Station Manager Jane Smith gives evidence on control room training deficiencies, revealing years of inadequate planning and resource allocation for FSG and emergency call management training at London Fire Brigade.
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00:00:00 Thank you.
00:00:29 You asked Ms Smith to come back in please. Thank you.
00:00:31 All right, Ms Smith?
00:00:43 Yes.
00:00:44 You ready to carry on?
00:00:44 Thank you, sir.
00:00:45 Thank you very much. Yes, Mr Milley.
00:00:47 Thank you, Mr Chairman. Ms Smith, we examined two of the three kinds of training from 2015,
00:00:53 informal and CBT, and I want to turn to the third of those, which is command unit training,
00:00:58 so far as concerns FSG calls. Can we go to paragraph 57 of your witness statement, page 22?
00:01:05 You say that despite the issues with vision, in 2016 we continued to roll out joint command
00:01:16 unit training with operational officers and control, which focused on FSG. The sessions
00:01:21 were run from brigade control and it was a live exercise based upon a high-rise multi-fire survival
00:01:27 guidance incident. I exhibit an email from my colleague, Chris Sharp, who ran these workshops,
00:01:32 setting out the timetable for the first session. The sessions began with a presentation to control
00:01:39 staff and command unit staff on FSG mobilizing, and then there was a live exercise where control
00:01:43 officers practiced receiving FSG calls and passing the information to the command unit staff.
00:01:48 And then I think you continued, you say you followed up via email.
00:01:56 And then there was a debrief. If we look at LFB00121228, we can see how that is carried out
00:02:09 in practice. This is an email, if you go to the foot of page one, from Chris Sharp to you on the
00:02:14 14th of April 2015, she says, good morning Joanne, I'd be grateful for your guidance. There are a
00:02:20 small number of command unit crews that need to complete their FSG second round workshops in
00:02:25 addition to starting round three. I've asked if management want these workshops to continue and
00:02:29 have had confirmation that this is the case. This has presented me with a logistical headache as we
00:02:34 have not got available control staff available in the afternoons to attend the workshops.
00:02:38 Then if we go over to page two, it says in the last three lines there, the workshops are interactive
00:02:47 and achieve two outcomes as this addresses refresher training for control staff. Without our
00:02:52 presence there is little can be done except presenting the mobilising presentation. You reply
00:02:59 to that on page one, if we get back to that please. Higher up the page and you say on the 23rd of
00:03:05 April 2015, you send an email to Chris Sharp and you say this, hi Chris, I appreciate this is very
00:03:10 difficult to achieve whilst you are undertaking RMS training. However, organisationally we cannot
00:03:15 stop or halt FSG training. Please could I ask you to identify when there are clashes and insufficient
00:03:21 staff available on what dates. It is still the propriety that all control staff receive annual
00:03:28 refresher training on FSG and we are happy to write to the OMs to reiterate this and ask them
00:03:34 to assist supplying staff who are due refresher training so no one falls out of the annual
00:03:38 programme. Please let me know and we will discuss how best we can ensure this is achieved. Now,
00:03:45 did you think at the time that the FSG command unit workshops were meeting the requirements of
00:03:51 CROs annual refresher training? I think some of it. I think that maybe when I had come back,
00:03:58 that either Chris or I had had a hand over that the command unit training was being successfully
00:04:10 undertaken and that they were covering an element of realism for both control staff and command unit
00:04:18 staff. So, I may have been left with the impression that the command unit training was achieving some
00:04:29 of what we had hoped to achieve in the FSG training and in 2015 carrying that on with
00:04:38 the, with, while we were undertaking RMS training, I would have been assured that we were actually
00:04:47 managing to get some staff trained and in using the policy and practice. You say I think some of
00:04:59 it. Which parts of it, namely the annual refresher training, was the command unit training not covering?
00:05:07 I don't know specifically, but I do know that it was a focus on, it had an element of role-playing
00:05:16 it because control officers were dealing with calls and taking calls on the mobilising system
00:05:22 and then ensuring that that information was passed to the CU. So, in terms of information
00:05:29 exchange and an element of role-playing realism with the calls that they were taking, I was aware
00:05:37 that that was being achieved. Role-play was being achieved, but role, what role, what was the role-play
00:05:51 that was achieved in the command unit exercises relating to FSG specifically? So, as I said before,
00:06:01 the command unit staff and some of our trainers would input calls to the control staff that were
00:06:07 playing that role and were taking part in the FSG workshop training and they would simulate real
00:06:13 FSG calls. I believe there were several scripts to support that. You say you believe there were
00:06:21 several scripts to support that. Did you see any at the time? Yes, I think I'd also attended an FSG
00:06:32 workshop if not in 2015, certainly in early 2016, but I think it might have been earlier than that,
00:06:40 in 2015. It was about the time that AC Brown asked us to include station managers and above
00:06:49 in the command unit workshops. You refer to scripts. You say you did see them at the time,
00:07:02 yes. When you saw them at the time, did you study them to make sure that the scripts of the
00:07:08 conversations between, well let me ask you, were they scripts of conversations between the
00:07:12 role-playing caller and the role-playing call handler? No, they were scripts from the person
00:07:19 that was playing the caller, so they provided the information and it was down to the control officer
00:07:26 to obtain that information and then make sure that that information was passed to the incident
00:07:31 ground. Now focusing on the middle part of that answer, down to the control officer to obtain that
00:07:38 information, did you study any script or any training material, CBT, PowerPoint presentations
00:07:46 of any kind, which would guide the control room officer about how to extract the relevant
00:07:56 information from the caller? Not personally, I didn't study the scripts. They had been created
00:08:04 by Chris Sharpe, who had taken the lead on FSG training and had formulated those based on her
00:08:13 experience with creating scripts and role-play. She'd done that previously, I believe, so I didn't
00:08:21 study them in detail to ensure that the control operators were gaining every element of 1093 out
00:08:31 of them. 1093, we've seen the two documents you produced in August and September 2011, so that's
00:08:40 a number of years before this now, of course. Yes. When you understood that at least some of FSG annual
00:08:49 refresher training was being delivered through the command unit exercises in about April 2015,
00:08:57 did you take any steps to make sure that the control room officers were covering all of the
00:09:05 points of criticism that you had raised on the training material as it was in 2011, which you
00:09:12 had made? No, as I said previously, I would have believed that the points that I had raised would
00:09:19 have been taken and dealt with at that time and the training packages would have been changed.
00:09:25 So is this right, that you assumed without checking that so far as the control room officers'
00:09:33 participation in these command unit exercises was concerned, they were operating or following the
00:09:40 questions and answers and covering the points that you had picked up by way of criticism
00:09:45 in the 2011 packages? Yes, as I said, I think the criticisms that I had made
00:09:54 having been asked to review the training and fed back to Scott and Lindsay, I would have expected
00:10:00 those to be in the training packages and when I returned in 2015 and having witnessed a command
00:10:08 unit exercise where there had been control staff role playing and passing information to the command
00:10:16 unit, I didn't have any observations that that wasn't being achieved and we also reviewed the
00:10:25 feedback from, so everyone had a feedback form on the FSG CU training and control staff were asked to
00:10:35 comment on that as well and we would have reviewed that periodically as well with the OST team.
00:10:42 Can I just ask, did you actually listen to any of these exercises,
00:10:47 were they recorded, could you listen to them after the event? They would have been recorded
00:10:52 because all of our systems record the telephone conversations, I didn't personally listen and
00:10:58 review them, I was in the control room or in the training area when they occurred. But after the
00:11:03 event, did you listen to them? No, I didn't personally.
00:11:07 Right, thank you. Looking at the email in the second paragraph,
00:11:12 at the end of the second paragraph you say, so no one falls out of the annual programme,
00:11:17 what was the annual programme? I don't know, I can't recall, I just would imagine that with
00:11:26 what was going on at the time in terms of vision and the changes and that Chris had already
00:11:33 raised the fact that the replacement mobilising system training was taken up a vast amount of time,
00:11:41 that having staff attend the CU refresher training would assist them in at least some
00:11:51 refresher training on FSG. How could you spare control room staff for the command unit exercises
00:11:58 but not spare them for sticking to the original one year on one year off
00:12:05 FSG refresher training programme as originally devised in 2010?
00:12:10 I can't recall but I think that might have been a decision that actually that we could achieve that
00:12:17 with CU training and I may have also approached staff and suggested that if they couldn't get
00:12:26 staff on duty, which looks like it because they couldn't afford to lose staff that some people
00:12:31 come in and undertook it on overtime, that would be something I've done in the past and we do now.
00:12:42 When you say you think it might have been a decision that you could achieve that with CU
00:12:48 training, does that mean that in fact in order to achieve the CU training, achieve the true purpose
00:12:53 of the CU training, you didn't really need very many control room staff, you simply needed one or
00:12:57 two people to be caller and one or two people to be call handler? No, I think also in the CU training
00:13:05 that they have had some supervisors there as well. That's from my recollection that there was a
00:13:11 supervisor to make some decisions and to assist control staff when they were undertaking the
00:13:16 role play. So I don't believe it was just one or two staff. Can you give us some idea of scale
00:13:22 because you've given us a very clear impression that the big problem in 2015 and into 2016 was
00:13:28 resourcing, lack of availability of staff to do the FSG refresher programme as originally conceived.
00:13:37 How many were necessary to achieve the CU programme including FSG as opposed to how many
00:13:46 would have been needed to carry out full FSG refresher training as originally conceived?
00:13:54 I don't think it was a case of numbers. I think Chris's email indicates that they were struggling
00:14:01 to get control staff. That might have been because of the resourcing on watches and that they were,
00:14:08 they didn't have sufficient staff on the watches because they were blown numbers and therefore,
00:14:15 as I understand from this email, she's asking me about what we can do about it.
00:14:19 And as I've said, I might have proposed that we get staff in and offer staff overtime to attend.
00:14:26 From recollection, and this is a vague recollection, five staff, five to six staff would attend
00:14:33 control unit CU refresher training. In the round looking at these two emails, was it the position
00:14:40 in April 2015 that you could achieve some of the annual refresher FSG training through the CU
00:14:49 programme but only for such control room staff as could be made available to attend and that was
00:14:55 a problem in itself? No, I think that as always in April 2015, we would have planned to have gone
00:15:03 live with the new mobilising system in the summer and therefore, we could roll out refresher training
00:15:08 to all staff in the latter part of the year but I would have welcomed any or I would have encouraged
00:15:17 any FSG training that control staff could take part in, especially with the CU in terms of
00:15:24 exchange of information. So, I would have just been encouraging that they were getting additional
00:15:30 training. In your email in your second paragraph, you're saying in the second half of that that you
00:15:40 want to ask the OMs to assist supplying staff who are due refresher training so no one falls out of
00:15:45 the annual programme. Now, at that stage, April 2015, refresher training wasn't due in fact until
00:15:50 the second or last quarter of 2015, was it? Or are you saying that there were staff who hadn't had it
00:15:56 the year before in 2014 and there was refresher training outstanding? Yes, that might be true. I
00:16:02 might have when I asked OST to provide me a list when I came back in the early part of 2015, I may
00:16:09 have realised that there were a number of staff that hadn't had it so to ensure that they received
00:16:15 some training. Now, let's look at the outline of the workshop. DELFB 404703.
00:16:27 This is entitled, Fire Survival Guidance Command Unit Strait SM Workshops, aimed to run a fire
00:16:35 survival guidance mini workshop. Objectives, understand what forms of communication are
00:16:40 available between control and the fire ground to demonstrate how information is relayed to the
00:16:44 relevant parties when received at an incident to evaluate how control processes FG calls on vision.
00:16:51 Briefing, control and trainers will have a complete copy of the script, command staff will have their
00:16:57 input, each page is labelled either control, operational or background. Now, in brief, I've
00:17:03 taken you a little bit into this but was this a document you saw at the time, April 2015? No,
00:17:09 because this says how to evaluate a control that an FSG processed on vision and we didn't go live
00:17:15 with vision until the end of 2015 so this wouldn't have been the workshop that I witnessed.
00:17:23 Was this the FSG Command Unit workshop training that you understood took place in 2016? Yes.
00:17:33 Right, I see. And on page one, if you look to the bottom of the page, you can see that it
00:17:38 says in the penultimate sentence, control staff will input the make-ups
00:17:42 and transmit messages to the incident. Was that the extent of the role of control staff?
00:17:47 I think as I've given from the evaluation and the feedback sheets, I think at the end,
00:17:53 certainly the end of 2016, I'd become aware that it had been, the role of the control had been
00:18:00 reduced to more of an input rather than the whole experience that I'd witnessed in 2015, yes.
00:18:07 Right, and I think, I'll be corrected if I'm wrong about this, but this is a document I think we can
00:18:12 date to March 2016. Would that be about right? Potentially, yes. Right, now we've looked through
00:18:20 the document, we can certainly scroll through it. Do you remember that there are five FSG calls
00:18:26 in which information is recorded as given to the CRO? No, I don't. You don't remember that? I don't
00:18:33 remember the detail. I do remember that we had been given, we had been asked to include station
00:18:41 managers at that time, and the group that the OST were delivering the training to had expanded
00:18:52 significantly to include station managers, and that's where I think the control element started
00:19:00 to become less, so if that is the same time as March 2016, that would be right. Yes, I see, yes,
00:19:06 and to be clear, inclusion of station managers was critical, but because it was station managers who
00:19:12 ran command units? It was station managers, so all senior officers that attend incidents.
00:19:22 If we just scroll through the document, let's start at page two, top of page two, control,
00:19:27 1500, first call received, and then 1501, second call, and we can scroll down,
00:19:33 and then operational, and then page four, control, 1503, third call, FSG. You see? Yes. So the first
00:19:44 two are not FSG, the third one is an FSG call, and then there's mobilizing data below that,
00:19:52 you see that? Yes. And then control, top of page five, control, 1506, fourth call, FSG,
00:20:01 that's the second FSG call with the detail, and just look at what's said there,
00:20:07 RT message to H351, further call received to flat 68 on sixth floor, female caller is shut in her
00:20:13 living room, she has said she can see smoke from the internal staircase, five survival guidance
00:20:17 being given, and then if you go down to page eight, 1509, fifth call, FSG, that's the third
00:20:28 FSG call, and you can just see the details there, flat 68 sixth floor, that seems to be a development,
00:20:37 more detail there, female caller in living room with window open, front door is hot and smoke
00:20:42 coming from under the door, fire survival guidance in progress, and then question how would you
00:20:49 record this information, and then there's background given on pages eight and nine,
00:20:54 and then bottom of page nine, sixth call, not an FSG call, different flat,
00:21:00 they're outside and can smell smoke, especially in the stairwell, what should they do? Caller advised
00:21:06 fire identified on top floor of block, no smoke entering their flat, so that's not an FSG call,
00:21:14 and then if you go on down to, I think one can continue down to,
00:21:27 I think in fact that that's all we need to see, but just looking at the detail I've shown you
00:21:30 already, you can see the nature of the information that's being gleaned by the CRO from the caller,
00:21:39 yes? Yes. Was there any opportunity in this exercise for control staff to carry out either
00:21:47 active or passive role play in taking any of these FSG calls? That was always the intention,
00:21:56 I was under that impression that that was still continuing in 2016, that the calls would be
00:22:02 given by command unit staff or trainers to control officers to take those details,
00:22:10 and the scenario there is the scenario that the CU staff or the trainers would give to the caller.
00:22:19 So just going back to page 8, using that as an example, this is the 5th call which is FSG at 1509,
00:22:28 fire in flat 68 on the 6th floor, you can see the detail on the screen there, the last detail of which
00:22:36 is fire survival guidance in progress, was there any role play as part of this exercise as between
00:22:45 the caller and the call handler about that fire survival guidance in progress? In other words,
00:22:54 the giving of it and the receiving of it? As I understood it, yes, that's how the CU command unit,
00:23:02 sorry, the control and command unit sessions worked. Right, did you say as I understood it,
00:23:07 what did you understand that from? From where I'd witnessed it in 2015,
00:23:13 from where I'd witnessed it in 2015 and that I wasn't aware that any changes had been made
00:23:18 to that format. So you witnessed, looking, this is 2016 of course, but you witnessed this sort of
00:23:25 thing did you in 2015 around April or say or perhaps thereafter, and in that role play,
00:23:32 did you witness all the points being covered that you had covered in your two documents
00:23:37 in August and September 2011? No, not all of them I don't believe.
00:23:42 So you would have realised at that stage that despite your trenchant criticisms of the training
00:23:48 packages in 2011 as they then stood then, that learning had not been embedded in the minds of
00:23:55 control room operators? No, sorry, I think I misunderstood the question, I think you,
00:24:02 assumed you were asking if I'd made sure that all the points were covered.
00:24:07 When I witnessed the CU training, I didn't notice any control staff that were actively role playing
00:24:13 in that, not covering any of the elements that had been contained in my criticism.
00:24:22 That depends doesn't it, whether you were looking for those or not. Were you looking out when you
00:24:26 were observing this role play in the command unit exercises in 2015, were you looking out for
00:24:33 whether or not control room operators were doing the right thing in accordance with your criticisms
00:24:40 of the training as it stood in 2011? Yes, I would always do that, I do that as a matter of course
00:24:45 and I have done that every time I've been in the control room to make sure that control staff are
00:24:50 following and providing the most suitable guidance to callers of any incident. So yes,
00:25:00 I would have been aware of that and would have picked up anything that wasn't.
00:25:06 Yes, did you do anything to make sure that in those role plays all of the points were covered
00:25:13 so that you could test for yourself whether all of your points such as reassurance,
00:25:18 such as the questions about proactive questioning, means of escape,
00:25:26 matters of that nature were actually covered? No, like I say, I had expected the training to
00:25:33 change and they had had some years of the riff when that had had contained proactive questioning
00:25:41 as well, but I didn't notice anything when I was... If we go back to page one, you can see
00:25:51 the list of people involved under briefing, yes? Yes. We can't see any input there from
00:25:58 fire safety officers, is it the case that these exercises did not have any input from fire safety
00:26:05 officers? No, so in terms of from fire safety department, no, but I would imagine that some of
00:26:12 the SMs that attended and GMs that attended were fire safety officers and were trained and probably
00:26:20 would have added some additional value in the discussions and when the presentation was being
00:26:28 given. But did you know that or are you just speculating? I could guarantee that some of the
00:26:34 SMs that took part in the exercise were fire safety officers and fire safety trained. You can
00:26:41 guarantee that? I can guarantee that, I couldn't tell you exactly what their comments were when
00:26:46 they were discussing. I don't know how many workshops we ran over the course, but yes.
00:26:54 And who were they, you're guaranteeing? I wouldn't know, so a lot of station managers, it's a tag,
00:27:01 it's a skill that they have, fire safety and as per we were asked to deliver training for all
00:27:09 SMs and GMs, so a number of them would have been fire safety trained. Yes, to your knowledge,
00:27:18 as best you can recall it, had any of them received any particular training or guidance on what
00:27:25 aspect of their fire safety expertise should be imparted to control room officers
00:27:30 undertaking this role play? No, I think this was just an additional benefit for them to come and
00:27:38 share their learning and share their understanding as would any officer that attended with a
00:27:45 different skill. Maybe some would have been able to share, for instance, ORT officers might have
00:27:50 been able to share some insight about how operational staff manage incidents and that's
00:27:57 probably why we thought it was a really useful tool in addition to the refresher training that
00:28:04 all control staff took part in. Were the RIFs used as part of the FSG advice being given?
00:28:13 Potentially, if a control officer was undertaking that role play and needed that support from a
00:28:19 RIF and just some prompts then they might have used the RIF. They were accessible on the training
00:28:24 system. Let me just understand that answer. You say potentially, do you mean
00:28:33 it could have happened or do you mean it did happen depending on the control room officer
00:28:40 and the conversation? I think both. It could have happened had the control officer undertaken the
00:28:46 role play, felt that they needed some additional support or maybe a prompt they could have accessed
00:28:52 the RIF. Let me try and be a little bit clearer. Did you observe when you saw the command unit
00:28:59 training in progress CROs using the RIFs in order to give fire survival guidance in any of these
00:29:09 mock calls? No, I can't recall that.
00:29:14 Do you recall any of the CROs using or asking to see policy 539 emergency call management
00:29:22 during any of these mock calls? No, I can't recall that. Let's go to LFB 00040541.
00:29:29 This is a set of minutes of the operational review team ORT 11th January 2017. Attendees included
00:29:47 as you can see from the middle column at the bottom you and some others.
00:29:54 And you may be able to you may be more familiar with the names and the guest speaker was Steve
00:29:59 Vaptor who was director of safety and assurance as you can see. Can we go please to page two?
00:30:07 We can see on page two that under the heading exercises training received since last meeting
00:30:13 JOS who is you we can check that by reference to page one FSG training and it says this has been
00:30:20 run but there will be changes made it is too focused on CUs and controller just facilitating
00:30:26 there will be a rewrite of the scripts where control will declare PR.
00:30:30 Just pausing there is that person's reported? It is yes. LD asked if that's Lee Drawbridge
00:30:36 asked if there would there could be more casualties in the training as the training he attended only
00:30:40 had one JOS took on board that there needs to be multiple. GE also commented that when an FSG
00:30:48 is happening the CUs are rarely involved that is as it is normally happening within the first five
00:30:54 minutes. JOS has spoken to IM about getting an FSG pump attribute sorry attribute I think that
00:31:02 should read on WMs and not on the appliance which would solve some of the issues. JS asked if the
00:31:08 changes to the FSG training would be completed by Friday as he is attending one then JOS as you
00:31:14 replied no but she would appreciate some feedback from him on this one.
00:31:18 Now the training that you're referring to there was that the command unit workshop training that
00:31:25 we saw the prompts for from 2016? Yes so that's what our meeting would have been interested in
00:31:34 the the interaction with operational staff. And what update were you seeking to provide at this
00:31:41 meeting? Just because they were also attending to and we I was a regular attendee at this meeting
00:31:50 I would just update on control room matters and one of them was that we had identified as I'd
00:31:56 explained earlier that it was becoming too focused on on CUs and I would say station managers rather
00:32:03 than control and and that we would look to refocus that and make sure that control were included.
00:32:10 Yes so does that tell us that when you said controller just facilitating you meant they
00:32:15 were simply providing established FSG information in a realistic way to the command unit? Yes. Yes
00:32:22 thank you. I'd like to just to ask you then about recording of training
00:32:28 and can we go please to page 25 of your statement paragraph 65.
00:32:32 Now
00:32:42 for the context I think you need the question asked at the very foot of the previous page.
00:32:50 Page 24.
00:32:53 Please state how the refresher training of CROs was recorded and monitored during this period
00:32:58 and if you go back to page 25 at the top paragraph 65 you say the trainer delivering the training
00:33:04 would record who attended the training on the OST internal spreadsheet as a number of people
00:33:08 were inputting information onto the OST database there is a risk of each session might be recorded
00:33:14 differently even though they relate to the same packages this meant that sometimes they could be
00:33:18 overlapping entries that were not identifiable as the same package and then at paragraph 66 you say
00:33:25 training attended by CROs was recorded on the OST database and uploaded to STEP in addition training
00:33:32 would be recorded on a CRO's ITR which was updated at least quarterly I think ITR is individual
00:33:39 training record isn't it? Yes. Would you agree that this method of recording training had the
00:33:45 potential at least to be inconsistent? Yes. Yes and what one of the recommendations of Tom George's
00:33:52 review in July 2016 is that all training must be recorded on an individual's ITR and that POMs and
00:34:02 SOMs should work with colleagues from the IMT the information management team to introduce an IT
00:34:09 solution. Yes. Was that system that he recommended ever established you know? Yes it is now.
00:34:16 It would? It is now. It is now. When was it established? I think maybe late 2017
00:34:26 early 2018 I would say more late 2017. Can we then turn to action 17 supervisor FSG training
00:34:37 and I can take this quite quickly I think if we go back to the Latin and Assurance report of August
00:34:42 2018 please at LFB quadruple 0 4801 let's go to page 16 in that and look at the left hand column
00:34:54 action 17 and in red it says
00:35:00 develop and deliver an enhanced fire survival guidance training package for control supervisors
00:35:04 in order to ensure the control supervisors are trained to support a control room officer when
00:35:08 they are handling a fire survival guidance call to a standard commensurate with the national guidance
00:35:14 then if you look below there are a number of paragraphs which show what the actions
00:35:19 implemented to date were and let's just look at that together an additional training the second
00:35:26 one down says an additional training presentation was developed for control supervisors which
00:35:30 concentrates on providing support to the control room officer as they take the fire survival
00:35:35 guidance call and on passing information to the incident ground familiarization was also provided
00:35:41 in relation to the reference information file fire survival guidance for control supervisors
00:35:45 see section one action nine this learning was supplemented for a number of control staff with
00:35:51 a fire survival guidance role play a number of fire survival guidance scenarios were developed
00:35:57 with the purpose of embedding learning and allowing control staff to practically explore
00:36:01 this learning in a realistic situation control supervisors played the role of supervisor or the
00:36:06 caller in these role play scenarios now you've exhibited to your witness statement at js21
00:36:14 the supervisor training presentation that was developed in 2011 haven't you
00:36:20 yes and it let's wait we can look at it before we do let's look at paragraph 85 of your statement
00:36:29 page 31
00:36:37 and you say there paragraph 85 as noted in my response to question 20a lindsey turner was
00:36:44 responsible for training when this package was developed in 2011 my involvement was limited and
00:36:49 i recalled that i was only involved by way of support as a fellow a apcon in giving some high
00:36:54 level comments on the material as such i cannot speak to her this particular training was deemed
00:36:59 to comply with national guidance but do note that any national guidance did not contain any details
00:37:05 on the role of control supervisors should play in managing fsg calls now can i take it from that
00:37:11 that you did review the training presentation no i i'm not sure that i did you didn't you don't
00:37:20 think no i don't i don't believe so i don't recall doing that well uh right do you remember
00:37:27 what your high level comments were probably as i've said there that it would be hard to
00:37:34 develop that in terms of there was no national guidance laid out for the role of a control
00:37:39 supervisor to play and maybe we had a conversation about what observations we'd come away with and
00:37:49 the lacanel board or the lacanel team had come away with and just making sure that supervisors
00:37:54 understood that i see um let's just be clear about the document you've exhibited lfb double zero one
00:38:00 two one two three three please is this the presentation yes it is uh do you know whether
00:38:14 this was uh initially delivered as a separate fsg set of training to supervisors i believe so from
00:38:21 recollection i think initially that uh supervisors uh did the the full day with control officers so
00:38:30 all control staff got the refresher training and then an additional training session for supervisors
00:38:38 an additional training session for existing supervisors yes right so it was it part of the
00:38:45 annual cio cro refresher training then i believe that was on the first uh when we first rolled out
00:38:53 annual refresher training i don't know if it continued as a separate package from then on i
00:38:59 think uh from my memory one of the recommendations from the board was to provide a specific supervisor
00:39:07 training for all different um different supervisor training and uh for survival guidance was a module
00:39:16 in that i see come your re-arrival back at the lfb in february in january 2015
00:39:23 uh what was the state of supervisors refresher training at that stage as i understood that all
00:39:31 supervisors had received some of the additional training that they needed in terms of the different
00:39:38 modules there had been a package created with all those modules in there and any new supervisors
00:39:44 were to receive that modulized training and that also included a week leadership course as well
00:39:53 and did that include fsg yes as part of one of the modules and how was that i mean leaving aside
00:39:58 the week-long leadership course which i'm assuming was trainer led was it it was trainer led yes did
00:40:04 that tell us that all that all supervisors got trainer led refresher training on lots of things
00:40:10 including fsg annually no uh i believe that was all existing as i understood it all existing
00:40:17 supervisors had had that modulized training and any new super new people that were new to the
00:40:24 supervisory role would receive that modulized training as well right so this is essentially
00:40:31 training given upon promotion yes what about refresher training so they were all supervisors
00:40:37 and all operations managers were part of the annual fsg refresher training i understand but
00:40:43 the refresher training there was no refresher training per se on supervisors no i see can we
00:40:49 then go to the lateral control report please at lfb quadruple zero four seven two four page 53
00:41:00 page 53 top box bottom two lines
00:41:06 uh action four three completed control have introduced a supervisor's course focusing on
00:41:13 leadership and general supervisory actions and role within the control room including fsg
00:41:19 was that a reference to the 2011 presentation that we've just looked at
00:41:26 uh possibly possibly are you able to tell us we can go back to the presentation but are you able
00:41:33 to tell us why the presentation did not include any details of the lacna house incident or any
00:41:38 learning points from it no do you know if supervisors were ever informed of the conclusions
00:41:44 that you'd come to in the lacna control report i say you the brigade had come to in the in the
00:41:48 lacna control report i would have hoped so i would have hoped this was published when i was
00:41:53 at cfoa but i would have hoped that that would have been shared with everyone do you know whether
00:41:58 the uh the training to supervisors was ever updated after november 2012
00:42:05 to reflect the conclusions in the lacna control report um i don't recall but i do know it has
00:42:14 been done since when you say since uh when would that be um during my tenure as uh being in charge
00:42:26 of ost so that's after 2020 no oh after 2015 yes do you know when after 2015 i don't but i can
00:42:35 remember that the the um module training package for supervisors was always being updated um
00:42:45 to make sure it reflected current practices so that would have been part of that
00:42:56 and can we go back please to page 49 of this document
00:43:03 uh you can see at f6 the conclusion about the handling of the fire
00:43:07 uh at lacna on the third of july 2009
00:43:15 do you agree that these conclusions which run for 10 paragraphs from 286 to 296
00:43:22 were relevant to supervisors who might have to manage a similar incident in the future
00:43:29 i can't recall the conclusions and i certainly uh when we drafted our report or i contributed
00:43:35 to drafting the report at the control report uh didn't make the same conclusions these have
00:43:42 been reworked and i i couldn't recall what they are offhand if you wanted me to comment on
00:43:48 if they addressed them or not yes that's i wasn't i wouldn't be able to do that now i don't recall
00:43:53 the document that's fair enough let's just look at them as quickly as i as we can
00:43:58 uh consistent with being fair to you as the witness but 286
00:44:05 uh i don't think i'm going to read it all to you but you can see the topics uh 286 covers
00:44:13 the national guidance and the gap and the absence of formal refresher training 287 is workload
00:44:20 uh and it says control in the third line controlled resources were dedicated to dealing
00:44:25 with three fsg calls at the same time and difficult that made things given the need for a supervisor
00:44:33 or other co2 support and then premises layout uh situational awareness 290m information gathering
00:44:45 290m information gathering just scroll down a bit further over the page to page 50 to 291 using the
00:44:53 riff 292 role of control supervisors 293 expectations that callers would be rescued and stay put advice
00:45:06 294 escape and alternative escape routes and in the second sentence neighbor to the
00:45:12 and in the second sentence no particularly where it said that um this may have caused
00:45:18 co2 move straight into the protect phase of fsg and not explore alternative escape routes with callers
00:45:27 in 295 assessment reassessment
00:45:31 some co2 did repeat questions
00:45:36 uh and then identified tendency to limit reassessment due to the protect ethos
00:45:42 although there is evidence that some proactive call handling techniques did take place 296
00:45:46 effective communication between control and incident command and then ending a call at 297
00:45:56 now those are and i'm i'm conscious that i've taken you fairly quickly through those but but
00:46:01 in general is this a general question do you agree that the conclusions in the national control
00:46:06 report were relevant to supervisors who might have to manage a similar incident in the future
00:46:11 yes yes do do you know why um supervisors were never given specific training on these particular
00:46:20 matters forming the conclusions in this report uh no and i would hope that the especially the
00:46:26 effective communication between control in the incident an instant command would have been in
00:46:32 that the the original training package
00:46:38 now can we go back a year or two to september 2010 to the minutes of the lacna house board of the
00:46:44 15th of september that year which we know you attended we saw this this morning lfb 00055192
00:46:53 if we go to page two we know you were in attendance from page one you go to page two
00:46:58 paragraph 5.9 says it is record it is also recommended to introduce a supervisory training
00:47:04 package of two weeks similar to the cm package this would include a maneuver type exercise
00:47:09 what was a maneuver type exercise i think it's it was it's known commonly as an instant command
00:47:16 exercise with the simulator and we must have used an old name of it but the intention was that
00:47:27 and whilst instant commanders were using that system and to validate their instant command
00:47:33 that that would be worthwhile using with control supervisors to undertake that task was that two
00:47:38 week training package ever created and delivered uh no so i think the supervisory training packages
00:47:44 would have been some of the leadership course some of the module course and an exercise
00:47:50 included in that which would simulate a supervisor dealing with an incident
00:47:58 which had a large amount of pumps to be mobilized and fsg calls do you know why that two week training
00:48:05 package that was contemplated there wasn't ever created and delivered i i think as i said the two
00:48:11 week training package was it was a week of uh the leadership skills and then it was modules delivered
00:48:20 by the training team the exercise that they refer to was never created and i did try and pursue that
00:48:26 several times and attended an instant command exercise to see how we could adopt that system
00:48:35 and use it for for control staff right i see so because we saw a document earlier namely the
00:48:41 conclusions in the lacanel control report about a foundation course being five days is that the
00:48:49 leadership course yes so that was the first week was it yes and then there was a second separate
00:48:54 week of modules yes right and when did that start i believe that started in in 2010 2011 and when
00:49:03 did it end did it it didn't end apart from that i don't think we send uh staff to attend leadership
00:49:16 courses actually i'm not sure that's correct i think we still when they're offered to us
00:49:22 if we have staff to attend we will ask if they want to attend
00:49:26 but the modulize supervisory training still continues now with all new supervisors
00:49:35 uh i'd like now to ask you about ac george's report and the training plan in july 2016 and february 2017
00:49:48 uh first as a general point do you accept this proposition that control should have had in place
00:49:54 a structured training plan yes yes
00:50:08 then let's look at the audit completed by station manager kelly ned kelly as you like to be called i
00:50:15 think in august 2010 at lfb three zeros five five two two zero and what i'm showing you is the version
00:50:22 exhibited to scott hayward's witness statement there are a number of different versions on it
00:50:26 which contain draft comments but this one was confirmed by scott hayward to be the final version
00:50:36 and if you look at paragraphs one and two on page three you can see what this document is
00:50:41 is
00:50:48 and the date of this document as you can see at the foot of each page is the third of august
00:50:54 2010 and if we go to page six please at paragraphs 47 to 49
00:51:01 it says at 47 we need to scroll down a bit further
00:51:05 uh page i think we need page seven in fact i'm sorry thank you um under systems for performance
00:51:13 management planning of training it says it appears that adequate long-term planning of the regularly
00:51:19 developed delivered elements of the bctd curriculum is not being carried out this may account for the
00:51:26 fact that the delivery of our survival continuation training to observed candidates fell outside the
00:51:31 parameters of recommendations found in the emergency call handling techniques
00:51:35 and fire survival guidance training document i.e. 12 monthly however brigade control principal
00:51:41 management have stated that once the current tranche of fire survival guidance fire survival
00:51:45 training is completed it is planned for all staff to receive a full course every 24 months with 12
00:51:50 monthly interim training being delivered via a computer-based training solution notwithstanding
00:51:56 the above it is vitally important that adequate training planning systems are implemented for all
00:52:01 courses including appropriate training records that support the cyclical training planning process
00:52:08 and then in bold paragraph 50 recommendations bullet point implement adequate training planning
00:52:14 and recording systems do you recall reading this finding and recommendation either in
00:52:20 draft form or in final form i think i've commented on the document um so yes i would have recalled
00:52:28 reading it you did i think not this version but i'm not sure it matters so you did you did
00:52:33 read this finding a recommendation yes yes were you surprised by it when you came to read it in
00:52:38 august 2010 possibly because the training team had been established for
00:52:46 uh quite a while and the the individuals in the training team had previously delivered training
00:52:53 plans i believe so yes and we've seen through the evidence shown to scott hayward and to you yourself
00:53:00 that during 2010 there was quite a lot of development of the training plans
00:53:05 and quite a lot of information given to the lacna house board about what training
00:53:09 plans were afoot yes in terms of fsg yes in terms of fsg particularly yes um
00:53:16 so did it not come as a surprise to you to discover that um mr kelly was less than impressed
00:53:23 with the adequacy of the long-term planning of the regularly developed
00:53:27 delivered elements of the curriculum
00:53:31 yes yes do you know what was done to implement an adequate training plan after this report was
00:53:38 published no i would imagine that that scott would have spoken to the ost trainers and lindsey
00:53:46 and asked for a training plan i see you imagine but yeah well i can imagine but do you know no
00:53:52 can we go to lfb 0011 3237
00:53:59 this is a minute of a brigade control management meeting a bcmm
00:54:07 on the 18th of july 2012 uh you can see that you are listed as present as the third person down
00:54:16 yes yes and ac chandler was also present at that stage did you report to him no to scott
00:54:23 hayward still you still reported to scott hayward what was it what was ac chandler's role in
00:54:27 this time july 2012 as i understand it he was brought in as the ac in charge of control and
00:54:33 mobilizing if we go to page seven you can see a heading training ac chandler
00:54:40 and it says ac chandler began by saying that he had attended a meeting recently which spoke
00:54:45 about the training commissioning and alteration process he stated that in the document there was
00:54:52 nothing showing that control had carried out any form of training he went on to say that he spoke
00:54:56 to control training to see if there was anything in place to show what form of training had been
00:55:00 received by staff the ac asked if there was a training matrix which control worked to the
00:55:05 response was no ac chandler asked the ops managers to see what training would be needed for their
00:55:10 watch all ops managers to present this information in the form of a spreadsheet so that he is able to
00:55:14 see what controls need needs are for the year ac chandler would then speak to nick to see what
00:55:20 can be done this information can be used by ops managers as guidance and also at the end of the
00:55:24 financial year for easy audit ost have been asked to produce a training matrix and just pausing
00:55:31 there now i appreciate that you were not responsible for training in july 2012 as you told us but do
00:55:37 you recall this discussion you were at the meeting i don't recall it no do you recall
00:55:42 ost working on producing a training matrix i don't know do you know if a training matrix was
00:55:48 completed i i don't know when you took charge of ost in january 2015 did you find out if a brigade
00:55:55 controlled training plan had been developed previously no but i think we had started to work
00:56:02 on a training plan as i've said that was scott had given me that to deliver a training plan for
00:56:10 vision and the vision mobilizing system and then we had discussions about rolling out
00:56:15 subsequent training packages that we need to include in fsg after delivery of vision
00:56:22 right and given this discussion summer 2012 ost task to produce a training matrix
00:56:30 when you came back in 2015 can you explain why you didn't ask the question what happened to the
00:56:35 training matrix um no i can't explain i can't recall the conversation and and the request for
00:56:44 a training matrix but it was asked of the ops managers to create and i would imagine that would
00:56:50 have been created and a list of subjects that they thought pertinent to cover on an annual basis
00:56:56 would have been given again you can imagine that but um did you at the time feel some surprise that
00:57:05 you were not given a training matrix that have been the subject of discussion two and a half
00:57:10 summers before no not at 2015 when i came back and was given the the task of implementing the
00:57:17 vision mobilizing system and and our focus was there but we did have discussions um about what
00:57:23 we would deliver after were you not surprised given that station manager kelly had specifically
00:57:30 identified the lack of adequate long-term training planning in his august 2010 report
00:57:36 uh no not not because i i just didn't recall that station manager kelly had recommended that and i
00:57:43 don't recall the minutes of this meeting but it was always a desire when i was in ost and or when
00:57:50 i was managing ost to create an annual training plan to deliver training to control staff right
00:57:57 focusing on the time january 2015 and after that was a training a detailed and consistent training
00:58:05 plan produced by ost yes um not in terms of detail but we would know what subjects that we were
00:58:15 trying to cover and that we needed to cover and and that we would then individuals as i've explained
00:58:22 would take the lead on that and develop a training package based on that
00:58:27 and we would come together review that and discuss how we were going to implement that
00:58:33 right and deliver that to control staff you say not in terms of detail but you would know
00:58:40 what subject you were trying to cover yeah let me just see if i can understand that a bit more
00:58:44 okay in and from january 2015 was there a document that everybody could in charge of training
00:58:54 within the ost or who had anything to do with training within the ost could go to to see what
00:59:01 the plan was for training for that year no that's what i meant in terms of not with that much detail
00:59:09 we had a training plan it was displayed on several calendars and individuals in ost would take
00:59:17 responsibility for one of those deliverable of one of those training feeds and and as i've
00:59:25 explained we would come together discuss those and discuss as a group how we were going to
00:59:29 roll it out to everyone right so it was displayed on several calendars yes what does that what does
00:59:35 that mean so just we had a i think we had a big calendar on on the wall in ost where we would write
00:59:44 what month and what training we were trying to deliver and i think it might have been in
00:59:50 just some emails as bullet points as what we would try and deliver over the year
00:59:54 but not a document that had a formal training plan and the content of that training right
01:00:00 minute and would this calendar identify individual cro's who would receive
01:00:08 individual training on individual dates no so it would be as it was ost t training it would be
01:00:15 training for all control staff delivered on a theme and spoken about fsg nta and then it would be the
01:00:24 responsible person in ost to lead to liaise with the om's on watch to make sure that those individuals
01:00:31 attended training and taking 2015 let's just try and work it through by way of an example
01:00:38 2015 i'm in the control room it's february 2015 i look on the wall and there's a calendar
01:00:44 and i can see uh fsg training on the 14th of march so is that what it would have looked like
01:00:53 no that would have what it would look like in the ost office right but not in the control room
01:00:59 in terms of control staff attending training they just would have been told by their operations
01:01:05 manager or their supervisor that they had training on that day and what it was when it came to fsg
01:01:10 training is this right that in 2015 and 16 this was the command unit training i don't believe it
01:01:20 was all just command unit training in 2016 i think there was some training that was undertaken
01:01:26 in terms of the cbt packages as well to the extent we've covered as well as the informal
01:01:31 training yes it's that right thank you can we then go to the bcm minutes of the 10th of march 2015
01:01:42 lfb 00123 178
01:01:48 and just to see how this worked uh you can see there the date of the meeting 10th of march you
01:01:53 can see that you are in attendance third attendee down in the list and if you go to page seven
01:01:59 please under item 12 you can see there's a heading training and in the last column you can see your
01:02:06 name yes and it says rms training and the early training system were discussed the training plan
01:02:14 was shared with the rbs som diamond informed the ops managers the training will run four hours every
01:02:21 afternoon seven days a week two till six p.m som stibards will email the documents to the ops
01:02:25 managers the training will be in phases five phases eight modules one of which is the supervisor's
01:02:30 role this will begin with the day duty what with the duty day watch nominations via ops managers
01:02:37 oh and more asked if they will be training notes these will be available through the training team
01:02:44 uh now what was the training plan that's referred to at the beginning of that first main paragraph
01:02:51 that was shared with the rbs that's the replacement mobilizing system training plan
01:02:56 that's vision is it yes there was a specific training plan a document for how they were going
01:03:01 to be trained on vision was there yes there was yes right but no such training plan in relation to
01:03:06 call handling fsgs emergency call management rif supervisors no as i've explained no who were the
01:03:14 rbs the representative bodies so i see we were trying to work it out representative bodies
01:03:19 they would have included the unions for this
01:03:21 yes
01:03:24 uh can you explain any more to us about the training that was planned to be delivered at this time
01:03:28 other than what you just told us this afternoon no just that it was as you can see all committed to
01:03:36 vision training four hours seven days a week for the training period yeah then if we move to january
01:03:42 2016 lfb double zero one two three one zero two
01:03:46 three one zero two
01:03:50 these are the bc mm minutes of that date
01:03:58 and we can see that you are in attendance there can you see that yes
01:04:02 som smith j senior management uh and um if you look please at uh page four item 10
01:04:11 the foot of the screen control training and then over to over the page to page page five within that
01:04:19 section of this minute halfway down the box it says som smith has a meeting planned with training
01:04:24 to discuss training for control for 2016 including the new entrance courses and considerations of
01:04:29 resources they might need at that time who did you meet do you remember
01:04:35 do you remember
01:04:38 uh i don't i think it probably relates to the ost team if we're discussing training and
01:04:44 resourcing was there a training plan or training matrix in place by then not a training matrix but
01:04:51 yes a training plan but not in the detail that you've described right so this would be the
01:04:57 wall mounted calendar in the ost office yes did you undertake yourself any long-term
01:05:04 planning of training needs at that stage uh yes i think that encompassed resourcing and what we
01:05:13 should do and maybe shortly after that i do write a report about the future of ost
01:05:20 and and and how it should be focused on a training team and a technical team
01:05:30 you say or it says that you had a meeting planned with training to discuss training
01:05:34 for control for 2016 did that include fsg training yes it would have rif training
01:05:41 no not our rift training no what about emergency call management policy so i believe that was still
01:05:48 included in uh the uh emergency sorry call handling was still included in the fsg training
01:05:57 i see no no training on specific policy now do you remember that in july 2016
01:06:04 ac tom george produced a report entitled review of big brigade control i do yeah did you have
01:06:10 any input into that report i didn't no you didn't uh now ac george says in his witness statement
01:06:19 we don't need to go to it but it's a paragraph 26 on page 7 that he provided the final report
01:06:25 on the 19th of july 2016 and he shared it with senior managers do you remember receiving a copy
01:06:30 at the time i do yes you do did you read it yes let's look at it lfb triple zero three two eight two six
01:06:45 there's the first page of it july 2016 review of brigade control summary a comprehensive review
01:06:51 of brigade control was undertaken between march and july 2016 with the objective to ensure that
01:06:56 brigade control was in the best possible position to deliver its functions effectively and efficiently
01:07:01 the review team undertook a quote's root and branch close quotes review into the culture and
01:07:07 processes that exist within brigade control and the impact they were having on the successful
01:07:11 operation of the service and function they provide
01:07:17 and if we look at page two please paragraph four we can see that
01:07:26 under the terms of reference the fourth bullet point from the bottom included as this
01:07:33 familiarization training and maintenance of skills including mandatory course
01:07:38 courses you see that yes and then if you go to page seven he sets out some key issues
01:07:46 in summary and he says this during the review a number of issues and concerns were raised by staff
01:07:53 by representative bodies and by managers a summary of the 10 key themes is listed below
01:07:58 in order of being raised from the most to the least this is based on responses at formal one
01:08:04 to one meetings or in the staff survey 30 responses around a third of the total number of staff polled
01:08:13 and if you look at the second bullet point down so this is the second most important or most raised
01:08:22 it says lack of regular training and development now just pausing there a member of the ost
01:08:31 somebody called joe rene or rene was part of ac george's review team isn't that right
01:08:37 you remember that i believe so yes did joe rene ever feed back to you the fact that so many staff
01:08:43 had apparently reported concerns to do with training i think it was a common knowledge that
01:08:53 uh staff would like regular training so when you read that second bullet point as the second
01:09:00 most raised concern you weren't surprised no i don't believe so if we go to page 11 paragraph 47
01:09:16 this is under the broader heading at the foot of the at the head of the screen
01:09:20 development in role paragraph 47 some staff feel that they are not adequately developed in
01:09:25 role or receive development to progress to a higher role the review has identified that
01:09:29 maintenance of skills training is ad hoc not planned in a robust manner and often not recorded
01:09:35 on individuals training records itr's whilst there is a responsibility and onus on individuals to
01:09:40 maintain their itr's correctly by manually entering completed training this is not often done and
01:09:46 staff are seldom instructed to do so by their managers and then at uh 48 a lack of regular
01:09:53 training and development has been raised as an issue by the vast majority of staff that were
01:09:57 spoken to or who responded to the survey this includes preparation for assessment centers and
01:10:03 training in role post-promotion some staff commented that they frequently felt bored
01:10:08 and that whilst they started their role full of enthusiasm as time progressed that the enthusiasm
01:10:13 dwindled introducing a comprehensive suite of training and development opportunities into
01:10:17 control is deemed to be a priority and then at 49 one reason for a lack of regular maintenance of
01:10:25 skills training has been the difficulty in getting the watch together away from the control room to
01:10:29 undertake team-based training sessions when the shift changed in 2011 it was proposed that such
01:10:34 training would be carried out on the short shift however this has rarely been achieved for a number
01:10:38 of reasons including a shortage of staff high sickness levels and the inflexibility of breaks
01:10:45 and then he identified a number of things that needed to change
01:10:51 just pausing there i've read you three paragraphs but particularly thought 49
01:10:57 did you agree with what ac george was saying yes i did and i've spoken to the group that joreen
01:11:04 was part of and and proposed a different shift system where it did give training as a team together
01:11:19 right were you when you read those three paragraphs
01:11:25 concerned to read those paragraphs given that sm kelly had picked up the problem about adequate
01:11:31 forward planning of training in august 2010 and here we are in the middle of 2016 and this remains
01:11:40 a problem it had been unaddressed for the best part of six years yes it was did that come as
01:11:50 seeing it in black and white is something of a real concern to you no it didn't come
01:11:54 sorry as a concern yes not as a surprise not as a surprise so a concern but not as a surprise
01:12:02 which tells us does it that even allowing for the two and a bit years that you were absent from
01:12:08 the brigade this problem about adequate forward planning of control room staff training had
01:12:14 remained unaddressed in a serious way for the best part of six years yes and i believe that
01:12:20 was due to lack of resources and had proposed several suggestions to try and address them
01:12:27 all of which it appears have fallen or did fall on deaf ears i'm not sure deaf ears i think some
01:12:34 were pursued but there i'm sure you've heard there are a lot of difficulties to get over and
01:12:40 agreements to make in terms of pursuing change in london fire brigade yes now let's go on i just
01:12:49 introduced the the recommendations that he made but let's look and see what he says a number of
01:12:56 things need to change this is just towards the foot of your screen within paragraph 49 a number
01:13:02 of things need to change to allow suitable sufficient and regular training and development
01:13:06 to take place including a ensuring that any overall staffing structure change and change to the system
01:13:14 of breaks allows and encourages staff training to take place be as previously agreed use babcock
01:13:21 the brigades training provider to provide easily accessible cbt computer-based training packages
01:13:26 within big learning and introduce new control specific training where necessary including
01:13:31 tactical decision making exercises now if you go over to paragraph 49c on page 12 we see this
01:13:40 each om is to ensure that an appropriate robust annual watch training plan is in place for their
01:13:45 watch agreed by their som and available to all watch members and managers all training must be
01:13:51 recorded on an individual's itr individual training record the pom som should work with colleagues
01:13:57 from the brigade's information management team to introduce an it solution to this
01:14:00 similar to the training diaries used by station staff
01:14:04 and then skip down to e provide appropriate training courses to staff particularly when changing roles
01:14:15 and and then at f you cast your eye down to f we can scroll down to it please introduce additional
01:14:21 training and development solutions into control including and there's a long list of things that
01:14:28 need to be uh need to be covered including the second bullet point familiarization on call
01:14:35 handling and caller engagement including the introduction of greater questioning for calls
01:14:39 to dwelling fires yes that that bullet point there is all about fsg isn't it uh no it's
01:14:46 i believe it's about general call handling and our engagement with callers for a variety of
01:14:51 incidents and we did achieve that i say it's all about fsg it certainly includes fsg
01:15:00 i think there is an element of fire survival guidance in it but as stated fire survival
01:15:07 guidance we wrote we wanted to roll out an annual refresher focusing on that and this is about our
01:15:12 call handling to a wide variety of incidents and engagement with callers looking at the list though
01:15:19 uh and f is the place to look look for that and it does go over the page but let's scroll down but
01:15:29 take it from me but you may know this better there was no fsg training referred to specifically in
01:15:37 that list no from reading the listener you've got page 12 let's skip to page 13 for completeness
01:15:45 where it continues but again you see nothing in there about fire survival guidance
01:15:50 uh fire survival guidance training no no
01:16:01 was fire survival guidance something specifically addressed by
01:16:05 ac tom george i don't believe so why is that do you know why i don't know i i in my role as uh some
01:16:14 i didn't contribute to this report just in general terms we've covered the six years but given the
01:16:20 1998 service manual fire service manual recommended that training should be structured and defined
01:16:26 are you able to explain why even in july 2016
01:16:33 there was still no annual watch training plan in place for control staff
01:16:37 that was satisfied that satisfied ac george i don't know in terms of satisfying
01:16:44 ac george there was some watch plans with what we intended to deliver in terms of ost
01:16:52 in 2016 did you ever go to ac george and say well look you've missed this element of our operations
01:17:01 we have a document a calendar sits on the wall of the ost office which has our training plan in it
01:17:08 surely that's good enough i possibly did that and i believe that we were we put all these actions
01:17:16 into a tracker and scott hayward nominated responsible officers for those and we were to
01:17:22 update those to tom george on on those actions so i may well have fed back at that time that there
01:17:29 was a training plan and what we were working towards in terms of delivering training for
01:17:35 control staff let's just take that in stages we'll come to the feedback in a moment because i'm not
01:17:40 quite finished with the report but at this stage july 2016 which is his we know it's his initial
01:17:47 report yeah before he produced it did you go to tom george and tell him uh that there was this
01:17:54 in place whereby there was a document hung on the wall of the ost office where people could see the
01:18:00 plan training for the year no had he had he asked me i would have told him or shared that with him
01:18:06 when you got this report did you communicate with him to tell him that he'd missed something of
01:18:11 importance namely that there was an adequate training plan in place all he had to do was
01:18:16 pay a visit to the ost office and see it hanging there not that i can recall but i probably would
01:18:21 have discussed these points with scott and cait at the time and would have fed back in terms of the
01:18:29 actions can we go to page 31 of this document please we can see that there is an appendix two
01:18:38 summary of actions do you remember reading this at the time yes and we've jumped into the middle
01:18:47 of it because this is where i want to go with it but if you can look to see on the left-hand side
01:18:52 a list of numbers 49 is the ref eight lines down and the action is discussed with staff side
01:18:59 representatives to implement enhancements to training and development as detailed in the report
01:19:05 and the responsibility identified there in the right-hand column is j.s is that you yes yes
01:19:11 yes
01:19:14 and enhancements to training and development as detailed in the report
01:19:20 was that a reference to paragraph 49 of the report which we've just looked at
01:19:28 possibly each om is to ensure that an appropriate robust annual watch training plan is in place
01:19:34 for their watch um no i wouldn't have thought so because i don't know why he the action would be
01:19:39 for me to discuss with staff side who are the the unions about implementing a training plan with
01:19:47 om's so what did you understand you had to do in response to this action i think some of the
01:19:56 training and development about in the bullet points it covers about assessment centers and
01:20:03 providing development before they went for assessment centers and things like that i would
01:20:08 imagine that that would have been something that's discussed with staff side about how we
01:20:12 would go about doing that i mean do you have a recollection of what it was you were supposed to
01:20:20 do by way of action uh no but i think that's not the action plan i recall i think there's a one
01:20:30 that's a bit more detailed uh that we've provided a narrative and we were to provide a narrative to
01:20:37 scott on a regular basis and that may have contained some more detail i certainly would
01:20:42 have asked if i didn't understand that and and i might have spoken to the representative bodies at
01:20:49 jcc meetings about the promotion process that's in my mind as i understood it looking at item
01:20:57 56 it says progress with two new entrance courses and maintain a regular check forward planning
01:21:04 and horizon scanning of establishment what was that about so that was about uh recruiting
01:21:11 more control officers uh providing trainers to deliver two new entrance course and the
01:21:17 recruitment process that goes with that and then as it says horizon scanning making sure that we
01:21:23 were aware of our establishment when our establishment would fall below and identifying that to scott and
01:21:31 sir tom george did anything change in the way you conducted and arranged your forward planning of
01:21:39 control room officers refresher training and recording that as a result of this report and
01:21:48 the actions recommended in it yes so in terms of getting access to station diary or lfb diary as
01:21:57 it's called in terms of providing um pr pdrs to staff i think as i look through the actions
01:22:09 all of them if not the vast majority are now complete
01:22:14 mr chairman is that a convenient moment for the break yes it's who i think it is yes i just should
01:22:19 say we're quite near the end of the questions i've got but it's probably better to take the
01:22:23 i think so yes we'll have the afternoon break at this point miss smith will
01:22:28 stop now we'll come back please at 20 to 4 and again remind you not to talk to anyone about
01:22:32 your evidence thank you thank you very much
01:22:47 thank you very much 20 to 40s
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01:40:20 would you ask miss smith to come back in please thank you
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01:40:33 all right miss miss ready to carry on yes sir thank you very much yes mr millet yes thank you very
01:40:38 much mr chairman can we then look at lfb 00083867
01:40:44 this is an email from scott hayward to tom george copying you in i'm sorry i should have given you
01:40:58 the page reference page seven in this email run
01:41:01 on
01:41:04 date of the 24th of february 2017 and says this morning tom and the subject is implementation
01:41:14 of recommendations from review of brigade control morning tom actions to date we have
01:41:18 commented where we can quite a bit is being done or underway and we are waiting for systems etc to
01:41:25 forward
01:41:27 and in the table underneath that you can see item 49 you see yes discussed with staff side
01:41:34 representatives to implement enhancements to training and development as detailed in the report
01:41:39 and then comment developing training plan in place staff being trained continually on vision
01:41:44 development of fsg mtfa and corresponding supervisor training is taking place for newly
01:41:51 promoted staff what did a development training plan in place mean i think that just refers to
01:41:58 as we were working on we had a structure in place and we knew the topics that we wanted to create
01:42:04 and roll out to training what was the training plan is that what you referred to earlier as the
01:42:12 calendar on the wall i believe so if this was in 2016 yes well no this is not this is january 27th
01:42:21 oh so yes there were that would have been what happened in 2016 and in 2017 we were
01:42:28 probably working on a more robust plan right let me just see if i can understand that
01:42:37 you say in 2017 we were probably working on a more robust plan yes uh right what happened
01:42:45 between july 2016 and january 2017 by way of working on a more robust training plan
01:42:54 so we would have had a plan in place and i believe we rolled out uh training
01:43:00 that was requested by us in terms of mta and and we probably covered corresponding training as well
01:43:07 so july 2016 you had the wall hung plan in the ost office as you told us before
01:43:17 with the calendar what document or matrix or plan or schedule spreadsheet
01:43:24 or anything did you develop between july 2016 and january 2017 which would show the training plan
01:43:34 being developed i'm not sure if anything substantially changed in 2016 because we'd
01:43:41 already had a plan so what i think that update is alluding to that in we were working on one
01:43:48 for the subsequent year in 2017 what were you working obviously you were working on well the
01:43:57 same wall hung uh calendar but just for the next year no i think it would have been a more robust
01:44:04 document and i can remember several emails with a station uh he might not have been a station manager
01:44:13 at the time and that was working with tom george about the structured training plan so the development
01:44:20 and maintenance of skills that the report talked about and i was working with him to
01:44:28 to create those subject topics right and when did you start doing that
01:44:36 i would imagine probably at the end of 2016 do you remember it ready for 2017 i don't remember
01:44:43 the exact time no but i do recall that i was working with him to do that and we had seconded
01:44:49 i believe another member of staff or shortly after that we seconded another member of staff to work
01:44:53 with uh lfb training team to undertake some further work on on those competencies and
01:45:02 maintenance of skills for control staff and what was the format of this more robust document that
01:45:09 you were developing at that time so in terms of just uh ensuring that we had documented what we
01:45:17 were going to deliver in terms of training to control staff when we were going to deliver it
01:45:21 who was going to deliver it and and share it with other stuff is there a document which does that
01:45:29 i mean for example in december 2016 or january 2017 was there a document a draft document which
01:45:37 contained all those things which we could look at uh i'm not sure there may have been one uh in ost
01:45:44 and we i might have seen sight of that because we were working on that
01:45:49 well you might say i might have seen sight of that because we were working on it
01:45:53 can you remember casting your mind back seeing some kind of draft document which was this more
01:45:59 robust developing training plan that you were developing um no i can't i can't recall
01:46:10 um what was development of fsg mtfa i mean mtfa is morauging terrorists isn't it yes and what was
01:46:21 the development of fsg mtfa and corresponding supervisor training what was that uh i think
01:46:29 that's a full stop at the end so development of fsg mta and corresponding full stop supervisor
01:46:34 training is taking place for newly promoted staff so i think that just refers to us refreshing
01:46:41 the training packages for all those subjects right and what was being done by way of refreshment of
01:46:47 the training packages for fsg mtfa and corresponding that we were looking at them that we were reviewing
01:46:55 them that we were making sure that they were current and appropriate and and looking where
01:47:00 we could deliver them to all control staff right in now this has been very focused development of
01:47:06 fsg looking at that element of the training packages do you remember yourself playing a
01:47:14 part in the review of those packages not so much the review but i do remember that we were discussing
01:47:22 uh the content and aligning the content and making sure that it was up to date
01:47:31 you were discussing the content and aligning the content and making sure it was up to date
01:47:36 when you did that did you make sure take steps to make sure that all of the criticisms of the
01:47:46 training as it stood a number of years before in 2011 were fully and clearly taken into account
01:47:54 so that so that control room operators handling fsg calls would have no doubt at all about
01:48:01 exactly what they should do i'm sure i would have because i was in charge of training therefore
01:48:07 could influence that a lot more between january or december 2016 and january 2017 and the date of the
01:48:13 grenfell tower fire were those training packages updated so as to bring them completely in line with
01:48:23 the points which were the subject of your criticisms back in august and september 2011
01:48:30 i can't recall what point we were working at developing and updating the fsg package
01:48:38 and in terms of what month of the year it would have been in 2017 getting ready to roll it out
01:48:47 for annual refresher training in the september of 2017 and i believe the mta
01:48:55 had already been rolled out and in the summer of 2017
01:49:02 can we then go to lfb 000 32824
01:49:08 this is the version of ac george's report that was presented to the corporate management board
01:49:15 on the 15th of february 2017 and it bears that date and you can see from the top right hand
01:49:19 corner of the screen that it says agenda item 2.1 and the summary is similar to the summary
01:49:25 that we saw in the july 16 version if we go to page six we can see this there's a heading
01:49:32 progress post review paragraph 22 a number of key improvements have already been made including
01:49:39 third bullet point down additional familiarization training to all staff on ncc and
01:49:44 fire survival guidance you see that do you know why it says to all staff
01:49:51 given the figures for fire survival guidance refresher training that scott hayward produced
01:49:57 in his witness statement that showed that only some 46 percent of staff had received
01:50:03 some fsg training in 2016 and there was none at all in the first six months of 2017
01:50:08 no i'm not sure i've seen this document there's no mention here about an annual watch training
01:50:14 plan being put in place is there no had it been completed by then do we do you know i don't know
01:50:22 no
01:50:25 can we go to page three please paragraph eight development and training
01:50:34 and under 8c i should give you the last sentence of eight a number of things need to change to
01:50:42 allow suitable sufficient and regular training and development to take place including and then see
01:50:47 each watch having an appropriate robust annual watch training plan in place
01:50:54 that's the same recommendation isn't it that we saw in the july 2016 report
01:50:59 yes so it hadn't been actioned yet at this stage february 2017 is that right i in in terms of
01:51:07 annual watch training plans um i probably can't recall if that was to come from the centre i
01:51:15 ost or if that was to be developed by the om's on watches
01:51:22 if it was to be developed with the om's on watches i would have spoken to them
01:51:26 or the three om's that i had responsibility for about that why was this still an outstanding
01:51:33 item in february 17 when it had been a recommendation item seven months before i
01:51:40 don't know like i say i would have updated and we had a plan an annual planner to update our progress
01:51:50 for our various responsibilities and i just would have updated it every month on progress
01:51:56 right i'm assuming perhaps this is wrong that when this report was produced you read it
01:52:03 no i february 17 the one that goes to the corporate management board no i don't believe
01:52:10 i've seen that no did anybody whether tom george or um scott hayward bring to your attention the
01:52:19 fact that this recommendation had not been addressed sufficiently by you or anybody else
01:52:27 in ost to tom george's satisfaction by february 2017 no i don't believe so as i said we were asked
01:52:35 to update on our progress regularly and i just would have updated with the progress we've made
01:52:43 can we look at lfb 00083867 page 11
01:52:53 this is an email from scott hayward to tom george you're not copied in on it
01:52:57 but it's dated the 1st of august 2017 so some six weeks after the grenfell tower fire
01:53:03 and the subject is again implementation of recommendations from review of brigade control
01:53:09 update august 2017 morning tom actions to date we've commented where we can quite a bit is being
01:53:14 done or underway and we're waiting for systems etc to move forward that's very much the same as
01:53:19 the february version of this same email and the box is the same in layout terms and you can see
01:53:25 what's appears to have been changed in red can you see complete complete complete looking down
01:53:32 yes remember you get to 49 towards the foot of your screen we get the same text as we've seen
01:53:39 in the previous version of this document and then the same text in the comment box in black
01:53:46 and then there's some red sorry some green which says ops manager placed into career development
01:53:50 services to assist with this refocus this week to deliver on control relevant development records
01:53:56 and training aids was that the extent of the update to the actions it looks like it yes
01:54:04 what was being done about the annual training plan
01:54:10 i don't know i can't recall with what my update was on the 1st of august
01:54:17 2017 why was assistance needed on the delivery of control relevant development records and training
01:54:24 aids i don't know i he's talking about one of the ops managers that were placed into
01:54:32 career development to work on pdrs for control and but i can't shed any light on his further comments
01:54:46 as the som with responsibility for all six watches i think and and the personnel on those watches
01:54:52 as i think you say in your statement i think at times throughout the the period we've been
01:54:57 speaking about i had responsibility at one time for all six watches and but i don't recall it
01:55:04 was then and because keith diamond was the other son so had responsibility for three of those
01:55:11 watches did you ever ensure as such that an annual watch training plan was put in place for the
01:55:17 watches and agreed by you as i say i'm not sure if that action is to be led through the centre
01:55:24 and it is referring to ost working to develop a regular maintenance of skills package and identify
01:55:34 the the training topics or if it is for the ops managers to develop an internal training pan on
01:55:43 watch for their staff do you know if the watch training plan was properly and fully developed
01:55:48 for each of the six watches before the grandville tower fire took place no i can't confirm that
01:56:00 now do you remember in july 2019 assistant commissioner jonathan smith writing a briefing
01:56:07 note entitled control overview and control improvement plan yes can we go to it please
01:56:13 at lfb 00084097
01:56:29 this is the first page of it it's the 22nd of july 2019
01:56:38 subject control overview and control improvement plan brief for tom george and andy roe
01:56:43 author assistant commissioner jonathan smith purpose this briefing note sets out my initial
01:56:48 findings on the current position of the control and mobilizing function within london fire brigade
01:56:53 lfb in order to better understand the current context i've conducted a literature review of
01:56:59 previous reports briefing notes and operational incidents of note which have made specific
01:57:03 observations and recommendations pertaining to control i've also noted the findings of robert
01:57:08 scott's interim report on training across lfb and then if you turn please to page three he says this
01:57:20 uh if you scroll down a bit yes at the bottom training assurance and professional development
01:57:25 and the last paragraph on the page says the current provision of training assurance
01:57:30 and professional development requires a complete and systematic overhaul training is ad hoc and
01:57:35 lacking in structure there is no system of quality assurance and the recording of training is
01:57:40 inconsistent pausing that do you agree
01:57:49 yes and are you able to explain why training was ad hoc and lacking in structure in 2019 if the
01:57:57 watch training plans that were supposed to be being developed were in use no i think we were
01:58:03 moving to a point we where we were getting sufficient resources where we were understanding
01:58:10 and beginning to fit in with the rest of the organization in terms of maintenance of skills
01:58:15 that they'd had for a considerable amount of time and and that we were receiving help from
01:58:21 other lfb departments to achieve that and i think we were making good progress towards that
01:58:27 uh but
01:58:34 when he arrived his observation that it was ad hoc and lacking in structure
01:58:38 and probably for the robust training plan that we have implemented now uh yes that would be true
01:58:50 you told us at the beginning of your evidence that you were promoted to
01:58:54 deputy assistant commissioner for control on the 1st of january 2021 this year i was yes
01:59:02 and you are senior control commander as you told us from the start of 2019 yes yes
01:59:09 and that was a change of name but not a change of role that's correct and now i think you as you
01:59:15 told us occupy the newly created role of dac for control and mobilizing i do yes are you the
01:59:22 senior most person in charge of control yes to whom do you report in that respect now
01:59:30 uh ac jonathan smith jonathan smith yes whose report we've just seen yes can i take it and
01:59:38 correct me if this is wrong that you read the phase one report when it was published
01:59:43 yes you did and did that include reading the criticisms of the control rooms performs on the
01:59:49 night of the fire it did yes and did you or do you accept those criticisms i accept that i accept
01:59:56 the criticisms and that we have made great efforts and endeavors to ensure that those
02:00:01 criticisms have been addressed especially since i've been in charge yes thank you very much
02:00:07 mr chairman that brings me to the end of my prepared questions i'm going to ask you now
02:00:12 for the usual break that i can check uh whether there's anything i haven't covered uh or whether
02:00:17 anybody listening to this has questions which it is right for me to put yes well thank you well
02:00:22 mr as you probably know at this point when council says he's finished answering asking the questions
02:00:27 he's prepared we always have a short break to give him a chance to make sure he's not
02:00:32 left anything out and also to enable others who are following uh the proceedings from elsewhere
02:00:37 to suggest additional questions that perhaps we ought to put to you so we'll have a break now
02:00:41 we'll come back at quarter past four and at that point we'll find out whether there are any more
02:00:46 questions for you thank you all right thank you very much
02:00:59 thank you
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02:14:59 would you ask mr smith to come back in please
02:15:01 thank you
02:15:12 all right mr smith we'll see if there are any more questions for you okay yes mr chairman yes there's
02:15:17 there's one or two perhaps depending on how you look at it can i ask you please to um be shown
02:15:23 the transcript for yesterday day 203 at page 171
02:15:31 um
02:15:49 and at line 13 you're dealing with an email that i was asking you about from christine sharp to
02:16:00 scott hayward on the 21st of january 2010 which sought guidance on training for cros about fsg
02:16:07 calls from high-rise buildings before i show you what you say about that there perhaps we can keep
02:16:12 that on the screen if it's possible and look at that email that is at lfb double zero one zero seven
02:16:19 four nine seven
02:16:24 you'll recall that email yes i put to you and you said if you go back to the transcript which is
02:16:40 temporarily disappeared from view page 171
02:16:55 um line 13 you say i do remember and recall from the conversations with the lacnal team that were
02:17:02 investigating that stay put was the appropriate advice to use to call us in high-rise buildings
02:17:10 now if we go then to the response which i also put to you or rather an email sent by
02:17:20 steve perry to you and lindsay turner on this very point that is at lfb double zero one one one eight
02:17:26 three six let's have that back up please lfb double zero one one one eight three six
02:17:35 uh
02:17:45 and uh this is an email from steve perry on the 21st of july 2011 to lindsay turner and to you
02:17:53 i'm not in fact sure we did see this together but let's look at it now uh in the first paragraph
02:18:01 uh steve perry says uh fsg training advises cro's to inform callers to get out and stay out unless
02:18:08 they are in flats in which case they are advised to stay in if it's safe to do so and ring back if
02:18:13 their circumstances change is this really sound advice following the experiences of lacanel should
02:18:18 we be informing all callers to get out and stay out regardless while they can i think we did see
02:18:25 that yesterday perhaps in a different format or perhaps in a different reference but never mind
02:18:29 about that now looking at both emails together both yours and the christine's and this email was
02:18:36 there some concern at the time this is july 2011 among control staff about the security of stay put
02:18:43 as a fundamental principle underpinning biotiting strategy and fire survival guidance at high rise
02:18:50 incidents i i don't believe i heard of any specific concerns about stay put i think from my discussions
02:18:59 with uh my understanding from the lacanel team tim cutbill and tom davis that there was a
02:19:06 recommendation that we use the stay put and we stick to the stay put guidance and and my role
02:19:13 was just in terms of advising training team to make that clear which it hadn't been in previous
02:19:20 training prior to lacanel do you remember whether you responded to om perry no i think i said
02:19:27 yesterday that the majority of these points referred to training where lindsey was in charge
02:19:35 of at the time yes i see yeah well thank you very much for that um that brings me to the end of my
02:19:42 questions for you miss smith it only remains for me to thank you very much for coming to phase two
02:19:48 and assisting us with our investigations we're extremely grateful to you so thank you very much
02:19:52 thank you and i'd like to thank you as well if i may miss smith on behalf of all members of the
02:19:57 panel you've it's been very helpful to hear what you have to tell us you've been giving
02:20:02 giving evidence for quite a long time and i'm sure it's been something of an ordeal but
02:20:06 we are very grateful and it's been very helpful to hear what you have to tell us so thank you
02:20:11 very much indeed thank you so now you're free to go thank you thank you
02:20:23 oh mr millet that's no doubt a convenient point to end for the day it is and we shall have another
02:20:30 witness tomorrow we do we have uh assistant commissioner tom george who will be questioned
02:20:34 by mr kinney a queens council good very well thank you very much well that'll be at 10 o'clock
02:20:39 tomorrow then please thank you thank you
02:20:52 you