoccupied there are however three similar blocks without knowing the exact fire development mechanism or if the other blocks have similar materials it is important not to jump to conclusions but we may want to advise as an interim
02:05:05 we may want to advise as an interim measure that early evacuation of the building should be considered rather than defend in place an increase in the pda may be justified to support this
02:05:17 to support this now
02:05:18 now i do i take it that you yourself have never seen this email no i haven't no um even when you came in as head of safety would you this wouldn't have been in a pack that you would have seen is that
02:05:29 pack that you would have seen is that right no it wasn't part of any pack um now
02:05:33 um now one can read this document but is it right that what mr firkins is saying
02:05:40 is saying is that a change to stay put due to the possibility uh that the sister blocks which were occupied might be at risk of external fire spread should be considered
02:05:51 fire spread should be considered i think if mr ferkington i know to have been a fire safety officer came to that conclusion then i would have to take a heed of his advice as a fire safety professional do you know was it the position
02:06:02 do you know was it the position or or view of the lfb at that time so this is summer 2010 that where there was a risk of rapid external fire spread due to the materials used in the facade of a high-rise building changing the state
02:06:14 high-rise building changing the state policy in whole or in part might be the appropriate step to take so a couple of things one i don't know if that was a consideration for lfb but of course the evacuation strategy is
02:06:26 of course the evacuation strategy is something for consideration by the responsible person for the building i think if lfp had concerns then those concerns should be shared with the rp as to
02:06:35 as to why they felt that stay put may not be appropriate given the other factors affecting that building so i'd expect it to be a dialogue but the decision ultimately sits with the rp
02:06:46 sits with the rp um but but there has to be the fire risk assessment would need to support that strategy and if llp wasn't comfortable in that in the regulatory role then it has the remit to take action right
02:06:59 action right do i understand from that answer that where a stay put would not remain in place
02:07:06 place in the event of an external fire spread such as that that is recorded as happening at maddingly then it was up to the building owner to
02:07:15 to introduce arrangements so as to facilitate uh significant partial or total evacuation of the building yes so it's it's the rp's responsibility in terms of the evacuation strategy that's informed
02:07:28 the evacuation strategy that's informed by the fire risk assessment now there will be a view from the fire service particularly because of the post-fire findings here to suggest that there are issues affecting the continuation of state put
02:07:39 continuation of state put and then if the rp was able to put in injury measures to the satisfaction of the fire service that made stay put still viable and sustainable then that that would be a a way of of maintaining
02:07:51 that would be a a way of of maintaining the evacuation strategy if they couldn't then it may well be that they would need to change the strategy for that building much in the same way as we're seeing now with a number of buildings as part of the risk review of high-rise buildings
02:08:02 the risk review of high-rise buildings across not just london but the country right
02:08:07 right had you
02:08:08 had you ever come across before june 2017
02:08:14 june 2017 uh an instance where the responsible person for a high-rise residential block of flats
02:08:20 of flats had in place uh an evacuation strategy which could be switched to in the event that the stay put policy for that building had to be changed
02:08:31 for that building had to be changed uh
02:08:32 uh no not in a dynamic context i think the um
02:08:37 um example i would point to is the sister block to lachen our house so given the circumstances at like in our house they were replicated in the sister block marie curie house and
02:08:47 and in conjunction with the local authority at the time they put a waking watch in place to
02:08:54 place to provide the facility of raising early alarm in the event of a fire because of the
02:09:00 the [Music]
02:09:01 [Music] compromises within the building that was similar to those in lacking our house so that's one example where evacuation strategy was supported by additional measures had those measures not been sufficient
02:09:12 had those measures not been sufficient then it may well have required either the decanting of that block or a separate strategy in terms of simultaneous evacuation yes
02:09:23 are you aware of
02:09:26 of what the lfb's understanding was at the time of the mattingly fire summer 2010 about whether the lfb had enforcement powers in relation to problems which had emerged with the facade panels
02:09:38 emerged with the facade panels uh i don't think i uh it wasn't my role in fire safety and it's not something i would have considered now can we go to page 127 in this bundle please this is an email of 7th of october 2010
02:09:49 an email of 7th of october 2010 from
02:09:50 from stephen walker to andy jack and
02:09:55 and stephen walker just to be clear for you was uh the team leader of the merton wandsworth and kingston fire safety team i think
02:10:06 safety team i think and the subject of the meeting
02:10:09 meeting or email is maddingly meeting 7th of october 2010. now it's a long email and i'll i'll just tell you in it he stephen walker summarizes a meeting he had attended with the officials from the royal borough of kingston rbk
02:10:23 borough of kingston rbk uh in the third paragraph he says i and i'll show it to you i then ran through the points that must be considered in a risk assessment of the other similar blocks uh or before this block is reoccupied
02:10:35 block is reoccupied one
02:10:36 one rapid vertical fire spread two fire spread onto the roof and associated issues with the protection of the ff lift motor room and prevention of debris falling from the roof onto the escape routes
02:10:46 routes three fire and smoke ingress into the single stair means of escape for clear signage to the dry rising main this was then discussed and then uh he says i then confirmed
02:10:58 and then uh he says i then confirmed that we had a duty to investigate this incident until considering enforcement under fire safety law and it was likely that an enforcement notice would be served and we were considering if there were grounds for prosecution
02:11:10 were grounds for prosecution etc
02:11:11 etc and then ian clements asked if an enforcement notice was necessary if the council put in place an action plan to mitigate the risk i said this would be taken into consideration now
02:11:21 now again i'm going to assume you knew nothing of this email or the discussions but
02:11:26 but would you agree with me that it appears from this that the lfb raised the possibility of enforcement action energy prosecution with the local authority in order to encourage them to take the matter seriously that's what it looks like yes no i think that's a fair um
02:11:40 like yes no i think that's a fair um summary of what's there and echoes to a certain degree uh circumstances that i've been in personally with regards to the um child cuts estate in camden right now gary steele has copied into
02:11:53 right now gary steele has copied into this email and other emails in the bundle regarding the response to the mattingly fire gareth steele i think remained a member of the fire safety department at the time of the grenfell tower of fire didn't he yes so he was part of your department yes once you took it over in
02:12:05 department yes once you took it over in march 16 yes yes yes um
02:12:10 um were you his direct line manager at that time he was i think one of your senior fire engineers yes so he would have reported to the deputy assistant commissioner with responsibility for this these uh
02:12:21 with responsibility for this these uh special teams engineering team say special teams sorry right and do you recall ever having discussed the mattingly fire with gareth steele no i don't
02:12:33 no i don't and would it follow you you don't recall discussing it with anybody else in the fire safety department no i don't would you agree with me that the issues raised by the mattingly fire
02:12:44 raised by the mattingly fire including fast bed and external panels and insulation was rightly a matter of concern for the lfb
02:12:52 lfb i think there are definitely issues here that are of concern and that prompts opportunities for learning i think if it helps um in my statement i think i've made the point that i'm not
02:13:04 think i've made the point that i'm not sure we've always taken every opportunity to learn as an organization i think that's a matter of record in my statement so if if what we are looking at here is examples of where your you're
02:13:16 where your you're demonstrating that then i think that's something that i've conceded in my statement anyway that protection wasn't always as high up the agenda as it needed to be and so the opportunities to learn from protection haven't always
02:13:27 to learn from protection haven't always been as well addressed i think we're better now i think we were on the path to improving that and i think we're better nationally on that regard as well through the work we're doing currently so the mattingly fire you would accept is a good example of a learning
02:13:40 is a good example of a learning event for the lfb where no learning or insufficient learning was taken i don't know that no learning was done but as an officer in the brigade at that time
02:13:48 that time um
02:13:50 um it's
02:13:51 it's i should have known about something related to this fire from what you've demonstrated that i won't aware of until today
02:13:57 today thank you now i'm going to go back to shepherd's court as i said i would um the shepherds caught fire just to reorientate you in the chronology happened on the 19th of august in the afternoon yes 2016. and i think you
02:14:08 afternoon yes 2016. and i think you attended that incident i did yes i was instant command at the end of it yes and i think you were the senior most incident commander weren't you yes i was monitored by mr dobson so we have a monitoring officer role who would be the
02:14:19 monitoring officer role who would be the most senior forest on the fire ground and i was the last instant commander of that incident yes and just a little bit of background i'm right i think that shepherd's court is a purpose-built high-rise block of flats which is yes
02:14:30 high-rise block of flats which is yes sitting in in fact in the london borough of hammersmith and fulham yes and the fire started in a flat on the seventh floor in a faulty white goods appliance yes and then i think fire penetrated the window and
02:14:42 think fire penetrated the window and spread vertically up the exterior of the building as far as the 11th floor yes yes yes now we'll get to the detail but in outline is it right that but there were these panels installed around the windows which the subsequent fire
02:14:55 the windows which the subsequent fire investigation found uh used or were comprised of combustible polystyrene insulation yes the exact makeup i don't recall but there was an issue with them yes we'll
02:15:06 there was an issue with them yes we'll come on to the uh fire investigation reports in a little bit of detail later on in your evidence but in summary do you remember that the investigation found that this combustible insulation contributed to the external fire spread
02:15:18 contributed to the external fire spread yes i think the testing it showed that the
02:15:21 the panels delaminated exposing the flammable core and that sustained external
02:15:27 external fire spread and at the time of that incident had you personally experienced that kind of external fire spread before i don't think so um i mean you may
02:15:39 i don't think so um i mean you may correct me if i've said differently in my statement but i don't i don't think i had but i was aware of it from
02:15:45 from lacking our house fire but i didn't attend that incident it was something that the learning from that had been shared and i was aware from that perspective uh
02:15:54 uh and at the time of that incident was it an incident that you're training as a firefighter and incident commander had equipped you prepared you to deal with yes i felt so you felt so yes
02:16:06 with yes i felt so you felt so yes now let's go to your statement your first witness statement please lfb 3032306
02:16:13 3032306 page 17
02:16:14 page 17 and let's look at paragraph 77. in the last paragraph last in the last uh part of 17 you say in my opinion the
02:16:25 part of 17 you say in my opinion the incident had similarities with the latin house fire in that it was the spandrel panels that had aided the external fire spread and fire spread back into other floors was greater where windows were open
02:16:36 windows were open as such this did not appear to be a new hazard to me awareness of external fire spread is referenced in our high-rise firefighting policy
02:16:46 and you go on to explain that in a bit more detail now if we go to your police statement let's look at that this is met307774
02:16:58 page four paragraph two
02:17:10 you say that with my fire safety background i felt that there was something unusual about that fire spread
02:17:18 can you explain what you can explain what you mean in both these statements was this fast spread nothing new or was it unusual so i think in in the first statement i'm saying it wasn't beyond my experience if
02:17:29 saying it wasn't beyond my experience if you like particularly from from references back to lacking our house when i use the term unusual it's that we wouldn't expect to see panels
02:17:40 panels usually um supporting sustained fire spread so it's unusual in that it shouldn't be happening on a building of that height um but not beyond my experience well don't explain the two
02:17:53 experience well don't explain the two yes i think we can agree that it shouldn't my question is if it's unusual as you say it was what was it about your fire safety background that prompted you to think that the first bird was unusual
02:18:04 to think that the first bird was unusual i think again i mentioned in one of my statements that um areas of fire safety and protection concern
02:18:12 concern became more of an issue for me when i took that reference on i think as an instant commander my protection learning gave me
02:18:19 gave me more options and i think attuned me to some of those factors that may be in my earlier career i wasn't um maybe as quick to to think about um in
02:18:30 maybe as quick to to think about um in the earlier part of an incident right so is it is it a little bit like we saw before
02:18:36 before not
02:18:36 not uncommon uh sorry uncommon but not a one-off
02:18:40 one-off yeah i didn't see this as a one-off but it was a fire spread that we shouldn't expect to see now you
02:18:46 now you um
02:18:49 say in your statement to page 18 if we can go to that this statement in the second last paragraph on that page
02:18:59 page we go to the bottom of page 18 you say
02:19:05 uh i do believe that fire safety knowledge has an important role to play as an incident since holding the role of assistant commissioner of fire safety i think i'm a better incident commander because of the enhanced knowledge of
02:19:16 because of the enhanced knowledge of fire safety i think it gives me more options in terms of my operational decision making it is one of the reasons we are bringing fire safety training back to operational crews it is something that fire services nationally
02:19:27 something that fire services nationally had stopped doing years ago which is now coming back
02:19:32 can you just explain first what you mean by more options there can you can you give some examples i think that i would more readily consider the facilities available to me uh in a
02:19:44 the facilities available to me uh in a particular building particular design i think i would consider the passive fire safety measures in a building more readily now more i would access that information i suppose in my um
02:19:55 information i suppose in my um initial decision making more readily than i had done earlier in my career um
02:20:02 i think it's it took me back to some of the work i did as a firefighter early days when i talked about doing fire safety checks i think it's why i personally have felt since taking over the department that it was an important
02:20:13 the department that it was an important area firefighters knowledge that i wanted to bring back and when i say services had stopped doing it nationally i mean generally there are some services that have kept that out of necessity um but as a general rule lots of
02:20:24 um but as a general rule lots of services when the change from the fpa to first place to workplace resident in the rro that was coincided with lots of services not carrying out regulatory fire safety functions with frontline crews
02:20:36 functions with frontline crews right um i i'm very sorry um to have to ask you again mr daley but might you be able to slow down a little bit yes i apologize our transcriber can get down what you're saying we had a few inaudibles in that answer sorry and we
02:20:47 inaudibles in that answer sorry and we don't want to have those if we can avoid them
02:20:50 them uh now are you able to give us some examples of situations where your fire safety knowledge made you a better incident commander i can think of an incident in a large warehouse in tottenham in north london
02:21:03 warehouse in tottenham in north london where the fire was spreading throughout the building through the fire loading in the building to an extent overrunning the efforts to suppress the fire and i think when i arrived
02:21:16 and i think when i arrived i immediately turned to the plans of the building to look to see what level of compartmentation was afforded which isn't usual within warehouses but there is occasionally some of those things and i was able to draw on
02:21:27 and i was able to draw on a clear compartment line and then start to dictate tactics for the
02:21:33 for the operational tactics through the operational commander to employ that would take advantage of that particular feature of the building design slow in the spread of the fire and enable us to put resources in place
02:21:45 and enable us to put resources in place beyond that to then uh suppress the fire that's the one that comes to mind right you mentioned childcuts earlier um is that was that a fire
02:21:57 was that a fire it wasn't in response to a fire um they have had fires there in the past and chao cuts was part of the work we were asked to undertake as all fire and rescue services were
02:22:08 rescue services were from government to check high-rise residential premises in the immediate aftermath of the grenfell tower fire right okay now um going back to shepard's court i think it's right isn't it that by the time you arrived at the incident the fire spread
02:22:21 arrived at the incident the fire spread was under control yes the dynamic phase of the incident had been dealt with um under the direction of doc hearn yes uh and you say i don't think we need to get back to it it's page four
02:22:32 to get back to it it's page four uh that by the time you got onto the command unit dac hearn had already put in place a number of things where crews were operating across a number of floors getting ahead of the fire and making those interventions before it could
02:22:43 those interventions before it could spread further now it's right i think the fire investigators also attended the shepherd's court fire didn't they they did yes and that was you say normal for an incident of that size they would
02:22:54 for an incident of that size they would have been mobilized yes but if we go um well we don't need to i don't think you say in your in your statement of paragraph two that you refer to one of your fire safety
02:23:05 you refer to one of your fire safety officers being there who was also a fire engineer do you know who that was yes it was jim flynn jim flynn uh and you say also in your um statement probably look at let's look at
02:23:17 statement probably look at let's look at page four for this paragraph two
02:23:24 page four
02:23:34 um paragraph two
02:23:39 uh you said you say in the middle of the paragraph i asked him to link up with the fire investigator and asked him to look at why the spandrel panels appear appear to have spread the fire the spandrel panels are the insulating
02:23:51 spandrel panels are the insulating panels that sit below the glazing in the upvc window setting would you have expected that to have been done if you hadn't suggested it when i spoke to um jim flynn who was
02:24:02 when i spoke to um jim flynn who was there in a capacity as a senior fire safety officer um he had already made that consideration um and was bringing that consideration i think back to the command unit and that's i think our our interaction kind
02:24:14 that's i think our our interaction kind of uh intersected his intentions to bring that to the awareness of instant commander and my intentions to bring it to his so
02:24:21 to his so together we were of a similar mind oh i see okay
02:24:25 see okay so he he'd already thought to do it but you confirmed it yes is i think what you're telling us yes i think that's yes first summary now um you you have explained in your police statement
02:24:37 explained in your police statement mainly to look at it but it is page 13 that the lfb has a process of debriefing fire crews and incident commanders after an incident and we know those to be i think a pro performance
02:24:49 those to be i think a pro performance review of operations for firefighters and a prc performance review of command or incident commanders yes that's correct uh and the pro will also look at the
02:25:01 and the pro will also look at the dynamic decision making on arrival and the initial tactics at that level yes yes
02:25:09 and the prc i think as you've explained is for the chain of command and that's the first incident incident commander all the way through to the ultimate the final incident commander and the monitoring officer uh
02:25:21 uh and you also go on to explain that the prc is independently chaired and the chair would ask each incident commander to talk their way through the incident with references to the
02:25:32 incident with references to the decision-making model
02:25:35 and you examine at what point the decisions are made uh whether why particular decisions are made and that's all examined all the way through the command chain is that a fair way of description
02:25:47 chain is that a fair way of description yes what role does the fire safety department play in a prc performance review of command so the plc would normally involve um
02:25:57 um from the initial call into the brigade so it could involve the control operators and then the instant commanders but the chair of the prc can call into the prc any other officers they feel have contributions that are
02:26:09 they feel have contributions that are valuable to the prc process and if we go to your statement of page
02:26:17 14 please
02:26:29 you say this at the conclusion of this everybody leaves the room apart from the chair the support officer and the minute taker they would consider all the evidence that has been presented once they've done so they will reconvene in open forum and share any learning with
02:26:41 open forum and share any learning with each ic in turn this does not mean that there will be particular feedback or learning for each ic
02:26:48 ic sometimes the feedback is that you did exactly what you were expecting what we expected you to do nothing exceptional nothing developmental and then you say this if there was any advisory points that an individual would be told if there was
02:27:00 individual would be told if there was something that fundamentally required some development for an individual that would generate a personal development record which their line manager would then address and manage through to completion the learning is delivered and shared openly in that meeting equally any
02:27:12 openly in that meeting equally any organizational learning is also recorded and taken away for action through the operational review team as well so there should be should have been some organizational learning recorded for shepherd's court in terms of the issues
02:27:23 shepherd's court in terms of the issues that i've raised earlier in this statement i did not recall if there was any specific exceptional items or development items for any of the ics in the prc for shepard's court
02:27:36 now is there a risk that an incident commander's concern about being given a or potentially being given a personal development record might distort the
02:27:47 development record might distort the evidence that he or she might give to the prc or the chairman chairperson i think that has to be accepted that may well be a risk yes
02:27:58 uh and when you refer to organizational learning
02:28:01 learning here in in terms of the issues that you've raised earlier in this statement what are you referring to so an organizational learning point could be
02:28:10 could be something to do with the resources that were sent to the incident
02:28:13 incident delays in mobilization um deficiencies in the kit and equipment that may be used at that incident in this particular example it may well be around
02:28:23 be around the fire spread that was witnessed at the time if it was deemed to be new or novel for the service what organizational learning points can you recall
02:28:34 you recall you considered that the shepherd's court fire had raised i don't recall seeing the end products and i can't remember what was on those um but in terms of the fire spread issue
02:28:45 um but in terms of the fire spread issue we were in ongoing dialogue
02:28:49 around how we were to follow up that learning because there was something for me in in
02:28:55 me in in how much of of this type of arrangement i'd seen in buildings across london and so uh notifying local authorities around the concerns that that gave to me and to the department um but then equally
02:29:07 um but then equally as that developed understanding to what extent this was an issue for firefighters across london would inform some learning opportunities [Music]
02:29:16 [Music] now we've seen a copy of the imp report for the shepherd court incident and that is lfb double zero one two zero nine nine eight can we please have that up
02:29:27 can we please have that up imp i think you'll agree stands for incident monitoring process yes and uh while that comes up just confirm it's right isn't it that any relevant individual or organizational conclusions
02:29:39 or organizational conclusions or findings from the pro or prc process get recorded onto the imp report for the incident yes they should yes yes now this is the imp report on the screen in front of you for shepard's
02:29:51 the screen in front of you for shepard's court have you seen it before uh yes i have seen this right cast your eye down it you would let the first one development comment no pickle was
02:30:03 development comment no pickle was available on the canteen van this lessened the enjoyment of my corned beef sandwich
02:30:08 sandwich now i mean um was it normal that an imp report would have solemnly recorded a senior officer's offhand joke uh absolutely not no can you can you account for that being there uh i can't account for it but i know that the
02:30:19 account for it but i know that the individual um was dealt with and returned to in regards to that particular statement right as i understand it right i mean that there's a serious point lurking here which is the question is it right
02:30:32 here which is the question is it right that some senior officers such as this one uh might have regarded the process of imp as something of a joke or to be taken less seriously than it ought no i think this
02:30:43 seriously than it ought no i think this this actually in in terms of that individual it's because they were about to retire imminently and so i think it was um
02:30:51 was um right
02:30:52 right a misplaced uh attempt at humour now leaving it aside that piece of misplaced humor would you agree that there is no reference on this report to the fact that this is an incident
02:31:03 the fact that this is an incident involving external fire spread as a result of combustible spandrel panels yes it's not there no would you expect an imp report to record information of that kind
02:31:15 record information of that kind if it was
02:31:16 if it was organizational learning that needed to to to be followed up on then it's the appropriate place for that learning to sit
02:31:24 sit i can't recall exactly how the prc ran and it may well be that the chair of the prc felt that the issue
02:31:32 the issue was already in hand in terms of the work that was ongoing in the fire safety department and the conversations with colleagues in ops policy around potential sharing that information for
02:31:43 potential sharing that information for operational news do you know why there was no reference to combustible spandrel panels in this imp no i don't say i can't i can't remember the
02:31:54 say i can't i can't remember the conversation that's place at the plc right
02:31:58 right if there weren't as we said there wasn't how else would you expect such information to be recorded and disseminated for future learning so as i say i think the chair may well have taken the view that there was already that the issue
02:32:10 that there was already that the issue didn't need to be recorded here because it was already being picked up elsewhere
02:32:16 that's one possibility but again i can't speak for the chair in this in this occasion right but i do know that i would have conveyed at the prc the work that we were undertaking in the department in terms of
02:32:27 department in terms of considering the information initially to hammersmith and fulham but then to the wider london local authorities about the concerns of this type of arrangement in a building
02:32:38 this type of arrangement in a building and then to understand the extent to which because although they may look similar may not actually be constructed similarly um understand the extent to which this offered learning for
02:32:50 offered learning for operational crews and ultimately that learning did emerge that
02:32:55 that i think you probably undoubtedly move on to
02:32:58 to that sometime later indeed too late uh
02:33:03 uh we come to it this is the sixth of april 2017 letter to the local authorities you're referring to we will come back to that before we do um i just want to ask you now some detailed questions
02:33:14 ask you now some detailed questions about the lfe's investigation into the shepherd's court fire now is it right do you recall that samples of the shepherd's court panels the spandrel panels were provided to bureau veritas who examined them and
02:33:27 bureau veritas who examined them and carried out tests on them between the 30 um
02:33:30 um sorry on the 30th of august 2016. yes yes and that's recorded in the subsequent report which we're going to look at in a moment now before we do can i show you some emails this is lfb3052135
02:33:46 and i'm going to show you here a chain of emails uh between members of the fire safety department uh which uh you can see there now if we go down to page six please we'll start with the earliest email
02:33:58 with the earliest email uh in the chain this is from uh
02:34:04 well um we need to see i think uh the very bottom sorry the very top of the very top of
02:34:15 the very top of start again the very bottom of page five where you have it charles romeo first of september 2016 to charlie pugsley copied to lindsay seal jim flynn colette o'hara john sutherland and
02:34:27 colette o'hara john sutherland and gareth steele and
02:34:31 and if we go down to the top of page seven we can see who see who charles romer is top of page seven this is a long email that straddles the three pages i'm afraid if we get to page seven we can
02:34:42 afraid if we get to page seven we can see that he is
02:34:45 in fact called charles ellie ray mayer uh and he has some uh post nominals he is a fire engineer in the fire engineering department he was yes he was
02:34:56 engineering department he was yes he was now um if we um go to uh
02:35:01 uh the bottom of page five and then we'll roll into the text of the email uh he
02:35:09 uh he calls the subject of the email test witnessing summary you can see that and then he says charlie please cite please find below a summary of the testing carried out and then he proceeds to do that
02:35:20 to do that and
02:35:21 and if you go to the third paragraph from the bottom of page six
02:35:31 he says this in and this is the paragraph above the yellow in conclusion the test revealed that the insulation provided in the sandwich panel was made out of polystyrene the tests
02:35:42 out of polystyrene the tests demonstrated that once the metal fascia was removed the insulation as well as the wooden backing was contributing to the combustion process increasing significantly the size of the flames as
02:35:53 significantly the size of the flames as well as the size of the burnt area it is therefore the fire engineering group opinion that the responsible person for this building needs to demonstrate compliance with applicable guidance this can be achieved through
02:36:05 guidance this can be achieved through the provision of the appropriate certification it is likely that further testing is required to determine if the sandwich panel's sandwich panel is of limited combustibility or is able to achieve the required performance when tested in
02:36:17 required performance when tested in accordance with bs8414 part 1 and 2. these tests are full scale and enable the system to be tested in its entirety now the opinion that i've read to you here in full
02:36:28 here in full uh was reached within a couple of days of the tests being witnessed it seems is that right uh yes it looks so from a the dates it looks like it because we could see from the top of the email that the test happened on the 29th uh and 30th of
02:36:41 happened on the 29th uh and 30th of august
02:36:42 august now you're not copied into this email but where you are aware uh of the this conclusion uh at this stage i'm not sure i was aware of this
02:36:53 i'm not sure i was aware of this conclusion but i certainly was aware that initial findings had been shared with individuals in the team and so it's not an unreasonable conclusion for them to draw right but before we move forward there was a
02:37:05 but before we move forward there was a second
02:37:06 second uh i believe a second series of testing to substantiate the initial test results now
02:37:14 after the testing of the panel from shepard's court in august 2016 as we've just seen
02:37:19 just seen the tall buildings facades presentation which we looked at earlier was updated wasn't it
02:37:25 wasn't it yes yes
02:37:27 yes yes now um in
02:37:29 now um in let's look at david green's witness statement again it's lfb3032917 this time let's look at page five uh paragraph 23.
02:37:44 um he says there um on 4th of october 20
02:37:50 20 2016 excuse me i presented a modified version of the tall building's facade's presentation at the senior fire safety officers sfso cp day and he explains that sfsa's operational
02:38:03 and he explains that sfsa's operational flexible duty staff members in the role of station manager and group manager who obtain specialist via safety officer attribute etc and he refers to the um slideshow itself a paragraph 24.
02:38:15 slideshow itself a paragraph 24. um
02:38:19 the
02:38:23 next paragraph down
02:38:26 down 25 says this i'm unsure exactly how this version of the presentation was requested by the officer who was planning cpd inputs for this specialist carder
02:38:35 carder the expected procedure would be for a request to fill a speaker slot from the organizer of the sfso day group manager spencer sutcliffe to have been made to the fire engineering group management
02:38:46 the fire engineering group management the tall buildings facade's presentation of 13th july 2016 which we saw earlier was updated by my colleague charles ellie romeyer he forwarded the revised presentation facade's presentation
02:38:58 presentation facade's presentation version 2 to me by email at 1859 on the 3rd of october 2016. on the email he describes the changes made as trimmed it down with regards to the technical content added the shepherd's fire thing
02:39:10 content added the shepherd's fire thing and the test carried out i also did a general tidy up and small amendments with regards to order
02:39:18 to order uh
02:39:19 uh 27 let's just look at that for completeness he says this the phrase shepherd's bush fire refers to the 20-pound pirate shepherd's court
02:39:28 now if we look at the updated version of the presentation which we looked at before lfb3032916
02:39:39 let's go to page fifteen
02:39:45 we looked at page twenty one was the which was the conclusions uh and we
02:39:49 uh and we we have your evidence about that but if we go to page 15 we have the case study 20 pump fire shepard's bush and there's a photograph of of the fire at shepherd's court
02:40:00 and on page 15 at the top bullet it's recorded that the fire started on seventh floor in two bedroom flat with rapid spread of the fire along the facade if we go to page 16 that sets out
02:40:11 facade if we go to page 16 that sets out some post-fire questions product recall and advice given and then there's a red arrow preliminary testing was carried out and witnessed by the fire engineering group to determine the behavior of the
02:40:23 group to determine the behavior of the facade and if further actions were required
02:40:26 required and then the presentation goes on to set out in some detail the results of two series of tests that were carried out on samples of panels taken from the scene of the fire now we'll return to those tests in more detail
02:40:39 tests in more detail shortly probably on monday now but for the moment i just want to take you to the photograph taken during the second series of tests which we'll find on page 19.
02:40:50 which we'll find on page 19. if we go there we can see the text on the left hand side and that says this in the second bullet point significant sustained flaming occurring following the removal of the ignition
02:41:01 following the removal of the ignition source
02:41:02 source test 3 was stopped after 5 minutes 44 seconds as the testing facilities were overcome by the size of the fire this series of tests revealed that the insulation contributed to the combustion
02:41:13 insulation contributed to the combustion when the metal fascia was removed and if we go to the next slide
02:41:22 page 20 in the conclusions in the first bullet
02:41:25 bullet it says the tests demonstrated that once the metal fascia was removed the insulation was contributing to the combustion process therefore the facade may have contributed to the fire spread
02:41:36 may have contributed to the fire spread now
02:41:37 now as the presentation was given on the fourth of october before the first bureau veritas report came to the lfb on the 3rd of november a month later can we take it that the information
02:41:49 can we take it that the information contained here in the presentation about the testing of the panels came most likely came from the lfb personnel who'd witnessed the testing yes i'd say so yes
02:42:00 yes i'd say so yes but there was no we've seen no preliminary testing from bureau veritas so
02:42:06 so are we right about that there wasn't an earlier no i think we we had i was certainly informed the results of initial testing um but a formal report would take some
02:42:19 um but a formal report would take some time to be returned to the brigade because there needs to be second testing to substantiate the findings and then the report drafted by bureau veritas which then becomes the document back to the brigade with the
02:42:31 the brigade with the findings
02:42:32 findings of the full test regime let's now look at the bureau of veritas test itself of the third of november 2016. we find that at lfb 6088
02:42:51 and you can see uh that this is the fire safety department report examination of clouding panels flat 28 shepherds court
02:43:03 shepherds court and
02:43:04 and there's an introduction and if you um go down to paragraph 2.2 on page one scroll down a little bit more you can see that it says this the first panel incomplete the sample from
02:43:15 first panel incomplete the sample from outside the living room flat 58 on the 12th floor the second panel complete with some samples from outside the living room of the flat on the far origin flat 28 seventh floor
02:43:26 origin flat 28 seventh floor and at the top of page two if you go to it please paragraph 2.5 the report describes the first panel it says it was incomplete as the external surface had come away during the fire exposing a blue plastic foam
02:43:37 the fire exposing a blue plastic foam underneath uh paragraph 2.6 the blue plastic foam was mounted on plywood board and the 2.9 you can read between if you like
02:43:48 you can read between if you like mr daily but 2.9 a sample of the blue foam was removed for further testing and it was confirmed to be polystyrene foam by infrared spectroscopy now if we go to 2.12
02:44:01 now if we go to 2.12 a little bit lower down the screen the front surface of the complete panel was a metal sheet approximately one millimeter in thickness the metal sheet attracted a magnet and was therefore presumed to be steel and at 12 16
02:44:14 and at 12 16 the same page lower down the screen the complete panel was subjected to three different flame tests involving three different sized ignition sources to gauge the ease with which it could be ignited and also to obtain the basic understanding of the fire behavior of
02:44:26 understanding of the fire behavior of the panel
02:44:27 the panel and the results of the tests set out at
02:44:30 at paragraph 219 towards the bottom of page two
02:44:33 two none of the flame tests penetrated the steel sheet however removal of the steel sheet revealed varying degrees of fire damage to the to the blue foam layer underneath and then the report goes on to consider
02:44:44 and then the report goes on to consider how these materials are likely to have behaved during the shepherds caught fire if you go to page three at three paragraph 3.4
02:44:57 and this is the last part i'll read you before we come to actually to a question uh it says this the flame tests show that small ignition sources acting in a localized fashion would not significantly threaten the
02:45:08 would not significantly threaten the integrity of the panel and would be unlikely to ignite a panel however as the fire develops and grows further it is possible that a wide flame front could end up acting on the steel sheet
02:45:19 could end up acting on the steel sheet of the panel the heat from the flames would be conducted through the steel sheet and would therefore melt away the blue foam layer underneath this would occur in progressive fashion as the fire develops and would ultimately lead to
02:45:30 develops and would ultimately lead to the steel sheet not being held in place by sufficient bonded blue foam the weight of the steel sheet would then ensure that it would become detached from the remainder of the panel likely fall away and expose the heat damaged
02:45:42 fall away and expose the heat damaged blue foam and plywood layers to the developed flame front this situation is likely to have occurred to the panels above the flap of fire origin when the living room windows of the flat of fire
02:45:53 living room windows of the flat of fire origin failed during the fire at this scene
02:45:57 scene now would you agree that the report does not record specifically what happened in the flame test on the incomplete panels in other words where the panels that didn't have the front metal sheet
02:46:08 that didn't have the front metal sheet attached and where the blue plastic flame frame underneath was exposed to the fire
02:46:13 the fire yes i think it describes the delamination if you like a better expression of a complete panel yes
02:46:25 now after that report was received and mr chairman i'm just thinking i'm actually onto a second sector documents in precisely the same topic
02:46:36 would it be inconvenient to you and to the witness if we if we stopped at that point i'm just thinking i'm not going to finish this run of documents before 4 30.
02:46:45 30. uh well if if you've got quite a few more questions to come
02:46:50 to come then um
02:46:52 then um yes i mean they're better taken at one go and they're long yes it probably would be best to take it all together but what i think we better remember to do because we can't come back to this before
02:47:03 come back to this before monday
02:47:04 monday is just to read back into it i think that's that's you might just have to exactly cover the old ground again to some extent sorry about that no no i think that's absolutely right i'm very happy to do
02:47:15 absolutely right i'm very happy to do that and we have plenty of time to do that yeah um well um all right thank you very much well mr
02:47:22 well mr daley as you've heard uh there are more questions to come on this subject and i think it would be better to try and take them as a single group um
02:47:31 um i think we'll all benefit from being reminded when we come back uh where we got to and how we got there so we're going to stop there for today i'm going to have to ask you i'm afraid to come back on monday but i think you
02:47:43 to come back on monday but i think you will probably expect i was expecting that anyway won't you that's good so it'll be 10 o'clock on monday morning and
02:47:50 and obviously they're going to be quite a long gap between uh finishing today and resuming on monday so it is very important that you remember not to talk to anyone about your evidence over the weekend i understand it right
02:48:03 over the weekend i understand it right yep that's fine thank you very much indeed well in that case as i say we'll stop there if you'd like to go with the usher we look forward to seeing you on monday morning thank you
02:48:21 right thank you very much mr millet uh 10 o'clock thank you mr chairman thank you
02:48:30 you