London Fire Brigade evidence session examining operational procedures, training practices, fire safety inspections, and communication systems related to high-rise buildings.
00:22:25 good morning everyone welcome to today's hearing
00:22:28 hearing uh today we're going to continue hearing evidence from mr david brown so would you ask mr brown to come back in please
00:22:45 good morning mr brown only sir all ready to carry on yes thank you very good thank you very much well when you're ready mr kane please thanks sir good morning again mr brown good morning um could we return to the email
00:22:56 um could we return to the email correspondence between you and mr tom george regarding the elwell report which can be found at lfb trouble zero four one three six zero forward slash eight
00:23:14 now here we have at 1344 email response from mr george the email you sent him on the same day namely the 16th of december which we're considering yesterday that email says this
00:23:26 yesterday that email says this my view is the publication of the revised pn 800 and ss7 so that service standard 7 of the 11 server standards it is the closest to completion go hand in hand
00:23:37 closest to completion go hand in hand with the creation of an inspection program
00:23:39 program the policy needs to define what a high priority building is with the required frequency for inspections and then the inspection program would fall out of that
00:23:49 that whilst i've made suggestions to andy bell on amendments to the policy i'm not sure how far away from finalizing it we are some of john's recommendations that's elwell could be implemented now others to be
00:24:01 could be implemented now others to be considered as more aspirational now just to put some further context on this um can we turn to mr george's statement which can be found at lfb trouble zero
00:24:12 which can be found at lfb trouble zero three two eight two three four slash nineteen and paragraph 73
00:24:20 now you'll see paragraph 73 there on the bottom half of the page mr george said this in december 2013 i suggested to the third officer that's you that each recommendation be carefully considered
00:24:32 recommendation be carefully considered i felt that implementing them would fully discharge action 18 b and significantly improve the process used to collate and share operational risk information it was my opinion that publication that
00:24:44 it was my opinion that publication that the publication of the revised pn 800 and service standard 7 went hand in hand with the creation of an inspection program
00:24:52 program i suggested that the policy define a high priority building and give the required frequency for inspections it was my view that the inspection regime would flow from the prioritization i
00:25:03 would flow from the prioritization i also suggested that some recommendations could be implemented immediately whilst others would take longer to achieve now aside from the email that we've just been looking at did you discuss the
00:25:15 been looking at did you discuss the elwell report or the elwell recommendations with mr george in any detail
00:25:21 detail we did discuss them yes and did you discuss them in or about the time you sent this email so around 16th of december around that time yes uh did mr george tell you during the
00:25:33 uh did mr george tell you during the course of those conversations that he felt that implementing the recommendations would fully discharge action 18b and significantly improve the process used to collate and share
00:25:44 process used to collate and share operational risk information word stuff hs did you agree with that view expressed by mr george i agreed with mr george that the
00:25:55 i agreed with mr george that the recommendations from john l world's report were helpful and that they either could be implemented immediately or over time and they certainly would support the the rollout of policy note 800
00:26:09 the the rollout of policy note 800 but then i reiterated mr george that what i wanted in terms of as a prioritization for uh getting buildings onto the operational risk database and that list as as helpful as
00:26:21 database and that list as as helpful as it was didn't give me that immediate prior resultation i was looking for and was that the reason why no steps were taken to implement the el well recommendations well some of the l well recommendations
00:26:32 well some of the l well recommendations were in hand anyway some were being implemented by john
00:26:37 by john through his uh input into policy note 800 and others would be implemented in time so it wasn't the case that they weren't implementing or ignored it's just that
00:26:48 implementing or ignored it's just that they weren't what i was looking for did you minute which recommendations you thought were being addressed already and those which would to use your phrase be implemented in time anyway no no
00:27:00 no no [Music]
00:27:01 [Music] and so those views were simply expressed during conversations with mr george is that right that's correct now the next email in the chain i'd like to
00:27:10 to look at
00:27:11 look at we can go back to lfb trouble zero four one three six zero uh forward slash eight and we can look at the email at the top of the page which is sent on the 22nd of january
00:27:23 which is sent on the 22nd of january 2014 so certainly more than a month after the initial correspondence mr george sent you an attachment to dave apologies for the delay on this i was hoping to send this
00:27:34 delay on this i was hoping to send this to you yesterday please see attached i'm really not sure if this is the type of thing you're after but can you please have a look and let me know your thoughts and where you'd like further work to focus
00:27:45 work to focus now if we can just look briefly at the attachment which mr george provided to you and that can be found at lfb trouble00833888
00:28:00 now first of all do you remember that as being the attachment uh that mr george provided you i don't immediately recall that no well you can take from me that is the attachment that was uh um
00:28:12 attachment that was uh um uh attached to that email if we turn to page two
00:28:18 you'll see at the top of the page it lists a number of property types and it says this
00:28:24 says this rather just before it says this pn 800 does not include a method for prioritizing types of premises to be visited and whilst the system adopted needs to be flexible a list of types of property in a priority order would be
00:28:36 property in a priority order would be deemed to be helpful to local managers the list below is not exhaustive if we turn over the page
00:28:45 coma sites for the uninitiated uh what does coma stand for uh control of major accident hazards so these are the large uh
00:28:55 uh chemical science nuclear science thank you and we see it number two high-rise residential buildings six floors and above
00:29:04 above is that right yes now this looks as if it was the priority list of building types that you'd ask mr george to prepare is that right yes
00:29:14 and by this time had you explicitly rejected
00:29:18 rejected uh dealing with each of the eight recommendations made by mr elwell or were you taking it incrementally i guess
00:29:27 i guess of those two options taking it incrementally they were never expressed expressly rejected or rejected at all actually they were just at
00:29:37 at risk of repeating what i've just said they were being dealt with as and when they fitted into the system some were being dealt with anyway some already had some with a joint to deal with and some were for the future but they were never
00:29:49 were for the future but they were never part of you to interrupt though they were never those well recommendations were never the subject of a reasoned consideration decision by you though were they
00:29:56 were they recorded in writing not recording writing but they certainly were subject to a reasoned consideration now can we go back to the email chain lfb double trouble zero four one three
00:30:07 lfb double trouble zero four one three six zero
00:30:08 six zero and page seven
00:30:11 and we see uh your response there to the
00:30:15 to the email from mr george in the attachment and you say in short the list is as below can you
00:30:22 can you ensure we make hmos so that's houses of multiple occupation uh clear in it and also share with the other dac so that's the deputy assistant uh commissioners for comment please
00:30:34 for comment please now if we look at lfb 004-22294
00:30:43 we can see that a few minutes after your email mr george sent an email to
00:30:48 to fcs ops mobilizing fcs stands for what uh
00:30:54 uh firing community safety optimobilis that's just a uh an email address for
00:31:00 for central service delivery thank you and in that second paragraph of that email he says this i sent an email to dave this morning as you can see below along with the attached the document we've
00:31:11 with the attached the document we've just been looking at from his response it is clear he literally only wants a priority list of property types and has asked me to run the list below past you and has asked for your comments to me please
00:31:22 please he is asked to include hmos which i will do this is likely to come up in pmb tomorrow i'm sure that you like me will have real reservations about taking such a simplistic approach
00:31:34 about taking such a simplistic approach we will all have differing opinions on premises we feel should be visited and risk scored and the way we prioritize them i hope my short attached summary puts my overall thoughts on the subject
00:31:45 puts my overall thoughts on the subject into some sort of context now bearing in mind that expression of opinion from mr george in relation to your direction can we return to the email change that you were having
00:31:56 email change that you were having with him which was at four one three lfb04136 zero page six okay sir
00:32:06 [Music] thank you and there we see uh yet further email from mr george uh to you copying in fcs ops immobilizing
00:32:17 fcs ops immobilizing now
00:32:19 now we can see in that text
00:32:23 that text red text are those your responses to the material or the draft text put forward by mr george yes so the email would have been from tom george and rather than write a long email in reply i've just
00:32:34 write a long email in reply i've just commented in red against each of his statements is it fair to say that you're a succinct communicator in the sense your emails are brief and to the point as exemplified by this in the previous
00:32:45 exemplified by this in the previous email
00:32:47 email yes i'm more inclined to be concise and verbose
00:32:50 verbose but then i received an awful lot of emails and that was a good way of just responding quickly and efficiently thank you now here we see there is a proposal for banding and we see bands one two and
00:33:01 for banding and we see bands one two and three set out there band one these properties will probably have already been visited it will probably already be on the ord by the operational risk database band two some of these properties are likely to have already
00:33:12 properties are likely to have already been visited and some some may already be on the ord and band three these properties are unlikely to have been visited risk scored and are unlikely to be on the board
00:33:23 be on the board and we go on below that summary of the bands
00:33:27 bands the text says this the proposal from the dacs is that properties within band 1 are to be visited and risk scored in line with pn 800 first only when these visits are complete should properties from band three be visited and visits to
00:33:39 from band three be visited and visits to band three properties will only commence after band two is complete and you agreed with that proposal in broad terms yes
00:33:46 yes that's exactly what i wanted and it was that banding system was what you were after absolutely and that's precisely what you've envisaged uh when discussing matters with tom george yes
00:33:57 with tom george yes now can we go and establish that can we go to mr george's first statement which can be found at lfb treble zero three two eight two three four slash two zero and
00:34:09 two three four slash two zero and paragraph 75 and 76. excuse me
00:34:14 excuse me now we can see it paragraph 75 mr george says this
00:34:17 says this following our analysis of policy but mainly based on our professional experience and judgment we drew up a banding system that we felt met the aim of action 18b to create an inspection
00:34:28 of action 18b to create an inspection regime targeted at high priority buildings
00:34:31 buildings the dac's proposal was that properties within band 1 were to be visited and risk scored only when these visits were complete from properties only when these visits were completion properties from bound to be visited and
00:34:42 properties from bound to be visited and visited ban three properties with only commence after that officers also felt that there would still need to be an element of flexibility where it could be justified e.g where a property came to our
00:34:53 e.g where a property came to our attention that was out of priority order whilst the banding system was intended to complete the lack of action i along with my area dac colleagues were not convinced it was entirely achievable i
00:35:05 convinced it was entirely achievable i expressed this reservation to the third officer and just before we come on to questions apologies another recitation of evidence can we go to mr george's second statement lfb treble zero eight three double eight
00:35:19 lfb treble zero eight three double eight four
00:35:19 four forward slash nineteen
00:35:25 and it's paragraph seventy four at the bottom of the page
00:35:29 mr george exemplifies the nature of his reservations i express my reservations that the review was quantitative not qualitative in conversations with third officer ac
00:35:41 in conversations with third officer ac brown between december 2013 and may 2014 our discussions took place in one-to-one meetings and in the principal management board meetings i expressed that i did not think that
00:35:52 i expressed that i did not think that creating a highly prescriptive over-the-page inspection regime targeted at high priority buildings that fall within a banding system would be achievable in that it would be virtually impossible for crews to visit
00:36:04 for crews to visit and undertake a meaningful inspection such a significant number of premises especially for inner london stations now that's a long run up to a short question did mr george indeed any other
00:36:16 question did mr george indeed any other dac colleague he refers to there say to you that the banding system was not achievable for the reasons he gives there i don't recall any of the decks raising that i had conversations with tom george
00:36:28 that i had conversations with tom george about john l world's report but certainly not the banding process in terms of being unachievable the the that group was a robust group we had open and frank discussions if they
00:36:40 had open and frank discussions if they if they disagreed with this they without doubt would have mentioned it and i don't recall them ever mentioning the disagreement so is mr george wholly mistaken in the evidence he sets out a paragraph 74 is that what you're saying
00:36:51 paragraph 74 is that what you're saying i have no recollection of it
00:36:56 having set out those reservations here um do you accept that there was some merit to the reservations that he expressed no i don't because because the whole
00:37:08 no i don't because because the whole point was to focus crews in terms of getting the right premises onto the operational risk database so
00:37:15 so the the danger was that we'd said to them
00:37:18 them there's clearly not enough buildings on there you need to get out and about on your station's ground get more premises on the operationalist database without direction from us there's the danger that they could be put in they could be
00:37:30 that they could be put in they could be choosing premises over and above something that was a high risk premise and should be on there sooner rather than later so the whole point was to give them some guidance and i totally agree with with tom in terms of the
00:37:42 agree with with tom in terms of the flexibility for a borough commander or station manager to step outside the list for good reason i would support that but he sets he puts it quite highly uh at the top there he says it's virtually
00:37:53 at the top there he says it's virtually impossible quote uh for cruz to visit and undertake a meaningful inspection do you agree with that criticism of the banding regime or the proposed banding regime
00:38:06 no i don't actually understand the rationale for saying it's virtually impossible so no i don't agree now for context can we now turn to lfb treble zero three two eight double three
00:38:17 treble zero three two eight double three which apologies is another email chain
00:38:21 now this flowed from the exchanges that you and tom george had been having and which we've already uh
00:38:28 uh read and discussed now on page one after the blue text at the top we see that mr george produced a draft email on your behalf setting out the
00:38:41 email on your behalf setting out the threefold banding system and 25 priority building types and we can set out we can see if we can de-amplify we can see that mr george sets out a fairly detailed explanation as to
00:38:53 detailed explanation as to what the banding regime would be and he sent that email to you on the 7th of february now having that as piece of context can we go back to your first witness statement
00:39:05 go back to your first witness statement which can be found at lfb trouble 0-321-6
00:39:09 0-321-6 forward 16.
00:39:17 and we see it paragraph 45 you say on the 24th of may 2014 i sent a further email to station based staff notifying them of all future 72d visits a premises risk assessment was also
00:39:29 a premises risk assessment was also required to be completed now the document you exhibit can be found at lfb 0032160
00:39:41 and we see it in the lower half of page one
00:39:45 one was an email again sent on your behalf to unknown recipients it's much briefer than the email that mr george drafted on your behalf and said
00:39:56 george drafted on your behalf and said this in addition to the regular visits as part of the 72d inspection program at stations a premises risk assessment must be carried out at all future 72d inspections this includes premises that already
00:40:08 this includes premises that already that already feature on the outside duties master schedule but have not yet had a premises risk assessment applied please refer to pn800 for details on the premises risk assessment and scoring
00:40:20 premises risk assessment and scoring process
00:40:22 process now at the bottom of page one and over to page two the email sets out the beginning of the banding priority list but appears to have been cut off and if we could we see that band one
00:40:34 we could we see that band one somewhat isolated at the bottom of page one if we turn over to page two
00:40:42 after five it abruptly ends i think mid-word for airport
00:40:50 do you know whether the full text of that email was ever approved and sent
00:40:59 it was it was sent the whether it was the full text or not uh probably not but it would have included the full banding system
00:41:09 system so would it what appears to be the start what appears to be cut off there is the list of priority buildings yes but
00:41:17 yes but i can't explain why that's cut off but that certainly wouldn't have been sent like that because it goes for a number of checking processes before the email goes out now the email was sent to
00:41:28 goes out now the email was sent to undisclosed recipients are you able to help the panel as to who those undisclosed recipients were likely to have been can i see the front of the email of course
00:41:41 oh yes so it would have been to all station based staff and their managers and borough commanders and dax and the reason that looks like it's undisclosed is
00:41:53 that looks like it's undisclosed is because
00:41:55 because emails were going out via the communications team so an email i sent out rather than me send it personally for my own email address i would send it by the communication team there was two reasons for that i don't we don't it's
00:42:06 reasons for that i don't we don't it's just i just want to know to whom okay the emails address which you've answered now according to the rule 43 action plan of march 2016 which we were looking at yesterday and which can be found at lfb trouble zero three one zero double six
00:42:19 trouble zero three one zero double six forward slash twenty one
00:42:27 and we see that in the far right hand column
00:42:31 column in relation to action
00:42:33 action 18b
00:42:35 18b it says this action ie 18b was opened on the third on the 4th of july
00:42:43 they probably need to turn over the paid
00:42:53 and closed on the 25th of february 2014.
00:42:59 2014. so
00:43:01 so i'm trying to find it now should it be further done just double check [Music]
00:43:12 i certainly lost it sorry this is my uh fault uh mr brown just referencing just getting the reference if we go to page 21 again
00:43:25 so if we go back sorry page 22.
00:43:31 uh you see in the middle
00:43:35 so we did have it and then we've moved anyway what i'll do we did have it if we go to the bottom row
00:43:44 row on page 23. i think it's the next page down isn't it because you apologize the page keeps on moving sir so i
00:43:52 so i yes well i've got the document up on my screen and 18b
00:43:59 um does
00:44:02 does say that it was open on the 4th of july which is what you were expecting to see i think yes page 24. um
00:44:11 um there we go yes right hand column sorry that was my fault
00:44:15 fault right hand column middle row this action 18b was opened on the 4th of july 2013 and closed on the 25th of february 2014.
00:44:26 february 2014. guidance has been created for station-based staff as to the priority order of visits that should be applied to different premises types this guidance ensures that staff at stations visit the highest priority premises first
00:44:37 premises first in addition details of premises where the brigade has attended an afa what's that automatic fire alarm or non-domestic fire over the past three years have been identified to ensure
00:44:48 years have been identified to ensure that 72d visits are carried out at these premises
00:44:52 premises now is the reference to guidance in the rule 43 action plan a reference to the email that was sent out to staff that contained the banding lists can you help us on that
00:45:03 us on that yes
00:45:05 yes was any other guidance produced
00:45:10 i don't believe so can we
00:45:13 can we bear in mind that answer can we go back to mr george's witness statement which can be found at lfb treble zero eight three double eight four forward slash 20 and paragraph 75
00:45:31 and what he says there is i would like to draw the gti's attention so that's the grandfather inquiry attention to the fact that the banding system was never incorporated into lfb policy and i was never asked to provide details of the
00:45:42 never asked to provide details of the third officer of how stations were performing in this area is mr george right that the banding system was not implemented
00:45:53 no it that's not correct that it wasn't implemented it wasn't incorporated into policy note 800 at that time whether it was incorporating future policy i can't comment on
00:46:05 policy i can't comment on but it was as a guide for that moment in time it wasn't necessarily something that was required for permanent policy so it wasn't incorporated into policy at
00:46:17 so it wasn't incorporated into policy at that time
00:46:18 that time so
00:46:19 so 13 2013 2014 and you can't say whether it was later incorporated into any other policy no
00:46:26 policy no but but so when i say not incorporating the policy what i mean by that it was not written into policy note 800 that doesn't mean to say that it wasn't policy as such it was certainly guidance
00:46:38 policy as such it was certainly guidance to assist staff in implementing their policy
00:46:44 why wasn't it specifically incorporated into pm 800 well it this banding system probably it came in the middle of the consultation i think in terms of policy
00:46:56 consultation i think in terms of policy note 800 being published but also it was just guidance for as i say that moment in time it wasn't something that we envisaged would be necessarily on a permanent basis once we
00:47:07 necessarily on a permanent basis once we got to the position where sufficient if not all
00:47:11 not all unknown premises were on the operation of this database then there would actually be no reason to have a banding system we could deal with premises as and when they become available but because we were so up against it in terms of numbers not on the system i
00:47:24 terms of numbers not on the system i wanted to prioritize well
00:47:27 well the
00:47:28 the problem about getting high priority buildings
00:47:31 buildings on the operational risk database or some central register had been continuing since 2009 and we're now 2014. the policy review cycle is every three
00:47:42 the policy review cycle is every three years
00:47:43 years now given that little if any substantive progress had been made by 2014 wasn't it sensible and necessary for the banding system to be included in this
00:47:54 banding system to be included in this iteration of 800 so that it was in place for three years so that you could achieve your aim of more and better quality records of high-rise high-risk or risk buildings on
00:48:06 high-rise high-risk or risk buildings on the ord
00:48:07 the ord it could have been included in policy but then it would have been enshrined as something that was was permanently the case and it wasn't it was just advice that was relevant for that period of
00:48:18 that was relevant for that period of time well it wouldn't be permanently enshrined would it be it would be in the policy for three years or such until such time as you felt that the objective had been met well that's true but there's but also
00:48:29 there's but also policies need to be succinct and there's nothing wrong with having guidance attached to a policy or crews aware of guidance in terms of delivering on a policy and that's what we saw that was
00:48:43 can we now turn to action 18d or action 2d which was the setting of corporate targets yes and just so we know what we're talking about after yesterday
00:48:54 yesterday 2d
00:48:56 2d was the action to establish a corporate mechanism by which targets for the brigade section 72d activities are set that became action 18d and it was assigned to you to complete is that a
00:49:07 assigned to you to complete is that a fair summary that's correct now you address action 2d at paragraph 74 to 76 of your first statement which we can find at lfb trouble zero three two one double six forward slash two
00:49:20 two one double six forward slash two three
00:49:25 now if we can look at paragraph 74 and really the fifth line from the bottom of that paragraph you say as director of operations i was responsible for 33 boroughs with 102
00:49:36 responsible for 33 boroughs with 102 fire stations with four watches on each station to ensure consistency in the delivery of our services i introduced operational service standards which helped measure whether a local unit was performing to the standards expected it
00:49:49 performing to the standards expected it is at this level that 72d visits would have been monitored the pool of premises that required 72d visits excuse me with those contained on the ord
00:49:59 the ord i expected that 100 of the premises on the ord would be risk assessed according to the criteria set out in lfb policy 800
00:50:08 800 and indeed that firefighters and officers would continually add new premises to that list the regularity of visits after the initial inspection would then be determined by the risk matrix i note that in the minutes of the
00:50:20 i note that in the minutes of the operations prevention and response department principal management board meeting
00:50:25 meeting of 18th december 2013 is recorded at paragraph 3.7d that the corporate target i had set was to complete all 72d inspections
00:50:36 was to complete all 72d inspections by that i meant that all premises on the ord
00:50:40 ord and any new ones added to it would need to be inspected in accordance with the risk assessment set out in lfb policy 800.
00:50:49 800. now just to get some clarity on this was the target that you set the hundred percent of scheduled 72d visits to be carried out in accordance
00:51:01 visits to be carried out in accordance with the timings prescribed by policy 800 yes
00:51:07 how is performance of that target to be monitored
00:51:11 monitored so
00:51:12 so i was working with information management to set up a performance management system on that where it could give me information as to
00:51:24 as to the inspections that were being completed and we agreed we will allow a four week
00:51:29 four week flexibility so the visit will be programmed in station diary so for example it'd be programmed on the first of august for maybe the red watch on a particular station to do a visit
00:51:40 visit and so i would have allowed four weeks for them to complete that visit so if by the first of september roughly hadn't been completed it was sharp as red on the information performance database
00:51:52 performance database now given the historic problem ensuring that high-risk buildings are properly recorded in operational risk database um does setting a target of scheduled 72d visits
00:52:04 72d visits meet that problem and i'll explain what i mean by this if properties that were not on the ord they wouldn't be scheduled for visits would they absolutely true yes so how do you meet
00:52:15 absolutely true yes so how do you meet that problem via the target of scheduled 72d visits well that
00:52:20 well that that particular target doesn't meet that problem because it's a separate problem and that separate problem is being addressed by the issues of staff being
00:52:31 addressed by the issues of staff being required to put more and more premises on the operation with database by my use of strategic resource to flood areas with appliances to be able to find those premises and put them on the database
00:52:43 premises and put them on the database and then we're on there we can then monitor through the process i've just described in terms of how regularly they're being visited thank you now just flowing on from that answer if we go probably back to page four of mr
00:52:54 probably back to page four of mr elwell's report uh lfb trouble zero eight double three eight nine forward slash four
00:53:05 and at the top of that page we see the heading current performance evaluation tool
00:53:10 tool and if we look at the second sentence under the table mr elwell made this observation this performance management approach does not measure the number of entries on the ord
00:53:22 on the ord and the quality of entries on the ord in order to improve both these measures it would be advisable to set a performance objective based on the numbers and quality
00:53:33 numbers and quality of ord entries and then you see recommendations set out seven set out there consideration is given to redefining the kpis and service standard seven within the pet which is the
00:53:44 seven within the pet which is the performance evaluation tool to include measurement of the quantity and quality of ord entries from this measure further assessment can be made on whether all applicable entries are being made in line with the guidance in
00:53:55 being made in line with the guidance in pn 800.
00:53:57 pn 800. now was any consideration given at this time to implementing targets relating to the quality of the data gathered as part of 72d visits
00:54:09 gathered as part of 72d visits yes
00:54:10 yes we was if we can just take it stage by stage when was that factor considered well at the time of this recommendation but it was an ongoing consideration in terms of
00:54:22 ongoing consideration in terms of indicators as to quality but indicators of quality are are
00:54:27 are very very difficult if not impossible well difficult if not impossible you were considering these matters in december 2013 what practical steps did you take to
00:54:39 what practical steps did you take to investigate formulating kpis relating to the quality of data extracted from 72d visits i looked at the existing quality assurance processes
00:54:50 the existing quality assurance processes in terms of station managers quality assuring the operational risk database and then predetermined attendance section quality assuring the work of the tactical plans
00:55:02 assuring the work of the tactical plans and thought long and hard about how do we turn that into an actual performance indicator
00:55:08 indicator and so i considered the numbers of quality assurance carried out could that be a performance indicator but that in itself still wouldn't look at the quality and this this is the this is the fundamental problem with trying to have
00:55:20 fundamental problem with trying to have performance indicators measures in quality performance indicators about how many things are done when they're done by it not how well they're done it's a fundamental challenge so it's it's it's a
00:55:33 so it's it's it's a it's a reasonable recommendation but it just doesn't manifest itself into a realistic performance indicator and again am i right in understanding that consideration of those matters you didn't reduce the writing at any stage
00:55:45 didn't reduce the writing at any stage no
00:55:49 can i turn to a separate distinct topic which is radio communications and 72d visits
00:55:55 visits and for that purpose can we return to appendix 1 of policy 633 which can be found at lfb quadruple zero one two five six forward slash nineteen
00:56:14 and if we could amplify the bottom of the bullet points because what i want to look at is the third bullet point from the bottom which is potential communication problems first of all uh
00:56:26 first of all uh those potential communication problems are set out as something that crews should be alive to when conducting 72d visits is that right yes and is that an issue which you'd expect
00:56:37 an issue which you'd expect the reasonably competent crew to be able to identify at least have an initial think about yes absolutely because crews use communications routinely operational incidents
00:56:51 and it wouldn't require any further specialist assistance not to identify potential communication problems in buildings now
00:57:01 now that issue potential communication problems is always also reflected in policy 800 we don't need to go to it but the reference is lfb trouble zero eight three eight four nine four 494-23
00:57:13 three eight four nine four 494-23 where
00:57:14 where i think crews are encouraged to identify any particular difficulties or alternative arrangements that apply and include details of control centers pa systems and internal telephones etc is
00:57:25 systems and internal telephones etc is that right yes now that would tend to indicate that operational crews on 72d visits were expected to consider the potential for communication difficulties where net
00:57:36 communication difficulties where net where applicable in high-rise buildings is that right in terms of using their radios in high-rise buildings to see whether they could communicate effectively with each other yes that was as far as it would go
00:57:48 other yes that was as far as it would go and at the time what practical guidance was given to crews as to work arounds if they did encounter communications problems fighting a fire in a high-rise building for example
00:57:59 there was a variety of equipment available to crews and there were training packages on leaky feeders and radio repeaters in terms of what they did where they were and who could
00:58:12 they did where they were and who could implement them now
00:58:14 now looking at this of nuts and bolts of this how would you expect a crew to go about
00:58:19 discovering whether there were going to be or may may be communications problems in a particular high-rise building well quite simply in a high-rise building when they're carrying out their seven two days and they're walking the
00:58:30 two days and they're walking the building starting at the top i'd expect them at some point in that building to literally test the radio communication so for one member of a crew to stand maybe at the end of a corridor another
00:58:41 maybe at the end of a corridor another member of a crew may be in the foyer and attempt to communicate with each other and see if there was successful communications or not is that something that would be
00:58:52 that would be the subject of training or is it something more elemental it would just be part and parcel of as you put it their everyday business it's everyday business and it's what would happen exactly if there was an operational
00:59:03 exactly if there was an operational incident so basically they're replicating what they would do had they turned up there an operational incident and just help us with this would they put on a breathing apparatus certain
00:59:15 put on a breathing apparatus certain tesla barry radios no not on this not on a 72d no
00:59:19 a 72d no any reason why not uh because the the the radios are the same radios but one is wired up for an earpiece for the the battery sets so it's the same type of radio it is but
00:59:31 it's the same type of radio it is but they operate on much lower frequencies much lower powered yes yes yes no no we wouldn't we wouldn't expect them to put a breathing operator on that thank you thank you
00:59:42 thank you thank you were you confident that crews had the technical knowledge to test the communications equipment in the way you've outlined is it purely based on the technical knowledge they need to be able to operate them an operational incident so
00:59:54 operate them an operational incident so on that basis yes just playing on from the chairman's question was there any suggestion at any time that it would be useful in the context of high-rise fires for them to test communications whilst wearing breathing apparatus
01:00:07 wearing breathing apparatus uh i don't believe it was ever suggested no it would it i can see the sense in the suggestion it would however involve a number of other issues that would follow on from doing that which would
01:00:19 follow on from doing that which would which would make it challenging so for example maybe recharging the cylinder cleaning the breathing upright set at the end of that particular session taking it at the top of the building etc so uh it's
01:00:31 so uh it's it wouldn't be without its challenges but it's it's a suggestion worth considering
01:00:39 was there any suggestion that reached you that crews weren't carrying out tests on communications equipment whilst conducting 72d visits and never come to my attention
01:00:52 now certainly to the lay eye mr brown neither policy 633 nor 800 advise crews how they should go about testing
01:01:03 crews how they should go about testing uh communications equipment during 72d visits is that a fair observation to make in respect to both those policies uh yes i guess but it's it's an assumption on our part that this is basic normal business and
01:01:16 basic normal business and it doesn't need any any further explanation again would you accept that neither 633 nor 800 provide any specific or practical guidance to crews on the
01:01:28 practical guidance to crews on the impact that materials such as concrete and high-rise buildings may have on the efficacy of communications would you accept that proposition i'd need to i'd need to read both again
01:01:39 i'd need to i'd need to read both again in detail but what what i do know is that training packages were issued that clearly made that point you can take it from either neither policies do give any uh specific guidance on those points so your
01:01:51 guidance on those points so your evidence is that uh that practical guidance would be given by training rather than policy i'm not saying i'm not saying it doesn't belong in policy if if that's not the suggestion i'm just trying to summarize
01:02:02 suggestion i'm just trying to summarize your evidence that the point was dealt with fire training is your evidence yes yes
01:02:12 now operational crews responding to an incident typically have use of two types of radios i think i'm writing saying and namely the handheld 4 watt radios and barry radios is that right yes
01:02:23 barry radios is that right yes putting it simply this does to extent flow from the chairman's question barry radios because they have a weaker power have a greater tendency to experience weaker signal high-rise buildings is
01:02:34 weaker signal high-rise buildings is that proposition consistent with your understanding yes without the addition of leaky feeders and radio repeaters that is the case yes was there any specific directional
01:02:45 was there any specific directional guidance given to operational crews but the need to consider and test potential difficulties with barry radios as well as with handheld radios during section 72d visits not to my knowledge now why
01:02:57 72d visits not to my knowledge now why not
01:02:58 not i think for the for the reasons we've we've discussed it's uh it will it will be logistically challenging to undertake those tests at every high rise and we knew that we had
01:03:09 every high rise and we knew that we had systems in place to assist barry radios if they were suffering challenges in terms of communications incidents
01:03:18 incidents is it right to say that the two types of radio the handheld forward and barrier radios can function very differently at an incident involving a concrete high-rise building yes can you give the for the pan on the
01:03:31 yes can you give the for the pan on the public listening what those variations and functionality might be
01:03:36 might be uh
01:03:40 transmission transmission of communications i guess is the best way to describe it and that is based on the level of wattage thank you
01:03:49 mr brown and i want to turn to a separate uh topic which is fire safety knowledge of cladding and the lga peer review
01:03:57 now if we can turn to your first statement which can be found at lfb trouble zero three two one double six forward slash two zero and paragraph sixty two
01:04:13 now paragraph 62 you set out in broad terms what the nature and extent of your involvement was with the fire safety regulation department and you say this the involvements commenced in april 2015 when rita dexter
01:04:25 commenced in april 2015 when rita dexter left after which my role of ac operations prevention and response was assimilated into the new role of director of operations at that point regulatory fire safety was added to my
01:04:36 regulatory fire safety was added to my existing role of head of operational mobilizing and community safety service to the whole of london
01:04:42 london my primary responsibilities towards fsr were to take a strategic overview of its planning direction and delivery i was responsible for ensuring that there were systems in place to monitor firstly far
01:04:54 systems in place to monitor firstly far safety inspections that fell within the scope of the regulatory reform fire safety order 2005 secondly inspections and premises not previously visited and thirdly inspections in high risk premises
01:05:06 inspections in high risk premises i also inherited from the deputy commissioner initiatives designed to reduce fire deaths in care homes excuse me in sheltered housing as well as overseeing the work that the ac fire safety regulation was tasked to complete
01:05:19 safety regulation was tasked to complete as part of the lachnal house action plan now you say here that your primary responsibilities towards fsr were to take a strategic overview its planning direction and delivery
01:05:31 direction and delivery what did that mean in practice on a day-to-day basis what was your involvement on a day-to-day basis with the fsr team
01:05:41 there probably wasn't a day-to-day involvement with the fsr team so i i for the first time had uh now had
01:05:51 now had well a group of assistant commissioners working for me who were detailed in that role to deal with it on a day-to-day basis so i would then as i say take their
01:06:03 i would then as i say take their strategic overview look at the strategy we had in the london safety plan and we had in the departmental plan and in regular meetings with ac fire safety would make sure that we're delivering
01:06:14 would make sure that we're delivering against those objectives and so through that structure of meetings you exercise your oversight functions is that right
01:06:22 in practical terms did it also mean that as director of operations the head of the fire safety department reported to you yes
01:06:31 you yes and that was dan daley from march 2016 onwards yes and before it it was neil orbel that's correct can i now turn to the specific topic of fire safety inspections and 72d visits
01:06:44 fire safety inspections and 72d visits um can you explain your understanding of the difference between the two types of visit i.e fire safety on the one hand and sem2d on the other okay so you could have one building that
01:06:56 okay so you could have one building that would be inspected by both sets of people one from a fire safety perspective they would do this as a fire safety audit as part of an enforcement
01:07:08 safety audit as part of an enforcement role in terms of the regulator reform order
01:07:11 order and then the same building can be inspected by crews at fire stations from a 72d perspective in terms of firefighting and saving life and
01:07:22 firefighting and saving life and property
01:07:23 property sometimes
01:07:24 sometimes in certain buildings we would require both sets to attend together so the shard for example is a perfect example because it requires a 72d visit but it's so complex crews would benefit
01:07:36 but it's so complex crews would benefit from a fire safety officer a company man on a visit they could do the visit at the same time together were those combined visits the exception rather than the norm they weren't they weren't usual because because most buildings didn't require
01:07:48 because most buildings didn't require that but but they did happen on occasions
01:07:50 occasions for building such of the shard yes now is it right that the premises risk assessments and related information produced
01:07:58 produced and gathered by section 72d visits would be stored on the ord but in contrast risk information generated from fire safety inspections was stored on a separate and distinct
01:08:09 was stored on a separate and distinct database called faranor that's f-a-r-y-n-o-r
01:08:14 that's correct yes can you help us what was the rationale for keeping two separate and distinct databases that must have shared identical or substantially similar information well it wasn't uh it wasn't identical
01:08:26 well it wasn't uh it wasn't identical information so farrando was very much about fire engineered solutions and fahrenheit existed a long time before the operational risk database so i think if he was to start a brigade
01:08:37 so i think if he was to start a brigade from afresh you probably would look at one database for both but because fahrenheit already existed and was well implanted in the culture of the organization we've tried to find ways to patched
01:08:49 we've tried to find ways to patched across the two to each other but operational crews had access to faran oil and fire safety also had access to the ord and so crews had ready access to both databases is that right
01:09:02 was information on either subject to any sort of permissions or any other restrictions on access uh farinal was because crews could access it but they couldn't uh change information on it
01:09:13 couldn't uh change information on it because the information on it was was far outside their level of expertise so it would have been dangerous to have let them touch any of the data now was um sharing of information 72d
01:09:25 now was um sharing of information 72d information and fire safety visit information was the sharing governed by policy 784 which is called notification of fire safety information uh yes
01:09:37 uh yes and the reference should anyone want to look at it's lfb trouble zero one two seven three four now ac dan daly told the inquiry that during his time as head of fire safety so from march 2016 onwards
01:09:48 onwards the flow of information between the operational and fire safety side of the lfb did not always work well is that an assessment with which you'd agree or disagree
01:10:00 agree or disagree we discovered uh some years beforehand despite that policy existing uh for some considerable time that the fly of information wasn't as uh as good as we would like it to be
01:10:13 as uh as good as we would like it to be hence we started monitoring this uh some considerable time before dan took up positions so we're already aware of this that was already highlighting the problem that we were already aware of yes if i could stop you there what
01:10:24 yes if i could stop you there what problems particular specific problems had you identified uh first of all it was from fire safety to uh fire stations uh we'd identified the fact that fire
01:10:35 uh we'd identified the fact that fire safety were aware of issues in buildings and they weren't being passed through or not being passed through as as regularly as we would like what can you give the panel an idea of the the type and the
01:10:46 panel an idea of the the type and the substance of the issues that weren't being communicated from fire safety to stations there were mostly low level issues so so for example if a fire safety inspection officer went to do a fire safety audit they might notice a
01:10:58 fire safety audit they might notice a buildup of rubbish outside of a building not necessarily interfering with fire exit but outside of a building which would have been of concern to crews and that information
01:11:09 concern to crews and that information might not have been being passed on apologies i interrupted you what other problems had you identified beyond
01:11:17 beyond um
01:11:17 um issues surrounding communication of problems or issues from fire safety to fire stations was that it yeah well that was an example of one of them yes now mr daley also referred to the nature
01:11:29 now mr daley also referred to the nature of information sharing as patchy and in
01:11:33 and in in that it would be better in some areas than others again is that an assessment with which you'd agree it was but then we put measures in place to deal with that taking a step back from your
01:11:44 taking a step back from your level what do you think was the reason the underlying cause of the patchy nature of sharing information practices i i think it was basically the nature of individuals some
01:11:56 basically the nature of individuals some individuals in fire safety were ex-operational officers maybe were more attuned to some of the issues that crews would be concerned about others weren't and
01:12:07 concerned about others weren't and that's no disrespect to others that weren't but it was just something organizationally we need to patch into and make sure everyone was aware of the need for that cross-fertilization of information what
01:12:19 cross-fertilization of information what measures did you put in place to address the patchiness problem so we we had area teams and area teams were
01:12:28 were administration sections serving each of the four areas and then we had fire safety officers win within those area teams but they answered to fire safety so they worked alongside the
01:12:40 fire safety so they worked alongside the area teams but not for them and that was one of the inherent challenges so what we did was we made sure there was an area fire safety manager that spoke to the deputy assistant commissioner so
01:12:51 the deputy assistant commissioner so fire safety and operations spoke at strategic level in the area and then we also allocated fire safety inspecting officers to every station so there was a link between the fire safety inspection
01:13:03 link between the fire safety inspection officer and the station the idea being that there was that channel of communication that could be opened up between operations and fire safety at a low level that maybe didn't exist as well as it should have done
01:13:14 exist as well as it should have done thank you one other matter which rita dexter mentioned in evidence was that
01:13:19 was that it would have fallen to you certainly during her time as deputy commissioner to speak to dac's responsible fire stations about how to improve and remedy patchiness is that a fair observation she made
01:13:31 is that a fair observation she made yes yes but we and we addressed that by deputy assistant commissioners inviting the area safety managers to their borough team meetings so the attacking northwest for example there will be the
01:13:42 northwest for example there will be the deputy assistant commissioner nine borough commanders and the area fire safety manager so that they would talk at a strategic area level about issues that
01:13:52 that affected each other were those measures effective do you think during your time they certainly they certainly was leading to improvement because we was monitoring the information flow between fire safety and stations and then we
01:14:03 fire safety and stations and then we introduced the reverse flow back from fire stations to fire safety and we we did checks to make sure it was improving and while some barriers were better than others we were putting pressure on borough commanders and the
01:14:15 pressure on borough commanders and the area deputy assistant commissioners to to increase the number of information flows and to deal with them thank you now mr daley and his evidence of the inquiry also explained that concerns
01:14:26 inquiry also explained that concerns about flow of information between ops and fire safety crews was one of the reasons that he sought to reintroduce fire safety training for station based personnel
01:14:36 personnel in the first year of his tenure as head of fire safety were you aware that mr daley was seeking to reintroduce fire safety training for station for operational crews yeah absolutely and this was something that
01:14:48 absolutely and this was something that dan daley and i had discussed and we put it in his departmental plan to do and it was it was it was something i wanted to do once i became director of operations because historically there was something
01:15:00 because historically there was something called a g-job years and years ago as a firefighter i did this and i used to personally as a firefighter carry out low-level fire safety inspections and for some reason over the years that got
01:15:12 for some reason over the years that got taken away from fire stations and i sought to to return it to fire stations because i it was it was useful gave some extra technical uh knowledge to firefighters but it also took the
01:15:23 firefighters but it also took the pressure for fire safety inspecting officers to enable them to get on some of the objectives in terms of visiting high-risk premises so for me it was a win-win situation and dan and i discussed it and uh he eventually turned
01:15:35 discussed it and uh he eventually turned that into what he was giving the inquiry evidence about fire safety checks and training to fire stations were you aware that mr daley had carried out pilots of the fire safety training at ilford and holloway
01:15:46 safety training at ilford and holloway fire stations no that happened after i retired
01:15:55 can i now turn to porous report recommendations and it's the february 2013 porous report that we or lfb responds to the porous report that we were considering yesterday
01:16:07 we were considering yesterday and that can be found at lfb 0091785
01:16:14 and if we go to page 13.
01:16:20 and we see in paragraph 8.13 in the bottom of the page it quoted the national guidance which was
01:16:30 which was the following effect fire safety and operational data capture should be integrated to take account to the plans of other category one and two responders and other agencies
01:16:41 and other agencies and the report sets out the lfp position in the far right hand column and it said this
01:16:47 this fire safety data including data from fire safety engineering is not routinely added to the ord addresses with recognized fire safety engineering solutions are highlighted to
01:16:59 engineering solutions are highlighted to cruise on the ndt as part of the mobilization message although these details are not on the ord a fire safety officer is ordered to a confirmed fire to these buildings
01:17:11 confirmed fire to these buildings an early decision was taken during the development of the ord that this would not add value to the existing data derived
01:17:19 derived from station outside duty visits there is an existing arrangement for fire safety inspecting officers to alert stations when they believe a regular visit to a particular site or building may be of benefit to operational crews
01:17:33 may be of benefit to operational crews an electronic way of achieving this exchange of data between the faranor and station diary systems is an agreed enhancement that may be possible with station diary rebuild
01:17:45 station diary rebuild due to commence in 2013. now were you aware of the decision taken during the development of the ord not routinely to add fire safety data to that database yes
01:17:58 that database yes can you help us who made that decision it would have been a decision predominantly by those managing the operational risk database and presumably
01:18:10 operational risk database and presumably information technology department can you help us as to when that decision was made
01:18:19 i i don't know for sure the ord was being developed from around about 2009 onwards so one imagines it would have been sometime in bet 10 11 but i don't
01:18:30 been sometime in bet 10 11 but i don't know for sure i'm afraid are you able to help us as to why it was concluded that fire safety data would not add value to the existing data derived from station outside duty visits
01:18:43 derived from station outside duty visits i think it was based on the mere fact of information overload so it was it was about the
01:18:50 the the mdt being able to provide sufficient information for an early strike in terms of attending the incident the dangers of having too much information is that crews won't
01:19:01 much information is that crews won't read it and actually has a detrimental effect in terms of they won't gain any information now it's playing from the uh parrot 8.13 that the authors of the
01:19:12 uh parrot 8.13 that the authors of the porous guidance thought there was value in integrated data capture to use their phrase um
01:19:20 phrase um what was your personal assessment on the value or not that would be brought by integration
01:19:28 if you can if you can manage to uh to find the correct high-level pieces of information then yes there is value i should also add there's premises information boxes
01:19:40 add there's premises information boxes at
01:19:42 at areas and buildings that have a fire engineered solution so there is that information available and also as it says here we do what a lot of other fire services don't do that we mobilize fire
01:19:54 services don't do that we mobilize fire safety officers uh to known risks on known premises that they can access the information and they can pass it on to crews thank you now just looking at the far
01:20:05 thank you now just looking at the far right hand column and it's roughly down the middle of the lfb's response there is a form which says this there is an existing arrangement for fire safety inspecting officers to alert stations
01:20:17 inspecting officers to alert stations when they believe a regular visit to a particular site or building may be of benefit to operational crews now was that existing arrangement policy 784
01:20:28 784 which we've just looked at or was it something else i believe it was 784 thank you
01:20:34 thank you and you certainly got no reason to believe it was anything else no thank you
01:20:39 can you help us to why the report made no mention of the fact that the policy was not securing an adequate flow of information between fire safety personnel and operational crews
01:21:03 no i i can't i can't suggest why it doesn't explicitly say this i can only imagine it's because we had started to introduce processes that we knew would remedy that it would have been
01:21:15 would remedy that it would have been relevant though to note that then prevailing problems about confronting information sharing wouldn't it
01:21:23 it yes but the people that were receiving this report by the cnb were aware of that anyway so it wasn't as if this was being kept from the members it was something that was
01:21:34 the members it was something that was was uh commonly aware and i think you adverted to an evidence earlier on that work was being done on the shore and ensuring electronic patches between faranor and the ord can
01:21:46 patches between faranor and the ord can you remember when did that particular work start and when did it when was it implemented
01:21:54 i i don't know for sure i'm afraid i'd only be guessing but it was would it have been after the response the porous guidance was given in february 2013.
01:22:11 as you've read out it says in the final part an electronic way of achieving this exchange of data is being considered uh in terms of the patches i think it would be around this time
01:22:25 but it did happen yes yes and was it as part of the station diary rebuild project as far as i can remember yes thank you and that did start sometime in 2013. yes there were constant rebuilds
01:22:38 yes there were constant rebuilds actually
01:22:39 actually going on for a station diary and attendance systems and various other technological solutions that we had in training
01:22:47 training thank you now could we stay in this document but go back to page one and look at recommendation c
01:22:58 that recommendation said this consider again whether there would be merit and incorporation of relevant fire safety regulation data in the ord and the extent to which there are benefits of information gathering direct from a
01:23:11 information gathering direct from a responsible person and or others if we turn over the page and look at recommendation e
01:23:20 progress arrangements to link the ord with other key systems where necessary including improvements to the interface with station diary now
01:23:30 now you've answered what steps were taken in relation to recommendation e um in relation to recommendation c can you help us to what measures were put in place
01:23:41 put in place can i say c again please yes of course
01:23:51 [Music]
01:24:00 you
01:24:04 all i can say on this one is that it was it was a constant consideration so whilst it's being raised here as if it's a moment in time consideration it was something that as more and more
01:24:15 something that as more and more information become available it was always on our minds i note that this particular recommendation was for the head of strategy and performance and and fire safety in terms of what they exactly did for c
01:24:28 in terms of what they exactly did for c i
01:24:29 i i
01:24:30 i can't recall i i know that extra things were being added to the operational risk database
01:24:37 database because we felt that they were really important but from a fire safety perspective i can't think of an example around this time where anything extra was added as a result of recommendation c thank you
01:24:51 result of recommendation c thank you now can we uh go back to the elwell report recommendations just on on this particular issue which can be found at lfb
01:24:58 lfb trouble zero three two eight two five forward slash two [Music]
01:25:07 and really i want to look at the bottom of page two and the substance of recommendation for what mr elwell commended there was this a feasibility study is undertaken into
01:25:19 a feasibility study is undertaken into the use of existing brigade data for example call data serd data
01:25:26 serd data for the the uninitiated what's that uh it's basically accident reporting thank you
01:25:32 you farenhour data etc to develop an appropriate methodology to identify higher risk premises given the criteria in the existing pra
01:25:43 in the existing pra furthermore this analysis could be used to amend and update the existing pra criteria
01:25:49 criteria did you agree that data from faranor so fire safety information represented one way of identifying higher risk premises yes
01:25:59 yes can you help us what action was taken to implement recommendation for if any well
01:26:06 well in terms of fahrenheit data
01:26:12 the existing data on there in terms of what was organizationally known in so much as buildings that existed as far as i'm concerned was being shared between fire safety and information
01:26:25 between fire safety and information management so in terms of the types of buildings that uh that we were aware of that maybe we hadn't done a 72d from was being uh mapped across so that
01:26:36 from was being uh mapped across so that we could we could inform crews at stations that we knew of buildings that he needed to do a 72d or indeed do we have enough information organization anyway to be able to complete an operational risk database entry without
01:26:48 operational risk database entry without the crews having to visit was the study that mr elworth proposed ever carried out well i think the the faranor data issue so this is an example of some of the
01:26:58 the you know sound recommendations that were that john was making but yet were already in trying so the fahrenheit data issue was the call data certainly was we'd used organizational knowledge of uh
01:27:11 we'd used organizational knowledge of uh incidents with attending through shutting lifts for example so we attend lots of high-rise for shutting lift so we knew about them and we use that data to alert crews to make sure that they attended in terms of 72d
01:27:24 sure that they attended in terms of 72d and accident reporting data much the same although that was that was less uh beneficial would you accept that there was much to commend this recommendation in the sense that it
01:27:35 recommendation in the sense that it allowed
01:27:36 allowed the author of the study to review all the available data sources and try and bring coherence and consistency of approach and bring that information together so as to better assist the identification of
01:27:47 better assist the identification of high-risk premises yes it's a it's it's a good recommendation uh but it's one which is an example of something that was already started or bits of it had
01:27:58 was already started or bits of it had been done
01:28:00 been done now can i turn to a separate distinct topic which is the lga peer review and we can find the lfb fire peer challenge report dated march
01:28:11 challenge report dated march april 2015 at lfb trouble zero four five nine six zero
01:28:21 have you seen that before yes i have um it's a report produced by a team of senior officers from other fire and rescue services is that right that's correct
01:28:32 correct and if we turn to page five
01:28:36 we can see the peer challenge team members identified in paragraph eight and if we can go to page four and paragraph six
01:28:48 there has set out the purpose of the challenge which was to quote to provide external challenge to help support improvement and to reflect how the brigade is performing across the area of focus
01:28:59 focus now in general terms what approach did the lfb take to
01:29:05 to the opinions and recommendations set out in this report uh we we paid a great deal of attention to it we we welcomed the peer review in fact i think we even invited it and we
01:29:17 fact i think we even invited it and we helped
01:29:19 helped uh or led on very much the four areas that we felt needed to be looked at and and for example the fact that we put industrial relations in there i think i think demonstrate how open we were to
01:29:31 demonstrate how open we were to improvement because our industrial relations were poor at the time so when you say you led on them the nfb identified the issues it wanted the peer challenge team to look at yes
01:29:43 the peer challenge team to look at yes and how were those issues identified was it you in consultation with the commission and other senior officers yeah so when we said leader i didn't mean me personally organizationally we led on them and yes it would have been
01:29:54 led on them and yes it would have been discussions at a corporate level and liaison with our elected members so there was a full and frank and open discussion and even with our staff side in terms of opening up industrial
01:30:06 in terms of opening up industrial relations for external challenge can we go to page 21 and paragraph 74 in this report
01:30:17 it sets out there this there is scope and capacity to use operational crews for fire protection work and to undertake joint regulatory reform order 72d visits with protection staff
01:30:28 72d visits with protection staff this should be explored to add additional value an enforcement officer is allocated to stations but this relationship with operational crews could be strengthened with more training in fire engineered solutions in
01:30:40 in fire engineered solutions in buildings and modern construction methods
01:30:44 methods now what was your view of the suggestion to have joint visits to premises essentially carrying out the regulatory fire safety and operational familiarization visits at the same time well
01:30:54 well as a reference to the shard that was something that did happen on occasions in terms of making it a more regular position then yes i was all in favor of
01:31:06 position then yes i was all in favor of that but we needed to be careful that we didn't
01:31:09 didn't duplicate people's work and add to their already busy schedules what i was much more in favor of which i think this also alludes to and something that as i said we work with
01:31:20 something that as i said we work with dan daley on is is training operational staff to be able to do fire safety inspections at a lower level to take some of the burden from fire safety inspecting officers so that was
01:31:32 safety inspecting officers so that was fully supportive of and and i think from this recommendation uh he is it supports that that concept now if we can go to lfb trouble zero
01:31:43 now if we can go to lfb trouble zero five four double eight one we should have the lfb's action plan produced in response to the peer challenge report and if we the suggestion that we saw in
01:31:56 and if we the suggestion that we saw in paragraph 74 is addressed in action 23 at the bottom of page four
01:32:03 [Music] and it says there at the very bottom involving operational crews in protection work that's scoped to use operational crews
01:32:15 that's scoped to use operational crews to undertake and then we go over the page 72d visits and if we go back to the bottom of page four
01:32:22 four and the second column from the right you are identified as the first allocated officer is that right uh yes with two of my reports fire safety ac in the fire stations ac but
01:32:35 safety ac in the fire stations ac but two people who report to you yes and if we look at the works action underway column which is the far right one
01:32:44 one it says joint working between operational crews and fire safety
01:32:51 and nothing more can you help us what practical can you give the evidence particular evidence as to what practical action was taken to implement joint
01:33:02 action was taken to implement joint visits to premises by fire safety and operational officers you've made you've given evidence about the shard but in practical terms what else was done to bring about joint working
01:33:13 bring about joint working there was
01:33:14 there was there was joint working on particular seasonal events so for example uh bonfire night there would be
01:33:22 would be a preponderance of shops that spring up selling fireworks so we would have crews and fire safety and local authority inspectors would do joint visits to these premises
01:33:33 these premises then we would also uh as well as the issues that i've raised about having a delineation between uh some lower level fire safety work
01:33:44 uh some lower level fire safety work being handed to operational crews uh to allow fire safety crews to do more of finding unknown premises and higher risk premises
01:33:52 premises and then and then we discussed with dan then this i didn't use this term with dan but as soon as we've used it this morning kind of this shard type approach
01:34:03 morning kind of this shard type approach we've tried to formalise which buildings there would be some joint inspections of if if only just to benefit both fire safety and fire stations also to take the burden away from commercial
01:34:15 the burden away from commercial buildings because they don't particularly understand and quite rightly so a fire engine turns up and then a week later a fire safety inspection officer turns up from their perspective
01:34:26 perspective you know
01:34:27 you know why have you got two separate units turning up to do what they see is the same thing now was any consideration given to joint working in relation to high-risk premises
01:34:38 high-risk premises [Music]
01:34:40 [Music] yes but that's what i guess i would the term is the shard initiative any particular consideration given to joint working in relation to visits to high-rise residential dwellings
01:34:51 high-rise residential dwellings only only where there had been particular issues so for example there had been a fire a high-rise premises and they've been a post-fire safety audit then we would also have crews attend to
01:35:03 then we would also have crews attend to do what we call hot strikes which is uh fire safety visits home fire safety visits afterwards so we would look to combine the crews and the fire safety inspecting officers at the same time if
01:35:15 inspecting officers at the same time if possible thank you so with immaculate timing that is an appropriate point to have a break subject to your permission well that sounds pretty good idea we'll take a short break now mr brown we'll come back
01:35:27 short break now mr brown we'll come back please at half-past 11 and as before please don't discuss your evidence or anything to do with it while you're out of the room thank you sir all right thank you very much would you give the usher please
01:35:44 all right thank you mr knee help us live
01:53:14 but would you ask mr brown to come back in please
01:53:27 all right mr brown ready to carry on thank you sir yes good thank you yes mr connor thank you sir mr brown can we now turn on to training and odcb yes now i think i'm right in saying that in your capacity first of all as assistant
01:53:39 your capacity first of all as assistant commissioner and then as director of operations uh you sat on the operational directorate's coordination board is that right that's correct and i think i'm right in saying was that board set up as an initiative on the part of rita dexter
01:53:52 an initiative on the part of rita dexter yes and quite possibly roy bishop before her yes
01:53:56 her yes can you remember now when did you become a member of odcb oh
01:54:03 if it helps we have a minute of you first attending on the 11th of march 2009. does that sound about right yes yes yeah probably right yes what did you understand the function of odcb to be
01:54:15 odcb to be originally it was established to assist better joint working between the two operational directorates that was that was the initial thinking behind it and then thereafter once it
01:54:28 behind it and then thereafter once it started
01:54:30 started it was
01:54:31 it was to receive reports from the information management database created by operational assurance department and that was all part of the dynamic intelligence operational training system
01:54:43 intelligence operational training system where we would learn from issues that were happening in the organisation discuss them at odcb decide how to address them if necessary
01:54:56 decide how to address them if necessary what news articles what training packages
01:54:59 packages liaise with babcock and then receive reports in terms of how effective those training packages were thank you um at the risk of facetiousness was the clue in the title coordination
01:55:11 coordination yes yeah yeah if it was one word to describe it then yes that would be a good word and part of the focus of coordination was identifying training needs and policy needs
01:55:22 needs and policy needs uh yes yes more training needs and policy needs but yes now uh you assumed the chair of odcb after rita dexter left the lfp is that right
01:55:32 right yes i i recall of course i may have shared it with danny cotton i'm not quite sure at some point i think when danny became a director we may have shared it but
01:55:44 a director we may have shared it but immediately when rita left yes i think so march 2015 onwards yes yeah um
01:55:49 um did you receive any form of handover briefing from rita dexter was one not considered necessary well richard and i work so closely together uh on and off of odcb and i was a regular
01:56:01 on and off of odcb and i was a regular attendee at odcb so we didn't need a formal handover as such but we did we did discuss matters in terms of the kind of issues that was the forefront of her mind although i was
01:56:13 the forefront of her mind although i was very familiar with those anyway were there any particular errors that you wanted to focus on when you succeeded as chair
01:56:20 chair uh i thought it was a a a good opportunity to refresh the bald i think we've renamed it operational professionalism bald because the the the coordination issue
01:56:33 because the the the coordination issue that you quite rightly mentioned i think is very much been embedded by then and it was an opportunity to make it more about operational professionalism and then i also spoke to all the
01:56:45 and then i also spoke to all the attendees in terms of ideas that they might have that we could refresh the board
01:56:51 board you know look at look at new opportunities did the odcb do what is intended to do in terms of coordinating training needs preeminently yeah i i believe so yes
01:57:03 preeminently yeah i i believe so yes and you've touched on this but odcb's processes and uh output were determined by the diot process is that right yes um would it be correct to summarize the d process in this way that odcb received
01:57:16 d process in this way that odcb received reports good and bad from previous incidents or training events and then considered how to respond to that information and including publication of operational news articles and the rest of it yes it
01:57:27 news articles and the rest of it yes it did other things as well but yes that was a a key role of it and personally whether any further training was required to mix a particular deficiency further training or instruction yes
01:57:40 from the outside it looks as if the diop process focused predominantly on the nfb's operational training experiences and what had gone wrong or right is that a fair takeaway
01:57:51 a fair takeaway uh
01:57:53 uh but
01:57:54 but by that do you mean just purely on the operational side of things i suppose the essential point of putting to you was the diot process essentially reactive
01:58:05 it was reactive in terms of it picked up information from things that had already happened
01:58:13 happened but it's it's its role was to try to therefore predict things that might happen in the future and prevent them occurring in the future as well so yes it was reactive but with also uh
01:58:27 yes it was reactive but with also uh the the looking forward aspect to it as well
01:58:32 were there any areas or topics within odcb's remit that you thought considered or thought deserved less attention uh than ms dexter had given to them
01:58:43 than ms dexter had given to them no no there were there were some areas that repeated themselves that uh that i found frustrating uh that we needed to address time and again what were those
01:58:55 address time and again what were those what were the sparks of that frustration well so examples of that will be things like sighting of appliances and crew dismounts et cetera so for me these were the very basic things uh in terms of on arrival tactics and we
01:59:09 uh in terms of on arrival tactics and we we found ourselves needing to remind crews on more than one or two occasions about the correct method of sighting appliances and dismounting appliances etc and and and that for me was low
01:59:22 etc and and and that for me was low level and i thought it was a shame that odcb we had to we had to focus on issues like that but that was no one's fault as such that was just the nature of the organization and you stayed as chair until you left in
01:59:34 you stayed as chair until you left in march 2017 is that right that's correct now um could i now turn to ask you questions about the intended review of odcb systems and processes in 2013 and 2014. so before you talk over as chair
01:59:48 2014. so before you talk over as chair now the inquiry has a set of minutes of odcb
01:59:52 of odcb where this intended project was referred to as and i quote a fundamental review of the current system and we don't need to go to the minutes but
02:00:01 but does that sound right to you yes
02:00:04 yes now if we can go to lfb trouble zero six seven eight one eight forward slash two
02:00:16 the trial director as we see he's gone on to the first page here just so you see it's some minutes of a meeting held on the 14th of october 2013. and if we look at paragraph two a
02:00:28 and if we look at paragraph two a and under the particular heading frequency of operational news and it says that uh the assistant commissioner operational assurance who was danny cotton i think at this time yes queried the feasibility of a
02:00:40 yes queried the feasibility of a increasing the frequency to three issues is agreed at the last meeting the dc so that's rita dexter suggested this might be an opportune time to have a fundamental review of the current system
02:00:50 system the third officer referred to the fact that the same issues repeatedly arise as an indication that review is needed such a review would look at whether the right tools are available and what system is
02:01:01 tools are available and what system is used in other organizations and it may lead to a review of the brigade operational response delivery model assistant commissioner operational assurance was asked to lead on the review which would report back by march
02:01:14 review which would report back by march 2014
02:01:15 2014 so
02:01:16 so roughly six months thereafter when you succeeded as a chair in june 2015
02:01:23 2015 did you consider that a fundamental review of the system was still required [Music]
02:01:31 no uh apar apart from a refresh of the of the uh approaches we took but no not a fundamental review but but also i don't recall what the outcome
02:01:43 but also i don't recall what the outcome of this
02:01:44 of this particular review was either that you've hopefully gone on to my next question i was going to ask you did the review happen do you know i don't recall the review happening i'm
02:01:55 i don't recall the review happening i'm not saying it didn't but i don't i don't recall the outcomes unless there's anything in minutes that would help me refresh my memory it's not immediately unfortunate i'd take you to them if there were but there aren't and want to
02:02:07 there were but there aren't and want to see whether you were able to assist us with your recollection but there we go now can i turn to the highly insulated buildings and rapid fire growth package which was initiated by odcb in march
02:02:20 which was initiated by odcb in march 2015 so just before you succeeded as chair
02:02:23 chair and the first document i'd like to go to is lfb travel zero double four seven eight five
02:02:33 [Music] now as you see this is an instant monitoring six monthly report uh provided to odcb for its march 2015
02:02:46 provided to odcb for its march 2015 meeting um before we descend into the detail of this document first of all what is an instant monitoring six monthly report so
02:02:57 so so i mentioned earlier about the information from the information management performance database that picked up on the good and the learning points happening
02:03:08 the learning points happening operational incidents so this six monthly report would be the report that gathered all that information together and as well as comments from other professional officers so operations
02:03:19 professional officers so operations review team fire safety officers professional judgment of some strategic managers etc puts it all together and tries to highlight trends and from those trends
02:03:31 highlight trends and from those trends suggests
02:03:33 suggests issues that we may consider for operational news in terms of articles and where appropriate training packages thank you and actually we see that reflected in the summary of the first paragraph and the bullet points
02:03:44 paragraph and the bullet points of the report itself now
02:03:48 now am i right also just to draw out the point explicitly that the monitoring reports would recommend topics for odcb to address in operational news articles yes
02:03:58 yes now if we can go to page four please
02:04:04 we see roughly halfway down the page the heading proposed articles for operational news 30 open brackets december 2015 and if we see item two on the list at
02:04:15 and if we see item two on the list at the bottom of page four and going over into page five is highly insulated buildings and rapid fire growth and if we could turn over to page five
02:04:25 page five it says this and apologies uh for having to listen to me reach out recent reports from across the uk fire sector have highlighted the specific dangers associated with fighting fires in highly insulated buildings as the
02:04:38 in highly insulated buildings as the level of insulation afforded in modern buildings increases two factors pertaining to fire are affected the ability of such buildings to contain heat increases this means that less energy is required to heat a room to the
02:04:50 energy is required to heat a room to the point where flashover might occur and the temperatures that can be achieved during a fire are increased the external indicators of the fire is occurring are reduced highly insulated
02:05:01 occurring are reduced highly insulated buildings need to be well sealed gaps or cracks in the building envelope allow heat to leak out reducing thermal efficiency and reducing their environmental performance as a result of steps taken to reduce
02:05:13 as a result of steps taken to reduce heat loss and seller i think that's seal isn't it
02:05:16 isn't it yes
02:05:18 yes less smoke from a fire will be able to exit the building to be seen by passers-by or members of the fire service attending an incident rapid fire growth is becoming an increasingly common feature in highly
02:05:30 increasingly common feature in highly insulated buildings studies have shown that firefighters have often been unprepared for such rapid fire growth and as a result have not used effective fire fighting tactics compartment fire behavior training in
02:05:43 compartment fire behavior training in simulator units has contributed towards this lack of preparedness in that the fire in these units rarely extends past the compartment of origin and therefore firefighters are not necessarily taught
02:05:54 firefighters are not necessarily taught how to identify signs and symptoms of impending sudden fire growth recommendation odcb is requested to consider an ops news article on highly insulated
02:06:07 news article on highly insulated buildings and the dangers of rapid fire spread
02:06:10 spread odcb is further requested to consider a proposal for a training solution to address the issues highlighted the training intervention should give firefighters an awareness of the
02:06:21 firefighters an awareness of the increase in the number of highly insulated buildings under construction in london and provide examples of the construction techniques and materials used
02:06:29 used the training solution should also highlight the dangers associated with firefighting in such buildings and outline how to identify signs and symptoms of rapid fire growth and the firefighting tactics that should be
02:06:40 firefighting tactics that should be deployed to contain and extinguish such fires
02:06:45 fires long run up to a short question do you recall reading this report yes looking specifically at the observation that studies have shown that firefighters have often been unprepared
02:06:56 firefighters have often been unprepared for such rapid fire growth and as a result have not used effective firefighting tactics do you know what studies are specifically been referred to here
02:07:07 no i don't did the observation of unpreparedness give you cause for concern when you read it uh yes
02:07:17 uh yes absolutely firefighter safety is a the forefront of our mind but we we also introduced firefighting technic tactics uh
02:07:28 technic tactics uh such as the use of spray as opposed to jets when entering buildings or compartments to to train firefighters in terms of potential for flashover and backdraft so
02:07:40 potential for flashover and backdraft so we were addressing that we also introduced a highly effective personal protective equipment in terms of terms of new fire gear as well to help protect firefighters so we were
02:07:51 help protect firefighters so we were aware of that but we were looking to we were dealing with it
02:07:56 with it it doesn't appear to have been looking at the minutes on the radar of odcb before this particular report um therefore if it was on the radar was it on the radar in another one of your
02:08:07 on the radar in another one of your capacities as director of ops so can you remind me of the the date of this report please yeah the date of this report is um
02:08:15 um well
02:08:16 well there's proposed articles for december 2015 and this is the report prepared for odcb in march 2015. okay so certainly the use of spray
02:08:28 the use of spray in terms of entering compartment fires was already in train by this point the new the new personal protective equipment might not have been it might
02:08:39 equipment might not have been it might be around this time or slightly after was there any discussion at odcb whether in light of the concerns regarding unpreparedness further steps beyond those recommended
02:08:51 further steps beyond those recommended were necessary and desirable
02:08:57 i think given given the
02:09:00 given the two
02:09:01 two issues that we were addressing at the time plus
02:09:04 time plus the introduction of this training package
02:09:08 package i seem to recall we felt that that was sufficient for that moment in time and then we would monitor particularly in terms of accident reports which also came as part
02:09:19 accident reports which also came as part of this report to see how effective or not those measures were thank you now if we can return for a moment to a document we looked at earlier which was commissioner dobson's response the latino house
02:09:30 dobson's response the latino house coroner and that can be found at lfb trouble042089
02:09:38 and if we could turn to page five of that letter
02:09:45 which dealt with recommendation number three that the coroner made in respect of instant command and the letter includes the following and the third paragraph onwards
02:09:58 and the third paragraph onwards these words it is also recommended that consideration be given to training of ics and potential ics that's incident commanders to enhance their performance in relation to the following and look at
02:10:09 in relation to the following and look at number three to anticipate that a fire might behave in a manner inconsistent with the compartmentation principle now commissioner dobson's letter then went on to set out
02:10:20 went on to set out the action that the lfb proposed to take and if we go to page six and the second paragraph on that page the commissioner said this the brigade will engage with its
02:10:32 the brigade will engage with its training contractor to ensure that the seven points identified in this recommendation are embedded within the current instant command training the brigade will ensure that these issues are further considered as part of
02:10:43 issues are further considered as part of the current review process of instant command training which is being undertaken with the brigades training contractor this work will aim to ensure that the training provided enhances performance
02:10:54 training provided enhances performance across the range of required skills and knowledge needed to support effective instant command now were you aware of the coroner's recommendation that training of incident commanders should anticipate that a fire
02:11:06 commanders should anticipate that a fire might behave in a manner inconsistent with the complementation principle yes
02:11:11 yes and was it at the forefront of your mind when odcb was considering these matters in march 2015 yes this this particular recommendation
02:11:22 yes this this particular recommendation as i think the letter highlights was broken down into subparts of which i had one of those as the lead and i think the others were within
02:11:31 within the operational resilience training directorate but yes i was aware of the work that was going on to address those other issues
02:11:42 those other issues now we don't need to go through it unless it would assist you but the implementation of that recommendation was recorded as being closed on the 3rd of march 2014
02:11:53 closed on the 3rd of march 2014 and the reference can be found in the monitoring report which is lfb trouble 0-310-6425
02:12:01 does that sound about right to you
02:12:04 yes so two years after the coroner's recommendation was made and a year after the brigade's corresponding action was marked closed the march 2015 incident monitoring report recorded that
02:12:16 report recorded that and if we go back to it lfb trouble zero excuse me
02:12:22 excuse me double four seven eight five forward slash five
02:12:28 [Music] and if we could look at the last sentence of item two just before the recommendation heading it says this
02:12:39 heading it says this compartment compartment fire behavior training in simulator units has contributed towards this lack of preparedness regarding rapid fire growth in that the fire in these units rarely extends past the compartments of origin
02:12:52 extends past the compartments of origin and therefore firefighters are not necessarily taught how to identify signs and symptoms of impending sudden fire growth
02:13:01 growth now that indicates that the training the nfb was delivering at the time of that report proceeded on the basis that fire would rarely extend beyond the compartment of origin would you agree with that
02:13:20 no you weren't put off in answering that question by the words fire in these units rarely extends parts past the compartment of origin now the reason i was deliberating before
02:13:32 now the reason i was deliberating before i answered is because i was wrestling with the fact that uh in terms of in terms of realistic fire training real fire training being able
02:13:43 training real fire training being able to simulate that very behavior is is is difficult and and probably wasn't done so in that respect that's true however
02:13:55 true however in the same breath the training also made staff aware of the very real danger of this actual thing happening so so to say training didn't cover it i don't think it's
02:14:07 didn't cover it i don't think it's strictly true in terms of real fire training probably not but certainly it's not the case that it wasn't brought to crews attention in the training well the question was this
02:14:19 training well the question was this that do you accept that this paragraph we've just looked at indicates that the training proceeded on the basis that fire would rarely extend beyond the compartment of origin
02:14:30 compartment of origin the actual practical real fire training yes thank you now the blunt fact that appears to arise from this is that the lfb hadn't implemented the coroner's recommendation would you accept that
02:14:41 recommendation would you accept that proposition [Music]
02:14:45 [Music] sorry can you just remind me of the exact wording please that the commoners recommend that well we can go back to it um if you'd like this please and
02:14:55 and just finding the right if we go to commissioner dobson's response lfb
02:15:01 lfb trouble zero four two zero eight nine forward slash five [Music]
02:15:07 [Music] it might be easy if that's put side by side with this ledger if that's possible
02:15:31 so it's really can you see point three to anticipate that a fire might behave in a manner inconsistent with the compartmentation principle that was the recommendation and then read over the right hand side
02:15:43 and then read over the right hand side that paragraph immediately above the word recommendation in paragraph two where it provides compartment fire behavior training and simulators has contributed towards this lack of
02:15:54 contributed towards this lack of preparedness in that the fire in these units rarely extends past the compartment of origin
02:16:02 [Music]
02:16:13 [Music] given given the holistic nature of the training and the fact that crews were well aware both through training and experience that
02:16:22 that compartmentation in terms of fire escaping externally through the window and some of the issues that were made aware at training in terms of the potential for extending
02:16:34 in terms of the potential for extending beyond the compartment internally for a range of reasons uh
02:16:40 uh i i i do think that we met the coroner's
02:16:44 coroner's recommendation uh i'll take on board completely the recommendation here but this is a living problem it's it just because we meet it at one point
02:16:57 we meet it at one point things things evolve and things always need to be kept under review so because we met at a moment in time it doesn't mean to say that we can sit back and think it's forever solved there's
02:17:08 and think it's forever solved there's always going to be a challenge for us in this regard ultimately be a question for the panel to decide absolutely but can we be slightly more specific you what training
02:17:19 slightly more specific you what training addressed fire spread beyond the compartment of origin well i think the training that was happening in terms of what we call real fire training which had been going on for some considerable time
02:17:30 for some considerable time and certainly since 2012 when babcock took on the contract there was real fire training facilities at bechton and park royal which massively enhanced their ability to be
02:17:42 massively enhanced their ability to be able to
02:17:43 able to show in practical terms to new uh firefighters and on refresher training
02:17:49 training the issues around compartment fires what seems to have troubled the coroner is a concern that crews might not which i'm sorry
02:18:01 i'm sorry incident commanders might not
02:18:06 really appreciate the danger of fire getting out of a compartment what training was there to enhance that aspect of their knowledge
02:18:19 we've seen what's said about the training on comfort compartment fire behavior
02:18:28 behavior but that suggests that that on the real fire training as you call it there wasn't much um experience of the fire getting out of the compartment but possibly because it
02:18:39 the compartment but possibly because it was a limited exercise so what training was there to make them aware that this could develop in other ways well
02:18:48 well so when i said breach of the compartment for a range of reasons one of the reasons is is when you first open the door to a compartment fire so i i think the the the common belief
02:19:01 so i i think the the the common belief probably is that the compartment just breaches of its own cold but actually there's a thing called door procedure so the minute you open the door and you introduce oxygen to what could be a smoldering fire you could then suddenly
02:19:13 smoldering fire you could then suddenly create a backdraft and basically an inferno
02:19:17 inferno will project like a blow torch out of the compartment into the corridor and then suddenly the compartment is breached
02:19:25 breached so there was intensive training on what we call door procedure by using spray to anticipate the potential for that and therefore when the door was open you're immediately aware of it and you're pushing the fire
02:19:37 aware of it and you're pushing the fire straight back into where it came from and not letting it get into the corridor so that was that was something that a lot of time was was spent on but then also i think something that troubled the
02:19:48 also i think something that troubled the coroner and indeed us was
02:19:51 was the external fire spread so windows is a real point of weakness in a compartment that the fire can escape externally and then the behaviour at lacanal where the fire went downwards
02:20:03 lacanal where the fire went downwards rather than upwards was something that that concerned everyone involved and i think that was uh that was one of the issues i think that lies behind point three of
02:20:14 three of that recommendation and then then of course a lack of house action plan that we put in place which involved the lack of house case study that got sent to all firefighters
02:20:26 sent to all firefighters and also the detailed uh lacrimal house presentation it was given to borough commanders and above as well uh dealt with raising awareness massively of of this
02:20:37 raising awareness massively of of this issue
02:20:39 issue yeah right thank you very much thank you yes
02:20:42 yes so just picking up on that last bit of evidence about raising awareness can we go to operational news 30 which was published in january 2016 which is lfb trouble zero six one four eight two
02:20:57 trouble zero six one four eight two [Music]
02:21:01 [Music] and if we turn to page five [Music]
02:21:06 [Music] if that could be slightly amplified [Music]
02:21:11 [Music] now you'll see here the article concerned with fires and highly insulated
02:21:17 insulated buildings and mother modern methods of construction now you can take it from me or if you wish you can read the article yourself but there is no reference there
02:21:28 yourself but there is no reference there to rapid fire growth or the issues and concerns that have been raised in the 2015 march 2015 incident monitoring report namely dangers of rapid fire spread including fire spread outside the
02:21:39 spread including fire spread outside the compartment of origin would you accept that [Music]
02:21:45 [Music] but based on your advice if you say you which i'm sure you have read this in detail and there isn't any reference to it then yes i'll accept your word can you help us as to why
02:21:56 you help us as to why those dangers were omitted from the article whose aim was to raise awareness of the issues well i can i can only assume that the associated
02:22:07 i can only assume that the associated training package with this would have dealt with uh the issue of rapid fire spread i think the the very reason it's in here rapid fire spread is also implicit in it
02:22:20 rapid fire spread is also implicit in it because otherwise there wouldn't be any reason for us to be having it as an article but i'm i'm confident that the training package would would support that
02:22:31 would would support that right if we could just look at that can we
02:22:34 we again if de-amplify if that's a word the article
02:22:38 article can we look at the example that's actually cited in this article which is uh
02:22:43 uh a fire at a travel lodge in east london in march 2015.
02:22:50 and on my reading it appears to be a fire which remained within the compartment and the text states that the tactical plan was formulated on that basis
02:22:58 basis is that a correct reading of what is set out there so this paragraph commencing in march 2015. yes
02:23:07 [Music]
02:23:22 [Music]
02:23:32 and you'll see and you'll see that sorry just before you aren't just i can draw something specifically to attention so you know where i'm coming from seven lines down the article states this mindful of the nature of construction and the fact that an intense fire had
02:23:44 and the fact that an intense fire had remained contained in the compartment the example cited in this article had nothing to do with the dangers of rapid fire spread outside the compartment of
02:23:55 fire spread outside the compartment of origin did it [Music]
02:24:01 [Music] well it the the the sentence prior to the one you've just read out refers to the fact that it started in the bathroom but spread developed into an intensifying involving
02:24:12 developed into an intensifying involving the entire hotel for the fact that an intensifier had remained contained in the compartment are you saying the compartment was the entire hotel yeah the entire hotel room yeah yeah that's
02:24:25 the entire hotel room yeah yeah that's why i was spending time on it thinking how can one be the other but i think the chair's correct in terms of uh the terminology there it's the entire room rather than what we would consider
02:24:37 room rather than what we would consider a compartment i think maybe the word in here is not as clear as it could be do you nonetheless consider it to be a useful example of the dangers of fire spread outside the compartment of origin
02:24:50 spread outside the compartment of origin it could be there could be better examples yes i'll grant you ones that involve fire spread outside the compartment of origin for example
02:25:00 yes but i think it's uh from the from the skills knowledge experience of london firefighters who have seen many examples of fires
02:25:11 fires escaping the compartment externally it's it's implicit in their own mind that one can
02:25:18 can lead to the other do you remember anyone raising the point that the article did not with sufficient clarity address the risk of fire spread beyond the compartment of origin no
02:25:31 can we look at the final page of this operational news issue at page
02:25:39 and we see the third row there fires in highly insulated buildings article is identified yes and the consequential training is that watches are referred to the lfe
02:25:51 is that watches are referred to the lfe policies on compartment firefighting and high-rise firefighting and to the highly insulated buildings computer-based training package now stopping there we know from peter groves as evidence that the related tcap
02:26:04 groves as evidence that the related tcap this cbt training package was zero two one two
02:26:08 one two and if we could briefly go to that tcap which is lfb double zero one zero double two one three
02:26:19 and if we go to page four and the third box on that page we see in box 1.3 you are identified as the client yes
02:26:29 yes [Music]
02:26:30 [Music] and andy rowe is also identified as the client in his capacity as director of operations is that right
02:26:39 yes that uh and that's because he succeeded you yeah it was actually tom george who succeeded me uh immediately that it over to so whether andy then succeeded tom on
02:26:52 so whether andy then succeeded tom on his retirement i'm not quite sure but nonetheless you were the client until you retired in march 2017. yes can you help us what does client mean in this context so client is who is the
02:27:03 this context so client is who is the main user of the training package the commissioning people will be who's going to prepare the package the client is a user so inevitably the majority of the time i would be the
02:27:15 the majority of the time i would be the client or my department director will be the client did you have any direct involvement yourself in the in the substance of the highly insulated buildings training package no who did
02:27:25 who did so in terms of representing me that would be central operations or formerly known as central service delivery so in actual people terms at this time would have been adrian fenton
02:27:38 have been adrian fenton in terms of oversight of when and how the brigade was delivering the training to cruz um was your role limited to ensuring confirmation that it had been done
02:27:50 confirmation that it had been done yes
02:27:53 would you in your capacitive chair of odcb had any additional oversight in relation to the provision of this training package so once i was chair of odcb then it would have been the head of
02:28:05 odcb then it would have been the head of fire stations as i would have then devolved it to him dominic ellis had been his responsibility to report to the board uh how how well crews were progressing in terms
02:28:17 how well crews were progressing in terms of completing the package then so my my role in odc had kind of stepped back one from it so i was therefore
02:28:27 therefore as much concerned with the effectiveness of the package and that would be picked up in in two ways so
02:28:35 so firstly the ongoing monitoring of the information management coming through as part of the die up process which was the bread and butter work of odcb but also by then we'd introduced a
02:28:47 but also by then we'd introduced a process where officers would go to fire stations and they would test each ops news so we had a system called question mark and it was a bit like
02:28:59 and it was a bit like ask the audience in who wants to be a millionaire so they all have little buttons where they could press and they'd get asked a number of questions on
02:29:06 on packages that had been released and the crews would ask a question and press a button in terms of the answer multiple choice and you'd instantly get a result at the end of the questions in terms of
02:29:17 at the end of the questions in terms of how well the package had been received and if we found a particular topic that was routinely not being understood then we could deal with that quickly thank you
02:29:28 with that quickly thank you now if we can look at the background context box at the bottom of page four of this tcap which extends over to page five [Music]
02:29:39 [Music] we see that in the final
02:29:45 paragraph the emphasis in the cbt package thank you
02:29:52 thank you cb the emphasis in the cbt package should be on the implications of modern methods of construction for firefighting tactics this should be in greater depth and currently exist in training package it is not sufficient to talk about rapid
02:30:04 it is not sufficient to talk about rapid fire
02:30:05 fire spread and or unusual fire spread through voids cavities etc now there seems to be an explicit recognition there that existing training did not address sufficiently
02:30:18 training did not address sufficiently the risk posed by modern methods of construction in sufficient depth would you accept that yes
02:30:25 yes but yes i would accept that and they'll also accept that this is all part of our continuous learning now we know from mr groves that although the package was developed it was not delivered to staff because of i.t issues
02:30:37 delivered to staff because of i.t issues is that consistent with your recollection there were iit issues in terms of bandwidth and we looked at a range of other issues such as cds to stations
02:30:46 stations to try to remedy that but it wasn't rolled out uh i don't know it was ultimately rolled out there certainly were issues that kept coming back to odcb and we brought along the head of iit to explain these
02:30:58 along the head of iit to explain these issues because obviously it was an important package and we were frustrated it's delay mindful of that and given that operational news had expressly referred to this training
02:31:13 why did operational news refer to training that the package for which wasn't available uh the package was available uh is my recollection the problem was once
02:31:24 recollection the problem was once once we tried to use it crews were reporting difficulties in terms of buffering at stations and the video is not loading up etc they couldn't access it yeah it was it was it was the access issues so we we just
02:31:37 was the access issues so we we just hadn't anticipated that so it was a and then rit was saying to us well there'll be bandwidth improvement so it's it's it's an issue we're aware of and we're dealing with it so it was
02:31:48 and we're dealing with it so it was forever
02:31:49 forever it'll be sorted in a month or two so we were waiting and waiting and waiting and in your time never happened i don't recall it happening and we and we discussed the issue of of cds which
02:32:01 we discussed the issue of of cds which which was reverting to a formal way of delivering training which is problematic so we we never pursued that thank you now we can uh see that tcap's
02:32:12 now we can uh see that tcap's progression was discussed by odcb on the 31st of march 2016 so two months or so after operational news 30 was published and if we can go to the minutes which are lfb zero four zero seven double one
02:32:25 are lfb zero four zero seven double one forward slash one
02:32:28 [Music]
02:32:34 that we can see that you were present at that meeting or the first on the list of attendees and if we can see under
02:32:45 and if we can see under item two
02:32:46 item two impd three monthly report
02:32:51 and we see under item two uh sorry we see the package the first in the list of updates and the update reads a note to be circulated reference the currently situation around the training
02:33:04 currently situation around the training package
02:33:05 package now we have been unable to find that note uh do you know whether one was provided
02:33:14 i can't say with certainty no if we turn over the page to item four we see that under the heading dynamic intelligent operational training procedures update
02:33:27 operational training procedures update and we look at roman 3 it says this fire in highly insulated buildings is a computer cbt package which has been developed but not gone live yet due to i.t issues it was confirmed that the i.t
02:33:40 i.t issues it was confirmed that the i.t solution lays with lfb and it was hoped that these issues will be resolved with the it rollout that is expected to begin in may
02:33:50 now again just for the avoidance of that that was the same it issue which we've discussed namely that training packages that incorporated videos were not accessible on the big learning internet platform at stations is that
02:34:02 internet platform at stations is that right
02:34:03 right yes because of the bandwidth issue now we can see from the right hand column that those responsible for progressing this action were the director of safety and assurance he was danny cotton at the time i think yes
02:34:14 danny cotton at the time i think yes the head of training assurance and business relations peter groves yes head of fire stations dominic ellis yes and you as director of operations yes
02:34:25 and you as director of operations yes what did you do in order to progress this action uh
02:34:29 uh i uh
02:34:31 i uh i spoke regularly with sue budden who was the director of uh iit and finance
02:34:41 reminding her although she didn't read reminding of the issues about this and the problems it was causing us organisationally and could she
02:34:52 and could she assist us with it in terms of the head of iit who worked directly to her so it was it was putting pressure on a strategic level to be able to deliver
02:35:03 strategic level to be able to deliver this to be fair the head of iit who had been the same head for some considerable time
02:35:08 time and may still will be there was was doing all he could in this regard
02:35:14 regard but it just was it was an issue that we were factually being told well we just need to wait until the bandwidth issue is resolved in terms of the rt rollout and although
02:35:25 terms of the rt rollout and although workarounds were discussed none was implemented is that right none was implemented there was a range of reasons why none was implemented which i'm happy to go into if you wish uh we covered that with mr grove so don't worry mr
02:35:36 that with mr grove so don't worry mr brown thank you but do you recall if there are any other training initiatives that were similarly delayed by i.t problems uh no just this one this this is the only one that springs to mind because it was so video intensive
02:35:49 video intensive uh could have slightly surprises me that babcock were it was produced by bab of course was it not the babcock were producing training materials which were
02:36:01 which were uh which couldn't be delivered by the by the lfb i mean were bob got not aware of the level of
02:36:10 level of i.t available to fire stations i think i think this caught everyone by surprise uh in terms of uh the issue so some of the workarounds were that we
02:36:21 the workarounds were that we we said to stations well we limited the number of stations watching it at a certain time to to deal with the bandwidth issue to be fair to babcock i don't think it would be made clear to them in terms of
02:36:34 would be made clear to them in terms of the bandwidth issue because it was something that caught everyone by surprise
02:36:38 surprise yeah
02:36:39 yeah all right thank you
02:36:46 can you give me two minutes uh apologies so i just wanted to of course
02:37:01 mr brown you may be pleased to know i've reached the end of my prepared questions um sir might i ask for the usual 15 minutes to see whether it matters which i haven't addressed which i want
02:37:12 which i haven't addressed which i want to and see whether any suggestions elsewhere well mr brown at this stage we always have a break to enable council to check he's not left anything else and also to allow a chance for other people who are following the proceedings
02:37:24 people who are following the proceedings but not from this room to suggest questions that perhaps should be put to you so we'll break now and we'll come back at half past 12 and then we'll see if there are any more questions that we need to ask you thank
02:37:36 questions that we need to ask you thank you all right thank you very much
02:37:47 and mr i hope that'll give you enough time but if you need more um just just ask the usher to come and tell us
03:01:41 would you ask mr brown to come back in please
03:01:54 all right mr brown well first of all i'm sorry we kept you waiting quite a lot longer than i'd indicated but people ask for more time and because that was a reasonable thing to do so anyway we'll find out now mr kunia have
03:02:05 anyway we'll find out now mr kunia have you found some questions from three three three right um mr brown was the occupancy profile of the building something you'd expect cruz to consider when conducting seven two d visits yes
03:02:16 when conducting seven two d visits yes did that include whether there were any vulnerable residents or residents with disabilities
03:02:23 crews carrying out a 72d visit wouldn't be obviously aware of vulnerable residents however we did as part of the latino house action plan we did
03:02:34 latino house action plan we did introduce a serious outstanding risk policy briefly what that involved was when crews did a home fire safety visit if they found that someone was in extra
03:02:46 they found that someone was in extra need over and above the advice you could give on a home fire safety visit so for example maybe someone who smoked and despite our advice was going to carry on smoking in bed then we would
03:02:58 carry on smoking in bed then we would look to work the local authority to provide fire retardant bedding so yes we did do work over and above but crews unless they actually carried out that home fire safety risk assessment
03:03:11 that home fire safety risk assessment arriving crews at highrise wouldn't know necessarily at flat 22 on the eighth floor there happened to be someone who was on an outstanding risk register we did however uh do a lot of work on
03:03:22 did however uh do a lot of work on hoarding
03:03:23 hoarding so holding was becoming an increasingly difficult issue and that's a fire loading problem and we did have that added to the operational risk database so crews would know that there's a fire
03:03:34 so crews would know that there's a fire load over and above what you would expect or certain premises thank you that answer deals with the questions i was going to ask you so that concludes your examination and the only thing i have to say is to thank you for
03:03:46 thing i have to say is to thank you for giving evidence it's been very useful thank you sir mr brown it's right i should thank you very much on behalf of all three members of the panel for coming here to give us your evidence i know it's taken up quite a lot of your time but i'd like you to
03:03:57 a lot of your time but i'd like you to know how valuable it is to us to hear from particularly from senior members who can answer some of the questions on the documents that we wouldn't otherwise be able to work out for ourselves so
03:04:08 be able to work out for ourselves so thank you very much for coming to help us and you're now free to go thank you very much thank you
03:04:23 well not mr canoe and there are i think at least one more witness perhaps more than one more witness but perhaps not today is that right that's right so we've come to the end of the evidence for this week um we've made speedier
03:04:35 for this week um we've made speedier progress than anticipated as a result of that we've investigated whether it's possible to bring forward witnesses at all that's not proved practical for a range
03:04:46 that's not proved practical for a range of reasons so for that reason mr grimwood who will be the final factual witness in week five will be called next wednesday right and his evidence will last um be dealt with
03:04:58 his evidence will last um be dealt with well within that day and that will then conclude the factual evidence and the expert evidence will start in the week commencing the 18th of october well thank you very much i perhaps you should be congratulated for getting through the
03:05:10 be congratulated for getting through the work faster than had been expected but anyway uh there it is so we'll expect to see mr grimwood on wednesday of next week yes
03:05:20 week yes and so at that point we will conclude the hearing for today and we will resume at 10 o'clock on wednesday which will be the 50th
03:05:32 which will be the 50th 13th 13th i think but next wednesday next wednesday whatever the date whatever that'll be next wednesday right thank you very much indeed thanks
03:05:50 you