Dani Cotton, former London Fire Commissioner, testifies about the LFB's operational assurance systems, learning from incidents, and responses to the Lakanal House fire lessons.
00:00:30 good morning everyone welcome to today's hearing today we're going to hear evidence from danny cotton formerly the london fire commissioner so uh
00:00:41 so uh yes mr millet mr chairman good morning morning members of the panel i now call miss danny cotton please thank you very much
00:00:57 good morning ms cotton good morning uh i understand you're going to take the oath so the testament should be there would you take it in your right hand and read the words on the screen please i swear by almighty god that the evidence i
00:01:09 by almighty god that the evidence i shall give shall be the truth the whole truth and nothing but the truth thank you very much now do sit down make us have comfortable there thank you
00:01:21 all right yes thank you good thank you yes mr midnight mr chairman thank you mr good morning and can i start by thanking you very much for coming back to the inquiry and assisting us with our phase two investigations we're extremely grateful
00:01:33 investigations we're extremely grateful to you my questions are intended to be short and simple sometimes they don't work out that way so i'm very happy to repeat the question or put the point or question in a different way can i ask you also please to keep your
00:01:45 can i ask you also please to keep your voice up so that the transcriber who sits to your right can take down everything you're saying it's very we capture every word accurately on the transcript yes can i also ask you not to
00:01:56 transcript yes can i also ask you not to nod or shake your head but to say yes or no as the case may be because otherwise a nod or a gesture doesn't come out on the transcript of course you need to break at any time other than the scheduled breaks that
00:02:07 other than the scheduled breaks that we'll take then please just let us know and we can take a break now you've given three rule nine witnesses to the inquiry for this phase uh let me show you those the first was
00:02:19 uh let me show you those the first was dated the 14th of february 2019 that is at lfb 0032 737 please
00:02:30 is that your first statement displayed there on your screen it is can you please go to page 10 is that your signature above the date it is
00:02:40 is now just to be clear that was of course wasn't it before the publication of the phase one report in october 2019. yes it was yes now the second statement is dated the 27th of may 2020 lfb double
00:02:53 dated the 27th of may 2020 lfb double zero double one eight two one three please
00:02:59 is that your second statement to the inquiry for phase two on the screen it is can you please go to page 13 is that your signature in there in the block above the date it is
00:03:10 block above the date it is you also have a third statement of the 7th of september 2020 lfb double zero double one eight nine one five can you please be shown that
00:03:22 is that your third statement displayed there on the screen it is thank you and if we go please to page six is that your signature above the date it is thank you very much
00:03:33 is thank you very much now you i think also given a witness statement to the metropolitan police on the 21st of february 2018 focusing primarily on the events of the night of the 14th of june 2017. i will not be
00:03:45 the 14th of june 2017. i will not be asking you about that statement but for reference purposes say that we have it it's at met triple zero one two four nine two
00:03:54 nine two uh the three statements that i've shown you this morning can you can you please confirm that you've read them recently i have yes and can you confirm that their contents are true they are yes are you happy for those statements to be taken as your
00:04:06 those statements to be taken as your evidence to the inquiry yes i am now your statements have a number of documents exhibited to to them can you confirm that you have reviewed those documents recently yes i have and have you discussed your evidence with anybody
00:04:18 you discussed your evidence with anybody before coming here today only with my legal counsel right now i'd like to begin with some questions about your roles and responsibilities within the lfb
00:04:27 lfb during the time covered by this part of the inquiry if we go back to your first witness statement please lfb triple zero 32737
00:04:40 page two paragraph five you tell us there that you joined the nfb as an operational firefighter in 1988 yes that's correct yes and you go on in that paragraph to say that you were made
00:04:51 that paragraph to say that you were made a deputy assistant commissioner within central operations as of 1st of october 2007. yes yes yes did you held any other senior officer
00:05:02 did you held any other senior officer roles before you were appointed as a dac no that was the first senior officer role i held you didn't right um what was the remit
00:05:13 the remit of the central operations department in which you were a dac so central operations was within the operations department and i was reporting to
00:05:24 reporting to assistant commissioner dave brown the role of central operations was to coordinate a number of the functions that took place for fire stations so for instance we would be a conduit
00:05:37 so for instance we would be a conduit for the four area deputy assistant commissioners to feed information into the assistant commissioner we would be responsible for sometimes
00:05:48 we would be responsible for sometimes for ensuring that messages and information were disseminated i was responsible also for another team that worked to me who
00:05:59 that worked to me who main role was to ensure that sufficient firefighters and officers were available on a daily basis to be at fire stations and therefore to
00:06:10 be at fire stations and therefore to ensure sufficient crewing levels so they manage the leave they manage the sickness
00:06:15 sickness for the whole of the operations for the london fire brigade right and is it right that that that department became known as the operations prevention and response department uh not the that specific role
00:06:28 department uh not the that specific role central operations remained a central operation so that's the whole directorate is the opnr so that was a much wider reaching directorate and what was your role yourself
00:06:39 yourself within the central operations department between october 2007 and february
00:06:45 february march 2012 so i was the deputy assistant commissioner in charge i had
00:06:51 i had four group managers and stations and station managers working directly to me at headquarters i had another team of two group managers working out of stratford and that was
00:07:02 working out of stratford and that was the um the team that managed the leave and basically the allocation of people to fire stations so i was directly day-to-day managing those and i also reported to
00:07:14 reported to assistant commissioner dave brown and for a while we also had other assistant commissioners when i think he explained the areas were split north and south so we had an assistant commissioner called andy barrett and then one called
00:07:25 called andy barrett and then one called andy hickmott and i reported into him as well yes i see so you were just to be clear during those years you reported uh to
00:07:35 uh to ac dave brown uh and
00:07:39 uh and ac andy hickman yes and his predecessor andy barrett and before him andy barrett did you report to anybody else during those years no not during that time uh now you go on in paragraph five of
00:07:51 uh now you go on in paragraph five of your statement on the screen in front of you
00:07:54 you to say that you became assistant commissioner for operational assurance or acoa on the 1st of march 2012. is that correct that's correct
00:08:05 that correct that's correct could you please give the panel a brief overview of the remit of the operational assurance department yes of course so operational assurance was a new department that was established um in
00:08:17 department that was established um in 2012.
00:08:19 2012. it was a result of the commissioner and the corporate management board wanting a greater oversight into various aspects of mainly firefighter
00:08:30 various aspects of mainly firefighter safety so it was amalgamating the health and safety department with a very small team of instant management the view was that it was a way of being
00:08:41 the view was that it was a way of being able to oversee the whole process of the operations on the fire ground so from the start point of crews attending the fire ground the actions that took place
00:08:52 fire ground the actions that took place there
00:08:53 there but then also collating those with accident information so the health and safety department were responsible for collating all accidents and near-misses whether that was personnel accidents vehicle accidents or near-miss accidents
00:09:06 vehicle accidents or near-miss accidents and those would literally go from you know broken pieces of equipment to more serious injuries to firefighters and i think there was a view by the commissioner at that time ron dobson
00:09:18 commissioner at that time ron dobson that we needed a more thorough way of being able to ensure that all those processes were identified so that we could identify if there was a risk for instance to firefighters in the future from repeat
00:09:30 firefighters in the future from repeat accidents happening was there a trigger to the best of your recollection for the creation of uh the operational assurance department in 2012. i don't think
00:09:42 department in 2012. i don't think anything specific i think that there were had been a number of issues with the then management of the health and safety department that i think the commissioner wanted to have an operational officer
00:09:53 operational officer as the overarching officer in charge but working with alongside a health and safety professional but i think there had been a number of operational incidents where firefighters
00:10:04 operational incidents where firefighters had been
00:10:05 had been either quite seriously injured or had the potential to be seriously injured and i think that the concern was that we weren't doing enough to identify those trends and to try and give information
00:10:16 trends and to try and give information to the workforce to prevent them happening again yes i see now if we go to page five of your statement please your first statement
00:10:25 statement look at paragraph 18 if you look at the third line down you say this as ac stroke o a my role included the provision of strategic advice
00:10:34 advice and support to resolve operational incidents planning implementing and leading organizational strategy evaluating performance and developing staff the ac stroke oa was a new role
00:10:45 staff the ac stroke oa was a new role created to provide combined leadership to the incident management team and the health and safety team dealing with firefighter safety and welfare this was done in order to streamline the process of investigating any health and safety
00:10:57 of investigating any health and safety failures occurring during nfb operational work and to learn and identify any trends
00:11:04 now you say there that the assistant commissioner oa was a new role was it created when you took up the post in march 2012 yes it was right so you were the first occupant of that post i
00:11:16 were the first occupant of that post i was um
00:11:18 was um and it sounds from what you've told us that the operational assurance department was an entirely new department but bringing together a number of different pre-existing functions yes that's right yes would it be fair to summarize your role
00:11:30 would it be fair to summarize your role as primarily being concerned with effective incident commands safe operations and management of risks on the fire ground yes that's correct and you say your role was created as you
00:11:41 and you say your role was created as you say to provide combined leadership to the incident management team and the health and safety team in order to streamline the process of investigating any health and safety failures why was that combined leadership and streamline
00:11:53 that combined leadership and streamline process required i think that the it was felt that the instant management team were very
00:12:01 were very sort of function on their own they were quite small team they were responsible for the oversight of the operational review team who went to the fire ground who were effectively the quality assurance team for the fire ground
00:12:13 assurance team for the fire ground but i think that it was felt that there wasn't potentially a strong enough link between them and then the accident investigation that the health and safety team undertook so i think the commissioner and the corporate management board wanted to tie
00:12:25 corporate management board wanted to tie those two functions together i see and the reference to health and safety is that a reference both to firefighters and to members of the public or just the firefighters so the health and safety
00:12:36 firefighters so the health and safety department were responsible for the overall health and safety of everyone working for london fire brigade that was their primary function so not just the operational staff but all of the staff in
00:12:46 in all of the offices control and everywhere else but when you refer there to investigating any health and safety failures are you referring to health and safety failures vis-a-vis staff only or
00:12:57 safety failures vis-a-vis staff only or do you include members of the public so these were health and safety failures primarily relating to operational firefighters but then if it was an operational incident that resulted in some form of
00:13:09 that resulted in some form of investigation there might naturally be an element of that that talked about members of the public but it wasn't that we never were specifically tasked with looking at operational failures in relation to the members of the public
00:13:20 relation to the members of the public yes
00:13:20 yes now uh is it right that the incident management policy group also sat within the operational assurance department that's the incident management team that was a team of five people so one deputy
00:13:32 was a team of five people so one deputy assistant commissioner um two group managers uh station manager and an administrative assistant and you were the dac no i was the assistant commissioner the
00:13:44 no i was the assistant commissioner the dac was great melissa right then the the dac was graeme ellis yes
00:13:51 yes i think he later became ac he did when i became promoted he then became ac and looked uh on the role of that department yes and is it right that incident management is another term for incident
00:14:02 management is another term for incident command
00:14:03 command yes it is it's the it's the joining of the two things so it's um command and management i find sometimes are used as an interchangeable term
00:14:11 term uh and uh you you tell us that the incident management policy group is the incident management team just to be clear what was the function of that policy group as a policy group
00:14:23 of that policy group as a policy group so it was primarily their function was the coordination of the information received from operational incidents so i think you've been familiar with the
00:14:36 so i think you've been familiar with the the database that was used for operational staff following operational incidents whether it was identification of learning points for individuals or teams or to do with organizational issues and
00:14:49 or to do with organizational issues and the operational review team who went out to significant incidents so it was the management of those functions the collection of that information and then how that was used to feed into
00:15:01 then how that was used to feed into things like operational news and to give informational uh to the odcb yes i see and and uh your database reference is that the impd it says yes i see uh now
00:15:12 that the impd it says yes i see uh now as i say therefore as assistant commissioner for operational assurance you would have had is this right ultimate responsibility for the lfb's incident command policy yes that's right yes and i think you remained in the role
00:15:24 yes and i think you remained in the role of uh ac for operational assurance until the 1st of december 2015 when you were appointed to director of safety and assurance with effect from the 1st of january 2016. that's correct yes
00:15:36 that's correct yes and that position is this right was formerly known as director of operations resilience and training or d-o-o-r-t yes that's correct and we heard i think in in
00:15:45 in module five that your immediate predecessor in that role was ac james dal gliesh from january 2015 and before him uh ac gary reason is that correct so
00:15:57 him uh ac gary reason is that correct so gary reason was an ac james doug leash was not an assistant commissioner he was a senior non-uniformed manager in the organisation
00:16:08 i see did he have a you say a senior non-uniformed well did he have a tag a role
00:16:14 role title so he was previously the head of hr and um organizational learning i think it was and then he stepped in when gary reason retired and did that role for a year as the
00:16:27 for a year as the head of that department or the head of that whole section so but he wasn't um so assistant commissioners are obviously all operational and uniformed the staff who are not uniformed all have different
00:16:38 who are not uniformed all have different titles depending on their what director or what team they manage are you able to help us with why the directorate changed its name from operations resilience and training to safety and assurance
00:16:49 training to safety and assurance i'm not sure the exact reason behind it again it was the decision of the commissioner and the corporate management board before i joined them um to change that name of that team before i took over so once again it
00:17:01 team before i took over so once again it was something that was established that i came into in my new role i follow now in your position as newly appointed director of ort is it right that you would have been responsible for
00:17:12 responsible for a number of departments let me list them and say yes or no as we go through them first develop development and training yes that's correct yes operational policy formally known as operational procedures that's correct operational
00:17:25 procedures that's correct operational resilience yes operational assurance yes operational review team the ort yes and health and safety that's yeah is there anything i've missed no i don't think so thank you how often do those departments
00:17:36 thank you how often do those departments and their relevant heads of service report to you so we would have one-to-one meetings on a monthly basis with all of the different heads but then we would also have
00:17:46 have a monthly management board meeting where the heads of those individual departments would all attend or send a deputy if they couldn't attend but on a more regular basis i would speak to them
00:17:57 more regular basis i would speak to them all on probably a weekly basis um for general catch-ups and which of those types of meetings that you've just described for us uh were formally minuted
00:18:08 were formally minuted so the management board meetings were formally administered the departmental management board so the dmbs but not your one-to-one meetings would you like monthly with the heads of service no they weren't ministered to what extent did you have oversight of the work that
00:18:20 did you have oversight of the work that your heads of service were undertaking so i had oversight so we would talk about the key functions of the department we would talk about any problems they were experiencing any
00:18:33 any problems they were experiencing any issues they had or if there were any areas of underperformance flagged for any reason through either corporate reporting or through something that had gone wrong
00:18:44 or through something that had gone wrong then we would have conversations and explore those issues did you monitor their work in any specific way by the regular meetings we had but also for any of the performance indicators
00:18:55 for any of the performance indicators they were responsible for and then for outputs in relation to whatever their department was specifically working on at that time right and you refer to performance indicators did each of those six departments that i
00:19:07 did each of those six departments that i we've discussed together have formal performance indicators so they wouldn't necessarily have formal ones that reported um as part of the corporate digest those were very specific but they
00:19:18 digest those were very specific but they would all have departmental performance indicators that they would work to you refer to the corporate digest what is that so that was a london fire brigade's corporate strategy where they would
00:19:31 corporate strategy where they would decide which key performance indicators they were going to be assessed against that they would report to the assembly on the regular assembly meetings that the commissioner be responsible for so i think you heard
00:19:42 responsible for so i think you heard dave brown talking about ones in relation to control and call handling times it was those kind of high level functions right now you also go on in paragraph five of your witness statement if we can go back
00:19:53 your witness statement if we can go back to page two please uh in the last three lines of that paragraph that you were appointed interim london fire commissioner uh
00:20:02 uh on the 1st of january 2017 and you say i was appointed to the substantive pace of commissioner on 14th of june 2017. why was your appointment initially on an
00:20:13 why was your appointment initially on an interim basis only there were some legislation changes coming into the fire and rescue service nationally where there were a number of different governance arrangements taking place
00:20:26 governance arrangements taking place so some fire and rescue services were working
00:20:31 working to a mayoral function some were working under police and crime commissioners and as part of that legislation change the role of the london fire brigade commissioner to become a corporation sold effectively
00:20:43 become a corporation sold effectively was going to take place unfortunately the legislation took a little longer than was anticipated so i was initially appointed as an interim while they were waiting for legislation which then took
00:20:54 waiting for legislation which then took a while so a decision was made in may that they were going to hold an appointments committee in june and put me into the post substantively right i see so so the role of interim was not as it were a trial run it was a
00:21:06 as it were a trial run it was a it was for constitutional reasons it was yes
00:21:09 yes i see
00:21:11 i see now we understand from a witness statement provided by former commissioner ron dobson that he gave you a handover between september 2016 and december 2016. do you
00:21:22 september 2016 and december 2016. do you recall that yes it wasn't as it wasn't as clear a handover as i think anyone would have liked under the circumstances because it was such an enormous role but we did i was obviously more familiar
00:21:35 but we did i was obviously more familiar with the day-to-day internal london fire brigade business but there was such a wide-ranging remit for the commissioner of external facing roles that those were the ones i felt
00:21:46 the ones i felt i wasn't quite as familiar with and what did the handover consist of do you remember so it was just some meetings we had
00:21:57 some meetings we had i was invited to attend meetings that the commissioner then went to internally mainly i didn't i think i only went to one externally facing meeting as a deputy for him because he was
00:22:09 as a deputy for him because he was unable to go but it was a relatively low key it wasn't minuted they weren't documented and it wasn't involving any kind of document handover or anything
00:22:20 kind of document handover or anything you didn't get a file of material and go through it with him no no i didn't uh
00:22:27 uh now can i just ask you about one or two other positions of responsibility uh touching on the lack of house board and the lack of house working group um if you stick with this page of your
00:22:38 um if you stick with this page of your statement and look at paragraph six please you say that you were a member of the operational directorate's coordination board the odcb chaired by the deputy commissioner rita dexter
00:22:50 the deputy commissioner rita dexter and you became a member of that in june 2012 after you were appointed to ac operational assurance in the march of that year is that that's correct
00:23:00 correct now if you look at the last three lines of paragraph six of your statement you say i outlined my involvement in the odcb at the outset because it played a key role in lfb learning and development
00:23:11 key role in lfb learning and development as a result of incidents that it and other fire services were involved in now on the basis of what you told us already would it be fair to say that that was a key responsibility of the operational assurance department
00:23:24 operational assurance department the
00:23:25 the odcb
00:23:27 odcb was very much a corporate management function which was chaired by the deputy commissioner and the
00:23:34 and the other directors sat on it as well so it was a very much a corporate board that the acoa was one key player involved in that in regard with all the
00:23:45 involved in that in regard with all the other assistant commissioners and heads of service that were relevant so it was a a very high level board and my role as acoa was to feed in in relation to operational incidents yes i
00:23:57 relation to operational incidents yes i mean you you use the expression key player for the role of the acoa on that board no no sorry that says that the odcb was a key role not that my role was key that says i am
00:24:09 not that my role was key that says i am outlined because it played a key role that odcb played the key role in operational learning and development yes it does and what i was building on was what you said about about the role of um acoa
00:24:23 of um acoa in respect of the odcb as a corporate management entity and you said that you were effectively a key player one of a number yes absolutely yes i see and i you remained a member of the odcb the
00:24:35 you remained a member of the odcb the operational directorate's coordination board
00:24:38 board upon your promotion to director of safety and assurance in december 2015. yes that's right yes did you remain a member
00:24:46 member until the odcb's final meeting of september 2016 when it was replaced by the operational professionalism board in december 2016. yes i did yes
00:24:58 december 2016. yes i did yes now both uh rita dexter and gary reason mentioned something called the commissioner's group they described that as an informal meeting of the commissioner and his three directors
00:25:09 three directors sue budden i left left out of the present discussion uh would you agree with that yes it is would you have become a member of that group on your promotion to director of
00:25:20 group on your promotion to director of safety and assurance in december 2015. yes i did you did we've also heard that a more formal but distinct group met regularly and that group was called the corporate
00:25:31 that group was called the corporate management board and you've already referred to it in your evidence or the cmb were you a member of that group yes upon promotion i became a member of that group so is this right that as
00:25:43 so is this right that as uh as of and after december 2015 as director of safety and assurance you would have had extensive uh involvement in or oversight and knowledge of the lfb's organizational workings and
00:25:55 lfb's organizational workings and priorities yes i did and he contributed to the lfb's key decisions and strategy yes i did yes
00:26:02 did yes now throughout your evidence we're going to be touching on the work of the latino house board and the latino house working group
00:26:08 group and straddling either side of the lateral housing quest in the first quarter of 2013. can i begin with the latino house board um it's right i think isn't it that that was an internal lfb board set up in july
00:26:22 was an internal lfb board set up in july 2009 to investigate the fire uh at latino house in in that year yes it was
00:26:29 it was uh and
00:26:30 uh and that was is this right to ensure that the lessons of lachenal were learnt yes yes am i right in thinking more generally that the fire at latino house with its
00:26:43 that the fire at latino house with its six fatalities was regarded at the time by the lfb as a defining incident for the brigade yes definitely and there's an opportunity to identify with precision what it could learn and improve on yes
00:26:57 what it could learn and improve on yes so just not a one can call a a a fatal incident run of the mill but if if one can not one of those no i don't i i think it would be unfair
00:27:08 no i don't i i think it would be unfair to say that we treated any incident involving a fatality or loss of life as run-of-the-mill i think that we used every one of those as an opportunity for learning because no two
00:27:19 opportunity for learning because no two operational incidents are the same and therefore it's important that we identify and learn lessons from all of those but obviously such a key incident with
00:27:27 with loss of six lives resulted
00:27:31 resulted in the coroner making recommendations is a key piece of learning for london fire brigade but would you accept that even before the coroner made those recommendations lachel was a something of a milestone a turning point yes
00:27:43 of a milestone a turning point yes definitely and the desire to learn with precision the lessons from lachenal were rooted in the event itself and not the coroner's recommendations yes and i think i believe that's the reason why
00:27:55 think i believe that's the reason why the commissioner and the corporate management board set up this internal investigation very early doors to start identifying those lessons before even the coroner's
00:28:07 those lessons before even the coroner's recommendations took place now you say in your first witness statement at page five if we can go back to it please paragraph 17
00:28:18 to it please paragraph 17 i was not involved with the board in my role as a dac say that the minutes of the board that i have reviewed indicated that i did attend a meeting on the 1st of october 2009 and then you go on to say in the first
00:28:30 and then you go on to say in the first line of paragraph 18 that you became a member of the board following your appointment to assistant commissioner in march 2012 and you attended the board's meetings as of 22nd of may
00:28:41 of may 2012.
00:28:43 2012. yes that's correct yes is it right that the board was in existence from july 2009 right through until the 30th of september 2013 when it was effectively disbanded yes
00:28:54 when it was effectively disbanded yes yes
00:28:55 yes now we've mentioned the separate latino house working group we've heard from earlier witnesses that that was a body established by the lfb's governing body the london fire and
00:29:06 governing body the london fire and emergency planning authority or el fipa and consisted of elfipa members is that right that's correct and we've also heard that that group was established in in june 2013 following
00:29:18 established in in june 2013 following the conclusion of the latino house inquest and the receipt by the brigade at the end of march of the coroner's rule 43 recommendations can you confirm that yes that's correct and can you also confirm for us that
00:29:30 and can you also confirm for us that that that board's primary purpose the lachenal house working group's purpose was to oversee the lfb's response to the rule 43 recommendations yes it
00:29:41 to the rule 43 recommendations yes it was
00:29:42 was and is it also right that although nfb officers did attend meetings to give presentations to the the lack of house working group you were not involved with it because it was ordinarily offices at director level
00:29:53 was ordinarily offices at director level and above who would attend el fiber committees that's correct now you
00:29:58 now you nonetheless would have known wouldn't you something at least of the work of the latino house working group because of your membership of the odcb after july 2013 or june 2013. yes yes
00:30:11 after july 2013 or june 2013. yes yes yes
00:30:12 yes i mean having joined it the previous year
00:30:14 year in 2012
00:30:16 in 2012 and and is it also right that you would have known something of the work of the latino house working group through your working with um
00:30:23 um gary reason ac gary reason yes that's right yes and you helped him i think with some of his reports to the lack of house working group yes yes let's then turn against that general background to
00:30:34 turn against that general background to the odcb and its general functioning processes and operational assurance input
00:30:39 input and i want to start by asking you something about how the odcb worked and your involvement in it as assistant commissioner for operational assurance or acoa as i think we
00:30:51 or acoa as i think we have seen it frequently abbreviated in the documents we know from rita dexter quite a lot about the odcb and the diat process and in summary as she explained it that
00:31:03 and in summary as she explained it that the function of the odcb was to provide essentially a forum for the two operational directorates to coordinate their activity and that one of the board's central functions was to identify risks to operational staff
00:31:15 identify risks to operational staff through the deodz process and to train them out
00:31:19 them out would you agree with that yes yes if we look at your witness statement of page two please back to page two paragraph seven you say this
00:31:31 you say this uh one of the key roles of the odcb was to consider learning points good and bad or deficiencies flagged up within the performance review of operations and performance review of command processes
00:31:42 performance review of command processes which take place following incidents involving six pumps or more and other incidents or other incidents of note rule 43 recommendations issued by coroners to fire services across the
00:31:53 coroners to fire services across the country as well as to the lfb were also discussed at the odcb and decisions were taken on training or awareness raising across the lfb that may have been required a significant aspect of my role
00:32:05 required a significant aspect of my role as acla was to gather that information for odcb to consider and take decisions on at each meeting now just focusing on that last sentence there we know that rita dexter told us how the imp or the
00:32:18 rita dexter told us how the imp or the incident monitoring process database impd and the incident monitoring six monthly reports were very central to adcb's work in respect of operational performance do
00:32:30 in respect of operational performance do you agree with that basic description yes definitely having shown you that let's look at paragraph 10 on page 3 of your first witness statement here and you say in the third line
00:32:42 the third line observations can you see it says observations on impd are analyzed on a quarterly basis and incorporated into a report to the odcb now is that the incident monitoring
00:32:54 now is that the incident monitoring report
00:32:55 report yes it is and that is it right then became six monthly rather than quarterly
00:33:02 i think it was reported six months at odcb there was a change but i do believe to my recollection that i was concerned that we would potentially lose the opportunity to
00:33:14 potentially lose the opportunity to identify
00:33:16 identify matters
00:33:18 matters that might be occurring in that six month period so it was then agreed that the information said the full list of uh impd matters would be shared with the
00:33:29 impd matters would be shared with the deputy commissioner i think it was outside of the meeting so that it there was a sort of a check on what was going on because i think
00:33:37 i think my concern was that six monthly was quite a long gap and things could occur in a six month period that you wouldn't wish to start not start addressing um because there hadn't been information shared with the meeting right
00:33:48 shared with the meeting right we've got a picture from rita dexter's evidence that it was in 2013 when it went down from quarterly to six monthly but then went back up back up again more frequently to something like three times
00:33:59 frequently to something like three times a year or something like that can you help us
00:34:03 help us um i can't recall the reason why it changed i do recall my concern about not having the information i think there was
00:34:11 was there was a view by some people that coarsely wasn't sufficient to give you a real taste of uh what was going on that it was such a short period of time you
00:34:22 was such a short period of time you might not see trends that you could readily identify my concern was that you know one or two occasions of something occurring might be enough of a trend for me to want to flag it to you
00:34:35 trend for me to want to flag it to you know prevent it happening again so i think there was a kind of twoing and throwing of opinion about whether or not it was a substantive period of time to identify trends in right do you remember a time when it became more frequently
00:34:47 a time when it became more frequently than six months um i'm sure it went back to quarterly um because the odcb meetings were more frequently in six months so i think that even if we had not shared the formal report then i
00:34:58 not shared the formal report then i would have the opportunity to raise any concerns i had about trends and information and do you remember when it went back to call to me no i'm sorry i don't recall let's look at an example lfb
00:35:09 lfb 3067840 please
00:35:13 this is an incident monitoring six monthly report this one is for september 2014
00:35:19 2014 and the meeting is the operational directorate's coordination board or odcb it's a report by dac graham ellis of operational assurance and it's a gender item number two for
00:35:30 and it's a gender item number two for that meeting uh i think dac ellis reported directly to you as you told us he did at that time
00:35:37 time now is it also right that dac graham ellis was head of the incident management policy group i think you've said that
00:35:42 said that yes um
00:35:44 yes um were you involved in in any way in the drafting of these six monthly reports no not the drafting i would be shown effectively a final draft um before it was submitted but it was a
00:35:55 was submitted but it was a responsibility of ellis and his team along with dr adrian bevin from the health and safety department to collate this information now you've said in your statement at
00:36:06 now you've said in your statement at paragraph seven which we've seen that a significant aspect of your role as acoa was to gather the information for the odcb to consider and then take decisions on if that's the case um what can you just
00:36:17 if that's the case um what can you just tell us how that fed into your role in the production of this report yeah so i had um like it sorry i'm i had uh both dac graham ellis and dr adrian bevin
00:36:28 dac graham ellis and dr adrian bevin both highly qualified members of my team who worked for me who were the ones who were responsible for the day-to-day administration of the two teams and they would collect this information but this
00:36:41 collect this information but this wouldn't be nothing in here would be a surprise to me because we would have regular meetings and where there were concerns about incidents either coming up as a result of a safety event or an
00:36:53 result of a safety event or an occurrence on the fire ground then i would be made aware of it at the time so this was the more formal reporting process
00:37:01 process that then allowed us to share that information with odcb can we assume that you read or habitually read reports like this before they were submitted to the odcb yes yes
00:37:12 they were submitted to the odcb yes yes looking at the summary section it says this this report for the september 2014 operational directorates coordination board odcb outlines operational performance trends individual team and
00:37:24 performance trends individual team and organizational for the reporting periods of quarter 4 2013 to 14 and quarter 1 2014 to 15 and then in brackets first of january 2014 to 30th of june 2014.
00:37:39 2014 to 30th of june 2014. so just on that it looks like the the reporting year runs march to march is that right yes that's right yes i see so this is a six monthly report identifying trends from
00:37:51 monthly report identifying trends from two contiguous quarters to sequential quarters yes that's right yeah and
00:37:57 and it sets out the source uh but just below that of the uh
00:38:03 uh of the trends identified utilizing data and information from the following sources and then there is a list of bullet points there and you can see those are those all the diot sources
00:38:14 see those are those all the diot sources no these are a far wider range of sources
00:38:18 sources these could have come in from especially things like the accident investigations and the safety event database which health and safety maintained these were although they contained some of the
00:38:30 although they contained some of the aspects of the deal this was a much wider ranging group of information that could be used to actually form this information and also in there could be information if
00:38:41 in there could be information if anything came in from external sources to so national fire service issues as it were right you they're not all dr sources as you've explained some of them are are they not there yes some of them are so the first
00:38:53 there yes some of them are so the first one
00:38:54 one yes yes and also the second one i think yes
00:38:57 yes uh
00:39:00 lisa dexter told us that it was your department's responsibility at that time to consider these sources of information and distill what you considered to be relevant into this six monthly report
00:39:11 this six monthly report uh first did she write about that yes yes and secondly does that mean that you had almost complete control uh or at least complete oversight uh over what issues went to the odcb
00:39:22 over what issues went to the odcb for consideration so far as incident monitoring was concerned um yes but in line with that we also um at our regular departmental meetings
00:39:34 at our regular departmental meetings with um gary reason at the time would discuss any of those issues because the relevant other heads from operational procedures and training would be in that department so it would be although the work would
00:39:47 so it would be although the work would come through my department it would be a result of more informed conversations with colleagues as well i see now look look at page two of this report please if you can we can see a
00:39:58 report please if you can we can see a list of proposed articles uh for the upcoming edition of operational news 28. can you see that yes i can and um it says the following list identifies
00:40:09 it says the following list identifies subject areas which odcb may wish to consider as the basis for articles in operational news 28 the subject areas have been identified following the guidance agreed in the paper identifying
00:40:21 guidance agreed in the paper identifying and prioritizing operational news features agreed by odcb in december 2012.
00:40:28 we'll come on back to this in a moment but we heard from rita dexter that the operational news newsletter was the odcb's primary output and its main way of updating firefighters and influencing their
00:40:39 firefighters and influencing their operational performance that's what she told us on day 178 is do you agree with that yes
00:40:46 that yes um did your department draw this list of proposed articles from its analysis and interpretation of the
00:40:55 the diode sources and others yes with in conjunction i said with other professional colleagues who would
00:41:01 who would raise concerns with us and suggest areas that we might want to include so it wasn't um it was something that was done very much as a sort of organizational overview with professional colleagues
00:41:12 professional colleagues did those other colleagues include anybody in the fire safety department yes they would have done so for instance fire investigation team worked directly to the fire safety department um and
00:41:24 to the fire safety department um and they obviously were standing members of odcb was the assistant commissioner for fire safety
00:41:32 i see
00:41:35 uh what was your method
00:41:40 method very
00:41:41 very basically if you can identify for us of going about identifying proposed articles
00:41:47 articles from the date from the data you had so it would be a process of looking at the instant management reports and ascertaining whether there were any trends
00:41:58 trends from people reporting either under performance failures of equipment or anything else so
00:42:06 so it wouldn't necessarily have to be you know large numbers of reporting on that because two or three incidents i said might be leading to a trend that was growing it would also be from
00:42:17 growing it would also be from other sources so for instance the one there highlighted on the screen talks about fire investigation issue of removing samples from the fire ground that would been directly fed into
00:42:28 ground that would been directly fed into us from the fire investigation team so it would it would be a wide range of looking across the piece of all the information and then coming up with a broad list that we considered
00:42:40 broad list that we considered would be relevant for conversations at odcb and not all of those items would be taken forward because it would then be a conversation amongst colleagues odcb to choose the priorities
00:42:51 choose the priorities yes um but the feeding in from that comes came in part at least from you was it your responsibility therefore to identify areas of the lfb's um performance on the fire ground that
00:43:03 um performance on the fire ground that required improvement yes very much through the operational review team and then in through the instant management team yes indeed one could say that that was the very essence of your department
00:43:14 was the very essence of your department yes along with um i wouldn't like to underestimate or underplay the significant role the health and safety team played in that as well because that was the sort of the role on so the instance on the fire ground and
00:43:25 instance on the fire ground and identifying any potential areas under performance would then roll on into where
00:43:31 where issues had occurred and accidents had happened and firefight has been injured which would then be investigated by the health and safety team and would equally identify areas of underperformance that have potentially led to that event
00:43:42 have potentially led to that event happening certainly now if we go to page five of this report please
00:43:48 please you will see a heading impd trend analysis reports quarter four and quarter one january 14 to june 14. introduction the impd performance
00:43:59 introduction the impd performance information in the following data sets and narratives continue to suggest a growing positive improvement in the use of the system the number of entries have again risen as is the quality and the number of positive
00:44:11 the quality and the number of positive comments
00:44:12 comments and then you can see the data um set out
00:44:18 set out graphically below that on the page um it's right isn't it that ultimately the impd's take-up was poor it wasn't as um well-used as we would have liked um yes
00:44:29 well-used as we would have liked um yes that was an ongoing frustration we had yes and we can see that in fact can't we from the gray pie chart below the introductory text which says that out of 47 105 incidents attended by the lfb one
00:44:42 47 105 incidents attended by the lfb one or more imp reports were made in 1679 cases some four percent of the overall number of incidents attended would you agree with that yes and would you agree that four percent of incidents
00:44:53 you agree that four percent of incidents is a very weak foundation on which to base decisions about the organization's operational performance and training needs
00:44:59 needs i think that it's also useful to reflect that um for the vast majority of operational incidents attended by london fire brigade there would be no need to generate an imp report because they were
00:45:10 generate an imp report because they were only generated on large scale incidents or something where there was a significant operational needs so for the vast majority of ordinary incidents there was
00:45:22 majority of ordinary incidents there was no requirement for an imp to be generated and therefore we wouldn't expect to see one unless there had been something that had occurred to attract an incident so yes it was low but actually i think it
00:45:33 yes it was low but actually i think it doesn't accurately affect how many of those operational and i think that's a failing having gone back and looked at it in preparation for this that it doesn't identify what we should have done which was how many of those incidents should have attracted an imp
00:45:45 incidents should have attracted an imp database entry which would have been considerably lower than 96 percent that exactly uh and that that's the point isn't it 96 is a very large maybe vast
00:45:55 vast but so also would be 65 and the difference between four percent and um yes 35 would have been helpful yes definitely um we heard also from dr sabrina cohen hatton who gave evidence
00:46:07 sabrina cohen hatton who gave evidence some weeks ago that an imp point uh also known as a development point i think
00:46:15 think would be reflected in a personal development plan or of course a pdp dr cohn hatton also told us on day 184 that the inp points the imp
00:46:27 on day 184 that the inp points the imp process and the pdps were cedars she put it punitive would you agree with that i think that it's important to understand the context of a large majority of inp
00:46:40 a large majority of inp points were not attributed necessarily to individuals because they could be attributed to either a team so directly to a whole watch that attended incident or as a result of an organizational or
00:46:52 or as a result of an organizational or equipment failure the individual points were those attributed as the result of predominantly the performance review of command which i think she probably explained to you which ways following
00:47:03 explained to you which ways following every significant operational incident a meeting was held independently chaired where the performance of all of the incident commanders was analyzed and that was what would often result in the
00:47:14 what would often result in the individual learning points and yes there was a perception that they were viewed negatively because i suppose the context in which to set this is that
00:47:26 this is that firefighters and officers are incredibly professional and they're i you know they only ever want to be seen as doing their job exceptionally well so i think any
00:47:37 exceptionally well so i think any criticism leveled at them was always hard to swallow i think people found criticism of operational performance incredibly difficult so we did do quite a bit of work to try and explain to people that it wasn't punitive and it
00:47:50 people that it wasn't punitive and it was a process to assist people with learning and development in order to not repeat the same issues again yes
00:47:59 yes now dr conhatton also told us that in the late summer of 2016 when you were a coa she conducted a review of personal development plans that's for those who
00:48:10 development plans that's for those who want to look it up it's a day eight 184 page 205 line 14. um
00:48:15 um uh do you recall her doing that first yes i do and before that review were you aware of the negative perception of imp points that you've just described oh very much so yes
00:48:27 very much so yes and do you agree that the perception of inp points is negative in the way you've described it and punitive in the way she's described it it was likely to have accounted for the low take-up of the impd
00:48:38 the low take-up of the impd as we've seen on the screen no no that wasn't um that wasn't the way the impd worked so the impd uh work that following any operational incident any
00:48:48 any fire ground officer could make an entry on the impd the ones that she's specifically referring to quite rightly are the ones following the performance review of command which
00:48:59 performance review of command which wasn't about the individuals themselves making those um judgments that was about the performance review of command and the ort
00:49:08 the ort recording those so they the the reason the people not putting entry on there was not to do the negative connotation because it would be unlikely i would suggest that an individual would enter themselves a
00:49:19 individual would enter themselves a negative comment but that would be more the reflection of the operational review team who attended the fire ground or for any other officers to be able so to
00:49:31 for any other officers to be able so to give an example to try and clarify sound i know i'll try to explain it sounds terribly complicated so if you were to attend an operational incident as a frontline
00:49:40 frontline firefighter or crew or watch manager and at that incident you were concerned because you thought that potentially something hadn't happened that you
00:49:51 something hadn't happened that you thought should have happened whether it was to do the water supply piece of equipment or another crew you could come back and make an entry on the database people didn't do that very often but the entries that were made
00:50:03 but the entries that were made individually to people following the performance rule of command weren't a choice they were something that happened as a function of the plc do you see any connection at all therefore between the low take-up
00:50:16 therefore between the low take-up of the impd and and the figures that we can see
00:50:19 can see on the screen and the negative perception or negative comment connotations among nfb staff about um
00:50:29 about um criticism no not really because it was a different mechanism that put those points on there i think for me the part of the incident of the load take up is i'll say the fact that it wasn't reflected very well
00:50:40 reflected very well at all in
00:50:42 at all in what instance should be on there but um and part of that i think was to do with somewhat maybe um you know and lack of understanding amongst crews about the importance of
00:50:54 amongst crews about the importance of entering information when they came back from incidents because i think sometimes
00:51:00 sometimes crews would go to an incident something minor would happen they wouldn't understand that that could actually have a reflection across the whole london fire brigade so that if they'd had an incident where they'd had a water failure or something it might have happened 20 other times
00:51:13 happened 20 other times and if they took the time to put that entry on there we would see that trend and so the the individual points the negative connotation i think was far more around the performance review of command i see did you or your department
00:51:24 command i see did you or your department try to do anything to improve these figures or figures such as these yes continuously it was one of the frustrations that we had and graham ellis and his team worked very hard to try and communicate
00:51:36 worked very hard to try and communicate via various methods including through operational news about the importance of people entering points where there was the need to so that would mean where there was
00:51:47 that would mean where there was something identified that could be an issue
00:51:52 and you say that he he uh
00:51:55 uh communicated via various methods including operational news what were those methods so
00:52:02 so i think that potentially it's come up before there were things where all the borough commanders came in for training sessions uh the sessions that dave brown ran when he was assistant commissioner
00:52:13 assistant commissioner we would have a regular uh slot to go and talk to the borough commanders and to share those concerns with them they would then disseminate that information through their station commanders to the fire stations
00:52:27 commanders to the fire stations we would also use sort of the opportunities from the operational review team if they were out on the fire ground so any method we can to try and promote
00:52:35 promote uh the use of the database for sharing of information to identify trends did it really work though no why not frustratingly a number of reasons i think i think that
00:52:47 a number of reasons i think i think that so there was the issue about um potentially frontline personnel not understanding significance um i think that
00:52:55 that it was
00:52:56 it was you know the i think that it worked to a certain extent where we managed to said here we've got an encouraging entries number of risen so i think when we had a push on it you'd get a rise of entries and
00:53:08 on it you'd get a rise of entries and then it would tail off again and then we would have another push but it was never as satisfactory as it could be right why would why are frontline personnel not understanding the significance of reporting
00:53:18 reporting uh given given the efforts that dac alice was making i think past the reason and i was sure we saw this as well with the other method of identifying issues which was
00:53:29 method of identifying issues which was the near-miss database so the two of them were hand-in-hand that we found we had very low reporting on near-misses near-misses are also a significant key
00:53:40 near-misses are also a significant key indicator of the potential for things to be going wrong we were trying to promote the both near misses and entries on here would be something that could identify issues that might well lead to a
00:53:52 issues that might well lead to a significant issue in the future that might involve them but i think people still feel failed to make that correlation does it mean i would say it is it does the poor take-up of the impd
00:54:03 the poor take-up of the impd as exemplified by this slide mean that the odcb was only ever receiving a very small part of the operational picture no and definitely not this was only a part of the jigsaw so the other part of
00:54:15 part of the jigsaw so the other part of the jigsaw was the verbal report that graham ellis brought from his team the
00:54:22 the operational review team met once a week on wednesday mornings and there they would have a two three hour meeting to talk about all of the operational incidents they'd attended in the previous week um dac ellis would share
00:54:34 previous week um dac ellis would share that so he would be very much aware of the conversations around uh you know what had happened what was going on what what potential areas of concern there were and he would use that to feed into the odcb as well yes i
00:54:46 to feed into the odcb as well yes i understand that but if one's looking at it statistically i wanted to go back over an objectively identifiable set of records but do you accept that if if all one had to go on was this document and
00:54:57 one had to go on was this document and that would mean that the odcb was receiving only a small part of the operational picture precisely because there were so many incidents that
00:55:05 that had just not fed through into the figures
00:55:07 figures so i think that if that was all you were looking at yes but that wasn't all they were looking at and the vast majority of the operational incidents attended daily by london fire brigade uh there were no issues and they would not require those
00:55:19 issues and they would not require those entries
00:55:20 entries can we look at met 307 8859 please
00:55:28 this is a witness statement from julian spooner who was a firefighter dated the 19th of october 2020 that he gave to the metropolitan police uh and he explains in his statement that
00:55:39 uh and he explains in his statement that he was in fact as of october 2020 a group manager within the incident command policy department do you remember him i do yes now if we go to page four of his statement
00:55:50 page four of his statement if you look at the page and look at the fourth paragraph down he explains uh the operation he explains operational uh news there and at the very foot of the page if you
00:56:02 and at the very foot of the page if you go to that we scroll down to the foot of the page he says this prior to the introduction of oip
00:56:09 of oip the organization would probably only have had information drawn from our information management system ims ims has a lot of positive points but it is only as good as the information
00:56:20 is only as good as the information people put into it if shepard's court wasn't entered multiple times to make it a trend as the organization looked at trends and not individual incidents necessarily then the information wouldn't have been identified
00:56:33 wouldn't have been identified do you agree that the diat process was too heavily focused on operational trends and was therefore susceptible uh to missing a serious learning point from
00:56:44 to missing a serious learning point from a one-off incident or event no definitely not um i know that for significant one-off events um they would have been the subject of a specific conversation at odcb
00:56:55 specific conversation at odcb and actually i think in and do my preparation for this um i read specifically in one of the papers that conversation had been had with the deputy commissioner about the fact that just because there was only
00:57:07 fact that just because there was only potentially one entry it didn't mean that wasn't a significant learning event so no i think that the the way that the organizational learning was shared was far wider than just looking at the
00:57:19 was far wider than just looking at the data trend from that so you don't agree with what mr spooner says here no i don't and you let me say that we're clear you don't agree with it because individual
00:57:30 don't agree with it because individual incidents
00:57:33 if significant would have been the subject of discussion at odcb meetings they definitely were because i attended all of those odcb meetings at this point um i'll say julian spooner came to work
00:57:45 um i'll say julian spooner came to work in department much later but um he would not have been familiar with what had happened at previous meetings and the conversations we've had now of course
00:57:54 course uh the
00:57:55 uh the um the diop process is what was heavily documented this discussion at odcb meetings would have been much less formal is that correct it would have
00:58:07 formal is that correct it would have been a minute it was a minute meeting so the conversations around individual issues would have formed part of the minutes of the meeting right and but when working out
00:58:18 working out what
00:58:19 what to train on through the operational news process or what priorities to give to competing operational news articles for the purposes of purposes of training
00:58:30 for the purposes of purposes of training were those minutes
00:58:33 minutes which would record discussion about one-off incidents used
00:58:38 used oh yes very much so well you say that was there a process by which uh
00:58:44 uh those deciding on training and priorities of training for operational news processes would look at all the data including discussion and input from your team about operational incidents
00:58:55 your team about operational incidents which were significant yes so what would happen would be that uh the deputy assistant commissioner graham ellis would present the information and we would then have a in-depth
00:59:06 and we would then have a in-depth discussion involving all of the relevant heads of department and bearing in mind that normally if there had been a significant incident the operational officer attended would quite regularly be at the odcb meeting
00:59:18 quite regularly be at the odcb meeting because all of the assistant commissioners were there so then the relevant information would be fed in so that would be a professional discussion around the issues
00:59:28 issues and any items of concern from that given what you told us about the low take-up
00:59:35 take-up as we've seen from the graphics and your continued frustration uh
00:59:39 uh about that at station level uh did you ever take any steps to look outside the brigade for any operational uh information learning system so that you could assure yourself
00:59:50 could assure yourself that what you were telling odcb was robust and reliable so as part of my role
00:59:58 my role we would
00:59:59 we would do outward horizon scanning of other fire and rescue services and the information they shared we would
01:00:06 we would take the opportunity so obviously there was the um before there was the national fire chiefs council there was the chief fire officers association and they had an operational board that sat and that
01:00:17 an operational board that sat and that would be used to collate information about operational issues nationwide that information would be fed back in the commissioner ron dobson sat
01:00:28 back in the commissioner ron dobson sat on that board so he would then bring information back in about the wider national operational arena
01:00:34 arena i don't think well correct me if i'm wrong
01:00:36 wrong that we see the results of that outward horizon scanning as you call it in any of the incident monitoring six monthly reports that would only
01:00:47 that would only feature in there if a specific area had been identified but it could be subject to part of a conversation but no you don't regularly see it as part of the minutes of the meeting
01:00:59 minutes of the meeting i do
01:01:00 i do think genuinely when i look back that information sharing nationally was generally poor i don't think there was as much sharing of operational learning as there
01:01:12 sharing of operational learning as there should have been or could have been what about international incidents did your out with horizon scanning uh ever capture those and feed those back to the odcb
01:01:23 to the odcb as a potential training point so internationally so dac graham ellis used to monitor
01:01:34 through an international forum some of the operational incidents that were occurring
01:01:39 occurring he was very interested in seeing what was happening and sometimes they would be the subject of a conversation but i have to say predominantly with the
01:01:50 but i have to say predominantly with the view of thank goodness that could never happen in the united kingdom because we have different regulations so although he would share informations about fires overseas
01:02:01 overseas the conversation would predominately i remember always be around thank goodness that could not be us really
01:02:07 us really um
01:02:08 um now just to tell you we'll put to you what has been said previously rita dexter told us that the first safety department and the odcb did not conduct research into international fires but she asked you as
01:02:20 international fires but she asked you as acoa
01:02:22 acoa considering whether um they were having the regard to the best available range of information or whether there was more that could be taken into account when learning from do you agree with that that she tasked
01:02:33 do you agree with that that she tasked you with that she had a conversation we had more than one conversation um about [Music]
01:02:40 [Music] rita's phrase was quite regularly i don't know what i don't know which meant that she wanted people to try and keep her informed of what was going on
01:02:48 going on generally across the fire service and she was always keen to understand organizational improvements so we did have conversations around and feed those in and i know that
01:03:00 feed those in and i know that dic graeme ellis would regularly share links with her as well where he'd seen incidents occurring overseas because she was very interested in the operational arena but i'm writing saying that you
01:03:12 arena but i'm writing saying that you never carried out a task whereby you set in place a process for gathering uh information about uh overseas fires analyzing them and then feeding them
01:03:23 analyzing them and then feeding them back to for example the odcb or other directorates no that was the role of the chief fire officers association they had an international function that required them to look across the piece and we
01:03:35 them to look across the piece and we would expect them obviously as a large reaching organisation to do that for the uk fire service otherwise opposite meant 43 individual fire and rescue services would have to conduct that piece of work but we did
01:03:47 conduct that piece of work but we did have an interested eye in um issues that were occurring overseas because
01:03:53 because it's a natural inquiring mind to the fire service to if you see an incident um this morning for instance there was a terrible fire in bulgaria that involved people on a bus and that would be the
01:04:04 people on a bus and that would be the sort of thing that we would then subsequently have a professional conversation around how that could have occurred yes i see and so far as ac gary reason is concerned he told us that there weren't any processes or procedures in place for
01:04:16 any processes or procedures in place for learning from international events but the you the brigade relied on government departments and the cfoa to provide guidance on international incidents he said that at day one eight two page one a one lines eight to
01:04:28 two page one a one lines eight to seventeen that's for our reference do you agree with him absolutely it was definitely the role of the national fire chiefs or cfa as it was and the government to liaise and provide that information to all of the uk fire
01:04:39 information to all of the uk fire service
01:04:41 service and
01:04:42 and turning to the question of other risk critical industries uh gary reason also told us day 182 page 103 lines 1-15 that the lfb did not seek to learn
01:04:54 that the lfb did not seek to learn from other risk critical industries in the uk
01:04:57 the uk because as he put it you probably wouldn't have the capacity even if he wanted to
01:05:02 wanted to and what it wasn't something that the lfb ever considered during his time that's what he told us can you confirm that from your knowledge i would definitely agree with him that
01:05:13 i would definitely agree with him that um unfortunately we wouldn't have had the resources i said the incident management team itself was a very small team um
01:05:20 team um and were kept kind of quite busy with day-to-day lfb functions um with with hindsight as with always it would have been interesting and useful to have been able to do that piece of work but uh with the
01:05:32 to do that piece of work but uh with the amount of resource we had at the time just not practical so does it follow from that
01:05:37 from that uh
01:05:38 uh and the discussion we've just had that the only
01:05:40 the only way of monitoring operational information and learning and ensuring that it was robust and reliable was in essence by looking within the lfb itself and to some extent horizon scanning for
01:05:53 and to some extent horizon scanning for what other fire and rescue services were doing subject to the limitations you've described yes yes now of the impd trends and issues that were proposed for operational news articles in the incident monitoring six
01:06:05 articles in the incident monitoring six monthly reports is it right that only half roughly half were actually chosen by the odcb
01:06:14 odcb for the newsletter yes probably half to two-thirds mainly i suppose it would depend on how many issues we presented in the paper um to be considered um and then mainly maybe
01:06:26 be considered um and then mainly maybe four or five would be taken forward for the operational news publication let's look at the lfb's diat policy uh
01:06:35 uh and that is at lfb uh triple zero five five one seven one please i'll just show you the first page of that document uh dealt dynamic and intelligent operational training
01:06:47 operational training that's what it stands for and this is the process this is the policy 825 april 2013 as you can see and if we go to please to page 7 paragraph 3.27 it says this
01:06:59 it says this the odcb report summarizes the information described in section three and identifies the eight most prominent subjects as well as any other significant trends to be included as articles within operational news
01:07:11 articles within operational news at six monthly intervals i.e the march and september odcb meetings four or five operational themes are prioritized for inclusion within operational news based on performance and say safety event data on a risk
01:07:23 and say safety event data on a risk assessed basis these themes become the priority for targeted training activity and from the content of the communications message to operational staff
01:07:32 staff now in your time how did the odcb select which four or five operational themes to use the words of the policy would be included within the operational news newsletter
01:07:44 the operational news newsletter so they would look at the recommendations that had been made
01:07:48 been made there would then be a professional conversation and discussion amongst the colleagues who were part of the odcb they would ask questions
01:08:00 they would ask questions around the specific issues that were being suggested so for instance you know if it was it may only have been say two or three reports of something and then the deputy commissioner would ask why that area had
01:08:12 commissioner would ask why that area had been recommended and we would have a conversation around what we consider the risks to be including the other professional colleagues from different departments and then a judgment will be made on what would consider to be the priority issues
01:08:25 would consider to be the priority issues to be raised and therefore to be subject to matters in operational news now you say half to two-thirds were selected of the other half or rather one-third of the themes
01:08:37 half or rather one-third of the themes in other words those not chosen for the newsletter how did your department look to ensure that operational performance in those areas was improved nonetheless so depending on the nature of the
01:08:49 so depending on the nature of the issue that was being raised there would be a number of different ways so whether that was sharing information through the operational arena so through dave brown and out to the fire station so we there
01:09:01 and out to the fire station so we there would be no issue with being able to share that information whether it was formal conversations with colleagues in different departments so if i gave an example of something
01:09:13 example of something we had a number of issues of relating to people using certain emollient creams that were soaking into bedding for people who are bed bound and
01:09:25 bedding for people who are bed bound and then they were catching fire that would then be a conversation that we would have with teams in the community safety department so that they could then share that awareness with their community safety teams when they were going out into the wider community and they would
01:09:37 into the wider community and they would share it with health professionals so that information could be given say these are the risks and the risks to members of the public so it depended on what the nature of the risk was as to who how the
01:09:49 the risk was as to who how the information could be shared but we would seek to try and make sure sometimes it was a case where it would be deferred to the next operational news where they would want further information to be gathered or see whether or not there
01:10:00 gathered or see whether or not there were any other issues that arose during the six month period as to whether they would then choose that as a next ops news article yes i can understand that there may of course be candidates that were deferred for the next operational
01:10:12 were deferred for the next operational newsletter but i'm really interested in those which had fallen by the wayside so to speak you you say um the information about this was shared and there was awareness
01:10:23 and there was awareness that's not the same as training there is it no not at all no not at all uh and therefore that was there not a risk a real risk uh that half to two-thirds of the
01:10:33 the of the trends that had emerged and come up for operational news as candidates for training uh didn't get trained and was subject therefore to a much more diffuse much woolier
01:10:44 woolier approach namely relying on the individual station managers to raise awareness so i would say that if that something was considered to be that high risk then it would have
01:10:55 that high risk then it would have featured as part of a ops news article and although there were the main articles in ops news there were smaller pieces of information shared as well so it wasn't just those four or five key
01:11:06 it wasn't just those four or five key items
01:11:08 items and if it was something that was to provide a significant risk then we would be very uh forward in our approach of saying that we wanted to be included um
01:11:19 that we wanted to be included um sometimes there would be things that were
01:11:22 were less of a risk to the organization and you know the ideally you'd train on absolutely everything and you'd have a whole booklet of ops news but it had to
01:11:33 whole booklet of ops news but it had to be done certain ways but prioritize articles that we're going to then receive training on
01:11:39 on i don't think that you know some of the i would not have been um in a position to allow something that i consider to be a significant risk to just be dropped off the radar
01:11:50 just be dropped off the radar you say that uh you were one voice at the odcb how would you have stopped it well by sharing my concerns with professional colleagues and having that raised i think that you know that one voice can be heard in a
01:12:01 voice can be heard in a group setting if you share your concerns out and identify risks that then other operational colleagues will understand that and you know the conversation and i would also be able to talk to my uh
01:12:12 would also be able to talk to my uh direct boss gary reason about my concerns um and that he would also have an influence in that voice as well so does this help me with the process here the ui your
01:12:23 with the process here the ui your department effectively identifies through the diode process and other processes as well as we've seen
01:12:30 seen what uh themes should be the subject of training and you put those up to the odcb for its final decision at the stage where you're at making that
01:12:41 at the stage where you're at making that decision about what should be included in your list do you do a a risk assessment so as to work out what risk level each theme presents so that you end up with a
01:12:53 theme presents so that you end up with a list of must-haves uh can lose uh debatable or or some sort of system whereby you can grade
01:13:04 grade these trainings by risk so i think that was the purpose of odcb would be to conduct that risk assessment as a meeting and as a board to consider the risks and i just want to
01:13:15 to consider the risks and i just want to be clear that because um an item wasn't subject to an operational news article didn't mean that there weren't training interventions taking place what the ops news article did was to
01:13:27 what the ops news article did was to highlight specific areas that had been that had occurred and not all of those were
01:13:34 were um
01:13:35 um situations that were providing risks to firefighters so as you would have seen the article that was mentioned about fire investigation about removals of samples from the fire ground that was as part of you know a process
01:13:47 that was as part of you know a process where investigation would happen to cause the fires so that was an awareness raising to crews but the things that were key aspects of training were all subject in their own right to individual training packages
01:13:59 right to individual training packages that would be being undertaken by fire station crews as part of their ongoing training on a daily basis so it wasn't things that were just being slipped through the net and forgotten the odcb highlighted areas and then put
01:14:11 the odcb highlighted areas and then put training packages together to reflect those areas or highlight the training packages that were already in place
01:14:23 can we go to your witness statement please page 4 paragraph 13. and you tell us in the final three lines there what happens once the
01:14:34 there what happens once the half or two thirds of articles are selected for inclusion in operational news you say this once a decision
01:14:41 decision had been made my team then had responsibility for collating the text for the articles from other departments this work was undertaken by dac ellis so is it right that the actual writing
01:14:52 so is it right that the actual writing of the articles was the responsibility of others yes it was and the incident management policy group would identify subject matter experts or smes inevitably yes yes that's correct
01:15:04 smes inevitably yes yes that's correct did your department play any role in drafting the articles they would only draft articles if um they were ones for anything that was owned by instant management apart from that they would um
01:15:16 that they would um ask for the article to be drafted by the person who had the expertise in that so whether it would be policy operational policy fire safety or whoever the team was that was relevant right
01:15:27 right did your department check uh the those for which you were responsible i think incident management for efficacy and accuracy those are responsible absolutely yes i see so your department to that
01:15:40 yes i see so your department to that extent uh and even your director gary reason i think had a role in considering the content of those articles at least yes yes mr german is this an appropriate moment for the break we're moving sub-topic
01:15:52 sub-topic yes i think it is thank you very much well it's time we had a break for the morning um we'll stop now we'll resume please at how fast 11 and i shall say this to you every time you leave the room but as you probably
01:16:03 you leave the room but as you probably remember from previous occasions please don't talk to anyone about your evidence while you're out of the room thank you sir thank you very much indeed
01:16:21 thank you mr millet half off
01:31:55 would you ask this cotton to come back in please okay
01:32:08 all right this cotton ready to carry on yes sir thank you very much yes yes mr chairman thank you i'd like to ask you now about training associated with operational news we've seen that some operational news articles were
01:32:19 operational news articles were accompanied by computer-based training or cbt packages that were created by babcock
01:32:25 babcock and indeed rita dexter told us that the odcb would make the final decision about whether or not an article was which was to be accompanied by a cbt package do you agree with that yes yeah and peter
01:32:36 you agree with that yes yeah and peter graves and gary reason also told us that that developing training packages with babcock was seen as as cumbersome and resource and time intensive process would you agree with that characterization yes i do and i think in
01:32:48 characterization yes i do and i think in your second statement if we look at your second statement please page 11. paragraph 53 you say amendments to training therefore had to be considered fully
01:32:57 fully and the proper process undertaken before lfb training would change and this could take some time the privatization of the lfb's training under the contract with babcock created inefficiencies within the lfb's training
01:33:09 inefficiencies within the lfb's training program particularly in terms of implementing changes to training babcock attended cmbs approximately eight every approximately every six months to discuss training i understand that ac
01:33:20 discuss training i understand that ac ellis is considering the challenges faced under the babcock contract in his witness statement did the fact that the privatization of nfb's training under the contract with babcock
01:33:31 babcock created inefficiencies within the nfp's training program dissuade you or the odcb more generally from suggesting or producing as many operational news training packages as you would have liked
01:33:43 liked i think that it was a consideration as to what we recommended for training because we were aware of the length of time
01:33:52 time it could take to produce a training package
01:33:55 package and i think that that wouldn't have affected the necessary the choice of article
01:34:01 article because there were other aspects of training that were already on the system that we could refer to for crews to take part in as to assist them but development of new training packages
01:34:12 but development of new training packages was indeed a cumbersome process right and
01:34:16 right and did that fact dissuade you or the odcb from
01:34:21 from on occasions suggesting or producing a particular operational news training package no i don't think it dissuaded us i think it was just the recognition that the length of time it would take to actually produce that training package
01:34:34 actually produce that training package was it a factor was that cumbersome process a factor in the
01:34:40 in the the figures for out turn in other words the half to one to two thirds that you described earlier no not at all so we wouldn't we wouldn't be dissuaded from having an ops news article on something that we
01:34:52 ops news article on something that we considered to be a key issue because of the
01:34:56 the length of time it would take to produce a training package because there would be other
01:35:01 be other training on the system that we could refer to in the meantime for crews to familiarize themselves with i'm sorry to introduce can you just help me understand this operational news
01:35:12 operational news uh was published in the form of a leaflet was it yes a pamphlet apparently and was there a limit on the length of the pamphlet no ideally i think for some reason and i'm not sure about why this decided it
01:35:24 i'm not sure about why this decided it was generally approximately eight pages long but on occasions there were uh ops news specials where we featured something in particular that could have been longer or shorter but it was
01:35:35 been longer or shorter but it was generally held between eight and ten pages i believe right so you didn't have um
01:35:42 um a physical limitation on the amount of space available the number of pages was flexible yes it was so but obviously you don't want it to get too large because it becomes too expensive to produce
01:35:53 it becomes too expensive to produce and also i think it was around the aspects of focusing crews attention to specific articles and if there were too many
01:36:01 many you might lose the focus of what was a priority yes now you've described it as a form of training i had understood that it was its purpose was principally to bring crews attention to
01:36:14 principally to bring crews attention to things that you wanted them to be aware of i mean you referred to the removal of materials from the fire ground
01:36:22 ground um
01:36:23 um was it regarded as a training tool or an informing tool if you can see the difference yes i can it was very much
01:36:32 much an information piece but with training attached to it so the the news articles would be contained within operational news the back page then had the links to the relevant
01:36:43 then had the links to the relevant training that would assist crews in understanding what the information was so there would be a complete back page and that training would be ranked red amber and green for whether
01:36:55 ranked red amber and green for whether or not it was something that was an absolute priority they had to do and then obviously amber known to green which was more information pieces and those would be computerized links would they they'd be computerized links and
01:37:07 they they'd be computerized links and yes and those would be then uploaded to the individuals training records that's very helpful thank you very much sorry coming back to paragraph 53 um did the
01:37:18 um did the um
01:37:20 um problems or inefficiencies created by the privatization of the lfb's training under the contract with babcock act as a factor in any way in deciding whether
01:37:31 whether the odcb would allocate a an amber or a green
01:37:36 green code or color to a particular topic no not still
01:37:41 not still so was there is this right i think on your evidence is it your recollection that the problems you've identified in paragraph 53 here of your second statement
01:37:51 statement had no bearing whatever on the numbers of um articles in operational news which was selected for training or on their grading red amber or green
01:38:04 or on their grading red amber or green that's right if a cd cbt package was produced with the operational assurance department always the commissioning department no no the commissioning department would be the subject matter experts who were
01:38:15 the subject matter experts who were relevant for that particular piece of training
01:38:18 training right let's let's just test that against something can we please look at um at met
01:38:25 met 3079358 please what i'm showing you is the police witness statement of nick markwell of the 17th of may 2021
01:38:37 of the 17th of may 2021 now
01:38:38 now you'll recall that mr markwell worked in the lfb's training commissioning department between 2012 and 2018 as he tells us and if you go to page three of his statement the first paragraph on that page he says
01:38:51 the first paragraph on that page he says the subject the subject content straight learning outcomes that were required for an operational used tcap would come from gm lee drawbridge and his department via recommendations from
01:39:02 his department via recommendations from odcb
01:39:05 odcb first is mr markwell right about that or wrong about that so yes uh lee drawbridge worked for graham ellis in the operational assurance department and lee would be the one who would
01:39:17 lee would be the one who would communicate the outcome of the odcb recommendations for the news articles and would share that with nick markwell yes so it's the operational assurance department that would
01:39:29 department that would direct the subject content or learning outcomes required for an operational news tcap is that right no we would just share the list with nick markwell he would then be in direct contact with the commissioning departments for the
01:39:41 commissioning departments for the content of those articles you say
01:39:44 you say he would be in direct contact with the commissioning department was there a training commissioning department per se or was the department doing the commissioning of any training something
01:39:55 commissioning of any training something that varied depending on the um subject matter of the training so um each individual department would have the ability to commission training requirements that would then go into the
01:40:07 requirements that would then go into the team that nick mark worked for which was the overall training commissioning department those were the ones who helped develop the training tcap packages and then worked alongside babcock's with a subject matter expert
01:40:19 babcock's with a subject matter expert from the commissioning department i follow so when we're talking of commissioning it it works at two levels i think is this right there's the client level and one sees those that that word used in the tcaps themselves and that
01:40:31 used in the tcaps themselves and that that would be in incident command u yes operational assurance and then there's the training commissioning department which actually takes the commission and gives it effect yes that's right i
01:40:43 gives it effect yes that's right i follow let's look at an example of an operational newsletter can we go please to lfb double zero double one eight nine five nine
01:40:54 now this is the one for 24th of march 2013.
01:40:58 2013. um there are seven articles in this issue but let's pick one let's go to page two we could see an article at the top of the page called fire survival guidance calls and the first paragraph says policy 790 explains what a fire
01:41:10 says policy 790 explains what a fire survival guidance fsg call is and describes the actions required by staff on the incident ground upon receipt of fsg information from control now the article then goes on as you can
01:41:22 now the article then goes on as you can see
01:41:23 see uh to set out a summary of what an fsg call is
01:41:27 call is the appliances that will be mobilized in response to an fsg call the role of control information forms or cifs and then if you look at the the red bullet points on the right hand side of the screen
01:41:38 the screen the
01:41:39 the penultimate paragraph says this it is vital that control is kept informed of the actions being taken to resolve each fsg call
01:41:47 fsg call the fact that control is aware of the actions being carried out on the incident ground will greatly enhance the advice given to fsg callers the policy lists the methods of communication available
01:41:59 communication available and there's then a next paragraph or final paragraph there on casualty information forms uh would it be fair to describe this as a potted version of policy 790 yes yes which came out i
01:42:13 policy 790 yes yes which came out i think in the february of 2012. i believe so
01:42:17 so what training is this article actually giving
01:42:21 giving so this article isn't given training um per se it's raising awareness of some of the contents you say in a summary form of policy 790 and then if you look on
01:42:32 of policy 790 and then if you look on the back page of this operational news information it will give you the training links for the crews to then follow yes
01:42:43 yes before we go to that what does this spotted version give the firefighters or anybody who is supposed to read this what they wouldn't get from a reading of
01:42:54 what they wouldn't get from a reading of the relevant policy which is only about seven pages long so this is awareness raising so this has obviously come to light as a result of something that has happened sometimes
01:43:05 something that has happened sometimes that was the publication of a new policy sometimes it was as a result of an event on the fire ground what this would do is draw crews attention to the fact that we wanted them to focus on fire survival guidance calls
01:43:17 focus on fire survival guidance calls and then direct them to the train that came with it so obviously if we had ops news just publishing lists of policies and details of policies it wouldn't be very very long for a start and wouldn't
01:43:28 very very long for a start and wouldn't be necessarily very interesting this is a summary to give people the flavor of what it is and then the trainings attached to it
01:43:38 if we go to page four of this newsletter we can see the list of training that was associated with these particular articles
01:43:44 articles and if you look at the fourth row down you can see fire survival guidance calls just towards the foot of your screen yeah there's cotton can you see i can yes and it says uh article first survival guidance calls
01:43:55 survival guidance calls training article guidance and supporting information policy 795 survival guidance calls and then step recording reference create on step and you can see that it says lecture stroke
01:44:06 you can see that it says lecture stroke subject strength incident management incident command stroke incident command procedure stroke fast survival guidance calls 790. so
01:44:16 so what would that be would that be a place on the
01:44:19 on the intranet the nfb's internet yes so they crew this is drawing the attention to the officer in charge of the watches on fire stations that they need to conduct
01:44:31 stations that they need to conduct training on policy 790 and that's the uh how they record it on the recording system basically that link will take them to the area in which they record that information against people's individual
01:44:43 information against people's individual training records right
01:44:48 uh and
01:44:51 and this uh is something that the firefighters would be asked to
01:44:57 asked to do is it you'd you'd you'd they'd be expected to read the new policy and is it right that the watch manager would then be expected to give a lecture on this topic based on
01:45:08 give a lecture on this topic based on what was on step uh there wouldn't be an essay based on step this would be based on the policy the watch manager it was mandatory for the watch manager on that article to conduct a training session in relation to that article with all their watches
01:45:20 to that article with all their watches and then record it on the step system so this the step system forgive me the step system is to record the fact that the
01:45:27 the uh the lecture was given when and when it was given by whom yes that's right so it's a wreck a training record if you like yes
01:45:34 like yes um
01:45:36 um this
01:45:37 this uh lecture would be held on as you say the lfb's database or intranet uh
01:45:43 uh is it right that the watch manager taking the station staff or station crews
01:45:49 crews through this would not be provided with any materials for that lecture um they would be provided with the uh policy which would give them the basis on which to conduct the training
01:46:00 on which to conduct the training watch managers were
01:46:03 were regularly i mean on a tour every tour every single tour of duty for a watch on a station they would be conducting some form of training so this would be a regular routine for them and this was to ensure that these
01:46:15 and this was to ensure that these specific articles were the focus of the training uh for the crews yes i mean this isn't a cbt package is it no that's just the uh policy for them to work out the training
01:46:27 policy for them to work out the training from and just look if you look at this page which is the which are the packages
01:46:32 packages uh we i think we see only one cbt at the bottom of page four uh if you go down you'll need to scroll down
01:46:43 scroll down you can see that the training is all article
01:46:45 article and then you get to artic aerial appliances article and package 72d visits article and package and then aerial appliances cbt package so that that shows that of all these
01:46:58 so that that shows that of all these particular items selected by the odcb for training only one got a cbt package namely aerial appliances is that right is that how to read this uh and the 72d visits by
01:47:09 uh and the 72d visits by well that's a package as opposed to a cbt package can you tell us the difference uh i'm not sure i understand what the difference means there training pack available
01:47:18 available well compare compare 72d visit article and package which is identified as a watch training package in the next column to the right yes
01:47:29 to the right yes with uh
01:47:31 with uh the next section of this which is senior office of computer-based training cbt and there you see aerial appliances cbt package
01:47:38 package can you tell us what is the difference between a package a watch training package and a cbt package um i think the difference is it's just different wording for the same thing but the top section refers to watch-based staff and
01:47:51 section refers to watch-based staff and the bottom to senior officers so
01:47:53 so obviously senior officers would not be undertaking watch-based staff training and although there were occasions when they would meet together and have training sessions it would be a responsibility of an individual senior
01:48:04 responsibility of an individual senior officer to access that cbt training package whereas the watch training package will be accessed by the watch manager and delivered to the watches but effectively i think they're both the same training package they're just called something slightly different
01:48:16 called something slightly different do you know that um i know that they were on the computer the um act the station training packages that were accessible were called watch training packages and they were cbt packages
01:48:28 packages and they were cbt packages um but the specific difference is that senior officers would only access those cbt packages they wouldn't be present at a unless it was a significant training input they wouldn't have a large
01:48:39 input they wouldn't have a large gathering of people together to be trained focusing on watch training packages then and focusing on fast survival guidance calls as we have been if you look at the right hand side of the column and will you just scroll up please to go back to
01:48:50 you just scroll up please to go back to that
01:48:53 scroll up the page to go back to it it's now towards the foot of your screen fire survival guidance calls you can see the lecture there that i read to you just to be clear
01:49:04 just to be clear you say that the watch manager would have the policy what else would the watch manager have by way of prompts or assistance or guidance to them when taking the station-based crew through
01:49:17 taking the station-based crew through the lecture so the policy itself would contain all of the detailed information regarding far survival guidance calls and that would be the basis on which the watch manager would produce their
01:49:28 watch manager would produce their lecture
01:49:30 lecture i see so there'd be no how to deliver a lecture
01:49:34 lecture um package which the watch manager would have no right so it was up to individual watch managers and their particular presentational skills as to how well it went
01:49:42 went yes it was and i'm assuming they never had any centralized training on how to teach it varies there were times where we did
01:49:53 it varies there were times where we did when i was a leading firefighter i underwent a week-long course in how to deliver training both practical and theoretical classroom-based training and then i know on other
01:50:06 and then i know on other crew commander and watch commander inputs they have had direct information about how to deliver training it wasn't consistent there were some people who probably haven't had it but um i know when when i went through
01:50:18 but um i know when when i went through the process it was a long time ago we did have a week's input on it yes you said it was a long time ago can you tell us when you did your week-long course and how to deliver training um
01:50:29 training um 1995. right right sorry it was it was yes even before uh
01:50:36 uh yeah a long time ago all right um peter graves told us that there was no no training on how to train after babcock came in in april 2012. would you agree with that
01:50:47 april 2012. would you agree with that yes yes
01:50:49 yes yes now this edition of operational news as we've seen was released in march 2013 uh that
01:50:57 uh that looking across the piece was the last month of the latin house inquest hearings wasn't it yes um
01:51:05 yes um the failure to transfer information back to the control room as a topic was a major feature of that incident wasn't it yes it was the national fire um indeed
01:51:15 um indeed can you confirm to the best of your recollection it was the very reason why policy 790 came into being in the first place yes it was and you won't have seen this from
01:51:26 and you won't have seen this from anything i've shown you today but you can you confirm from your recollection that it was one of the 34 prelational actions it was yes yes and yet there's no mention
01:51:37 and yet there's no mention uh in this article of latino house as an incident
01:51:43 incident or the provenance the origins of policy 790. we can see that why is that
01:51:51 i'm not sure i the department who wrote the article would have made the decision on that now looking back it would have been
01:52:03 now looking back it would have been very helpful and very relevant to have uh included that because obviously all the operational crews were very familiar with the lack of house fire so to have made that link in would have been very useful
01:52:14 useful you say looking back it would have been very helpful the point of lachenal and all the work that the lfb was doing after 2009 up to this point march 2013 was looking
01:52:26 up to this point march 2013 was looking back it was looking back to the incident so why why hindsight now and not hindsight then i'm not sure how i can't answer that
01:52:37 i'm not sure how i can't answer that we've seen and we can go back uh two pages
01:52:40 pages let's do that to page two to the paragraph i read to you underneath the red bullet points if we go back to page two um the paragraph which starts it is vital that control is kept informed that the actions being taken to resolve
01:52:52 that the actions being taken to resolve each fsg call that's wording taken from the article but it doesn't focus and this doesn't focus on information transfer between the incident ground and control
01:53:03 the incident ground and control do you know why that is um no i don't i'm sorry do you accept that operational news articles in the form we see them could only ever be a high level and cursory
01:53:15 only ever be a high level and cursory exploration of an operational topic yes they weren't um designed to be a summary or sort of a news bite of it to then
01:53:24 to then inform the crews what was coming their way as regards to training yes and as a system
01:53:30 system the operational news at least as a document and as a system uh
01:53:35 uh inherently relied on local crews being proactive not only in completing the training but in all also in taking steps to try to embed it in their own minds and their own operational approach
01:53:46 and their own operational approach i wouldn't say it required being proactive because it was mandatory so it was
01:53:50 was followed up the station commanders were responsible for ensuring that all of their crews had completed that training and there were also teams working directly to the area dax
01:54:03 teams working directly to the area dax who were responsible for ensuring that uh training was undertaken in those each of those geographical areas
01:54:13 areas so
01:54:13 so are you telling us that there was quantitative oversight at least of of whether or not training on a particular package or particular topic had been completed at particular stations yes there was and what happened
01:54:25 stations yes there was and what happened was that there was a team of people who would run the reports from the step recording system that would give updates to the area dax and to assistant commissioner dave brown about the percentage of completion rate by the
01:54:36 percentage of completion rate by the watches and they would then be fed back to in to ensure that those who had not completed did so yes
01:54:45 yes but i think you also accept that the quality of the training reliant as it was on watch managers who had not been trained to train and have not been given a prompt list or pac training package on
01:54:56 a prompt list or pac training package on how to go about the task was dependent on the individual skills of the watch manager concerned and the um keenness of the crew crews to
01:55:07 and the um keenness of the crew crews to take on what was being shown to them yes i would say there would be a prompt list because there was the list of information in the policy that were the key areas for them to focus on the key points there was a key point summary
01:55:19 points there was a key point summary included i can't what time that came in but
01:55:22 but it was
01:55:23 it was um yeah individually based on the watch officer's ability yes do you accept this proposition that by the system we've been looking at
01:55:34 the system we've been looking at with its reliance on local crews local station managers and particularly the skills of the watch manager concerned that it was in essence impossible for the operational news system of training
01:55:45 the operational news system of training or diffusing training topics to have a direct impact on the performance of crews on the fire ground it could only ever be indirect and only as good as the training they got on the day or the night when they were being trained well
01:55:56 night when they were being trained well i think that there were direct impacts because i think that where you know and i know anecdotally from talking to cruz that where awareness had been raised of a certain
01:56:05 a certain uh piece of information through operational news that they then came across that situation on the fire ground and what they had learned through the operational news and the subsequent training was very relevant to them to
01:56:16 training was very relevant to them to understand different situations that occurred
01:56:26 now
01:56:30 do you accept the general proposition that
01:56:33 that uh given the trend of decline as we've seen i think uncontested in this inquiry of operational incidents in the 21st century in london
01:56:44 in the 21st century in london firefighters require rather more in the way of training than simply reading policies and completing computer-based training packages yes and that was why there were a number of other training interventions
01:56:56 of other training interventions continually taking place across london fire brigade whether that was access to operational training through babcocks whether that was large-scale or small-scale training exercises that regularly took
01:57:08 exercises that regularly took place in different areas and then it has to be born in mind that the training on fire stations wasn't solely based on crews sitting in a fire station listening to a watch manager those would
01:57:20 listening to a watch manager those would be translated into operational training events at fire stations on a very regular basis so it wasn't just a case of sitting and having a policy read to them did you ever yourself raise the need for more
01:57:32 yourself raise the need for more practical training with anyone the need to embed learning through practice and guidance beyond the operational news system we've seen i think that was a conversation we regularly had at odcb
01:57:43 conversation we regularly had at odcb and
01:57:44 and dave brown would supply the information about the operational exercises that were taking place both those small and large scale to give an indication of what was happening across london fire brigade it was very
01:57:55 across london fire brigade it was very important the practical training took place
01:57:57 place right did you ever encounter any reluctance either within the operational insurance department itself from your own staff or from those on the odcb about the need for such and such um exercises as you've
01:58:09 such and such um exercises as you've described no definitely not everyone's very supportive of the idea right
01:58:16 let's go to the odcb minutes of october
01:58:20 october 14th of october 2013 at lfb triple zero six seven eight one eight
01:58:31 now uh this as you can see is the minutes of an interim meeting on that day i've given you the date uh you can see that you were there uh if you go to page two uh you were there uh uh at as uh ac operational
01:58:45 there uh uh at as uh ac operational assurance you see that fourth from the bottom yes and we can also see uh if you look a little bit lower down the screen i think it'll be a scroll down to see it matters arising under 2a
01:58:57 to see it matters arising under 2a frequency of operational news and you are recorded as saying as querying the feasibility of increasing the frequency to three issues as agreed at the last meeting
01:59:08 at the last meeting the dc suggested that the dc was rita dexter the dc suggested that this might be an opportune time to have a fundamental review of the current system the third officer that was dave brown
01:59:20 the third officer that was dave brown referred to the fact that the same issues repeatedly arise as an indication that a review is needed such a review would look at whether the right tools are available and what system is used in other
01:59:31 and what system is used in other organizations and it may lead to a review of the brigades operational response delivery model acoa was asked to lead on the review which should report back by march 2014
01:59:43 report back by march 2014 say six months or five months time uh what was unfeasible about increasing the frequency of operations operational news
01:59:52 news i don't think it was unfeasible i thought it was a good idea um i think the feasibility may purely have been around the production there may have
02:00:03 around the production there may have been concerns raised around the time taken to produce the articles by the individual departments and then to translate that into the operational news pamphlet itself but there were sometimes
02:00:17 pamphlet itself but there were sometimes issues where departments were clearly especially the operational policy department because that relied quite heavily on those for the production of articles as a lot of it was relevant to the policies they owned and i think sometimes that they felt they didn't
02:00:30 sometimes that they felt they didn't have sufficient time to produce those articles and then for them to be published so that might have been it wasn't any reluctance on my part to increase it um i was
02:00:41 um i was very proactive in the idea of wanting that to be increased why does it record you as querying the feasibility of increasing the frequency i think that means it was conversation with colleagues about whether they felt their departments were going to be
02:00:52 their departments were going to be sufficiently in a place to be able to produce the articles and turn around in the time it would require why did the odcb consider it necessary to review the frequency of operational news
02:01:02 news i think it was a conversation we had had at previous meetings around the fact that six months was a long time period between
02:01:10 between um operational news um and that it would be
02:01:13 be useful to be able to have a sort of more speedy conduit by which to be able to raise those issues did the odcb have concerns that the system wasn't functioning properly
02:01:24 system wasn't functioning properly i think there was a mixed view about whether it would be more beneficial to have a more frequent publication against the issues there that are clearly recorded by the third officer
02:01:35 clearly recorded by the third officer that he felt that it would just mean that we would have things repeated more often and i think the very rightly at that point the conversation was around that if we are
02:01:47 conversation was around that if we are repeating an ops news article and the events are still taking place one of those i can give you an example one of the things that regularly occurred was something called sighting of appliances
02:01:59 of appliances so that was about when crews arrive at operational incidents making sure they park the fire engines in the correct way to allow
02:02:08 to allow for things like ambulances to park to allow for aerial appliances to park and to also ensure that the fire engine was not at risk if the fire developed further that you wouldn't have
02:02:19 developed further that you wouldn't have risk of having to move your fire engine in the middle of operational incident that subject seemed to come up very frequently so it seemed to be a message that wasn't clearly received by
02:02:29 by the methods we used to try and tell people not to do it effectively or how to do it
02:02:34 to do it there's a reference to you conducting a review did you conduct a review of the current system i remember i vaguely remember this i don't remember the detail of it i do remember
02:02:46 the detail of it i do remember graeme ellis undertaking a piece of work about looking at how we gathered the information how we shared that and how it was learnt i don't remember it says used in other organizations i don't remember
02:02:59 other organizations i don't remember how and whether that was done or not i can't recall i'm sorry you were the person instructed to carry out that fundamental review in particular using looking at what other systems were used by other organizations but you can't is
02:03:10 by other organizations but you can't is that right you can't remember whether you did one or not no it was done and i think it was done by graham ellis and i believe dr adrian bevin because he was uh very familiar with health and safety processes that also followed a similar
02:03:22 processes that also followed a similar pattern in other organizations and he'd also worked for the hse himself did you delegate the task of conducting the review that you were instructed to carry out down to them yes and did they report back to you i believe so but i don't
02:03:34 back to you i believe so but i don't recall we've not i think seen a report of this fundamental review of the current system was that one i can't remember and unfortunately um i can't find one on the system but i believe
02:03:46 find one on the system but i believe i mean the what i would say is everything that was detailed to be done and came up as an action point in odcb was very strongly followed up so it would have been done and followed up can
02:03:57 would have been done and followed up can you help us what your recollection is to take to the extent you have any of the results of ellis and bra and bevan's review
02:04:06 review i'm really sorry i genuinely can't remember that now the next substantive update on this issue was at the odcb meeting of the 30th of july 2014. that's
02:04:17 meeting of the 30th of july 2014. that's at lfb3040719 [Music]
02:04:22 [Music] we can see from that that
02:04:29 you are present third item or third person down rita dexter in the chair and just note peter critchell pc head of operational resilience there there's also an attendance you see that yes and
02:04:42 also an attendance you see that yes and if you uh look at page two please in this minute you can see item seven review of odcb process the board agreed the five
02:04:53 odcb process the board agreed the five recommendations and that operational news should be published four times a year you see that the dc fep ask the hoor
02:05:04 ask the hoor that's head of operational resilience i think to report back on progress in establishing a central register of exercises at september's odcb details at page six so paragraph six
02:05:15 details at page six so paragraph six page six
02:05:16 page six now the inquiry doesn't hold a copy of the report referred to in those minutes uh is that the report that you've just described the ellis beven report yes it is it is is it right
02:05:27 beven report yes it is it is is it right do you remember what the five recommendations were that were agreed there
02:05:31 there no i don't but i do now i'm reading this recollect that ac steve hamm who was the head of operational resilience who was obviously being
02:05:42 being deputised for by peter critchell did a large-scale piece of work of establishing this central register of all exercises taking part across london fire brigade
02:05:53 fire brigade i think from recollection of six pumps and above
02:05:57 and above so that was and i think this came about following um the olympics in 2012 when there were a large number of operational exercises taking place to prepare for the olympics and operational resilience
02:06:09 the olympics and operational resilience held that database and it was decided it'd be very useful to widen the remit of that database to all operational exercises that were being held i think that
02:06:22 definitely where it says about sharing accident near misinformation more widely that was one of the recommendations because i felt that there had been a reluctance in the past
02:06:34 there had been a reluctance in the past to share the information that london fire brigade had around safety events with the wider fire rescue service
02:06:43 service and to my mind that was very important because if it was happening in one fire service there was a fair chance it would be happening another fire service and i would have hated for london fire brigade to hold information around an event that
02:06:55 to hold information around an event that had occurred and for it not to be shared more widely and that event to be repeated in another fire service and if you look at the last paragraph under seven there it says the dc fep which i think is the deputy
02:07:06 dc fep which i think is the deputy commissioner of fire and emergency planning correct me if i'm if i'm wrong about that that's correct um also asked whether there were any mechanisms in which we could get better feedback from stations and whether the hooa head of
02:07:18 stations and whether the hooa head of operational assurance could consult with the homic homic um i struggled with that i'm guessing head of management of internal communications uh management of information system information something
02:07:30 information system information something it was the head of management information yeah and look at this as part of the internal communications review in october now just looking at that what sort of information can you remember rita dexter was after from stations
02:07:43 was after from stations um i can't recall it but unfortunately it would be useful to have uh seen the review of odc be processed paper but i think it would be only i would been speculating but
02:07:54 only i would been speculating but um
02:07:55 um i suspect maybe it would be information feedback from stations on how uh we were sharing information with them but if i was doing in conjunction with the head of management information they
02:08:07 the head of management information they were the ones that held all of the um detailed information so i'm really not quite sure right do you remember looking into this it was you who was given the action i think
02:08:19 action i think i would have looked into it definitely with um david wyatt was the head of management information at the time do you remember where what your findings were whether you did discover that whether there were any mechanisms by which you could get better feedback from
02:08:30 which you could get better feedback from stations no i don't but it would the findings we found would have been fed into the
02:08:36 into the internal communications review which was across the all of the communications that took place in london fire brigade yes
02:08:44 yes now based on what we've been discussing so far this morning about the odcb and the diot process i just want to put a number of propositions to you and see whether you agree or disagree um first do you agree that the scope of the
02:08:56 do you agree that the scope of the odcb's work was to look at past incidents
02:08:59 incidents uh or training events and identify learning points for the future yes yes the the diot process as part of that relied fundamentally on the cooperation and proactiveness of individual officers
02:09:11 and proactiveness of individual officers on the ground as part of that function not entirely do you agree that in the context of diminishing numbers of operational incidents the diat sources per se were an increasingly narrow pool of learning
02:09:23 an increasingly narrow pool of learning opportunities they were one aspect of learning opportunities that yes because of increasing operational experience was a small piece but they were only a part of the jigsaw yeah but an increasingly
02:09:34 of the jigsaw yeah but an increasingly narrow yes as operational incidents decreased then it was an increasingly narrow pool and do you agree that the odcb's primary training output namely operational news articles and associated
02:09:45 operational news articles and associated study or self-study materials equally relied on individual station-based staff being proactive and being able effectively to impart that training
02:09:58 able effectively to impart that training i wouldn't agree it relied on their proactivity it was part of their core function and their daily role that wouldn't mean them being proactive it was their job and they were monitored against that by not only their individual station
02:10:10 not only their individual station commanders but by the area support teams so that i wouldn't describe that as productivity that was their day-to-day role uh closely monitored right what about the second part of my question
02:10:22 about the second part of my question namely relied on them being able effectively to impart that training yes it did it did and the adc odcb itself never directly instigated any practical training events
02:10:33 instigated any practical training events itself did it no that wasn't the function of odcb that would have been instigated by a number of different reasons through opportunities in different areas and through station-based staff and
02:10:45 and through station-based staff and through the individual training plans of each of those fire stations
02:10:51 do you agree that it was something of a missed opportunity for the odcb to identify operational improvements declining incidents and actually direct
02:11:01 direct what practical exercises should take place
02:11:04 place now i think that the work that odcb did would have fed into that because those would have come into the station training plans the station training plans were very closely linked to the risk
02:11:15 risk not only for individual fire stations but the wider london fire brigade risk and that would encompass what occurred at odcb so that would have been a part of it would have been a part of it do you agree that the odcb missed opportunities to scan the horizon for
02:11:27 opportunities to scan the horizon for learning opportunities both in the uk and overseas i think that the odcb and london fire brigade would have quite rightly relied on information to have come in centrally
02:11:38 on information to have come in centrally both through the seafarer and the government that it would have been very difficult for individual fire and rescue services to do that piece of work because it would have been a very
02:11:49 because it would have been a very wide-ranging function to undone that scanning
02:11:52 scanning do you agree that the odc being missed opportunities to adopt particular practices then in place in other fire and rescue services um i don't see that particularly i think
02:12:03 um i don't see that particularly i think that
02:12:04 that where that was shared then where we knew about it and the problem is going back to read to point what don't i know is that if the opportunities occur in other fire and rescue services that we weren't made aware of it would have been very difficult for odcb to have
02:12:16 difficult for odcb to have identified those what about those you were aware of but rejected rice for example kent so i wasn't aware of the rice at all until i started doing the work to prepare for this
02:12:28 prepare for this so yes but i think that should have been part of sifo's work because any individual fire and rescue service could develop something that could either be a really good opportunity for training or
02:12:39 good opportunity for training or something that might only be specific to their area and unless that was shared nationally through seafarer and that cfo did the work to make recommendations on it then it wouldn't have come into individual fire services
02:12:50 have come into individual fire services necessarily but it was shared wasn't it directly between kent and the lfb yes it was so never mind cfo why wasn't it given that it wasn't adopted doesn't that tell us that there were learning opportunities that were missed
02:13:01 opportunities that were missed i say i'm not familiar with the detail of the rice i've seen as part of this so i'm not sure about what assessment was made by london fire brigade about whether or not to adopt that
02:13:12 that i think that that should be a national piece of work to collect those recommendations and i know that when i was on national fire chiefs council the number of individual different interventions that were raised on a
02:13:24 interventions that were raised on a regular basis um it would have been very difficult to have adopted each and every one of those but i think that there should be a wider scale piece of work done
02:13:32 done to assess each of those and to assess their
02:13:35 their suitability whether or not they should be shared and adopted more widely do you agree that in focusing on specific diat sources the odcb failed to maximize its potential as a
02:13:46 maximize its potential as a cross-directorate meeting of senior officers
02:13:48 officers for training no no you don't can i then turn to a different topic which is your role in the latino pre-inquest action monitoring and first your involvement with the
02:13:59 and first your involvement with the lachenal house board we we touched earlier on that board and on the fire itself july 2009 and you tell us in your first witness statement we don't need to turn it up that you had no operational role
02:14:10 that you had no operational role yourself at the latin house fire no i didn't
02:14:13 didn't uh you also tell us in your first statement it's paragraphs 16 and 17
02:14:19 16 and 17 on page five we can have those up just for the
02:14:22 for the record um that you that that ron dobson set up the lfb lateral house bought himself in october 2009 some three months after the latter house fire in
02:14:33 months after the latter house fire in july that's correct yes do you also say in paragraph 17 and i'm summarizing i hope accurately that other than a couple of discrete attendances for specific reasons in 2009 and 2010
02:14:46 for specific reasons in 2009 and 2010 you were not involved with the latin house board in your capacity as dac in central operations no i wasn't and you go on to say in paragraph 18 that because of your appointment to assistant
02:14:57 because of your appointment to assistant commissioner for operational assurance in march 2012 you were made a member of the latter house board yes i was
02:15:05 yes i was so as it came with the job did it it did yes what was it about the role of ac operational assurance that resulted you in you becoming a member of the latin house board
02:15:16 the latin house board i'm not entirely sure i think that
02:15:20 the commissioner uh decided that it would be useful for me in my new role um i was very unfamiliar with that to sit on the board i don't think there was anything specific that um
02:15:32 anything specific that um that the
02:15:33 that the either the commission or the corporate management board was seeking from that but i think that they decided that as a new role of operational assurance it would be i would be a useful member to the board
02:15:45 i was going to suggest a reason was it because your department was central to the learning and embedding of the operational lessons to be learned from the lack of house fire um i wouldn't say the department was
02:15:57 um i wouldn't say the department was central to that that was definitely a role for the operational department and dave brown himself but for us to then monitor the ongoing performance on the fire ground yes uh
02:16:07 uh right you say um a role for the operational department could you just tell us as briefly as you can the differences between dave brown's operational department and your operational assurance department yes
02:16:19 operational assurance department yes certainly so dave brown was responsible for all of the um then 113 fire stations in london fire brigade their day-to-day functioning and running the training they undertook
02:16:30 the training they undertook and basically everything that took place on a fire station as operational assurance uh we were responsible for monitoring operational performance on the fire ground and feeding information
02:16:41 the fire ground and feeding information from that
02:16:42 from that back in through odcb right those roles essentially overlapped though didn't they
02:16:47 they only extend yes that we were out monitoring operational crews on the fire ground but we didn't do any monitoring for instance of day-to-day training on fire stations or day-to-day management of any of that
02:16:58 or day-to-day management of any of that no you as you told us as operational assurance you were responsible for monitoring operational performance on the fire ground yes and my suggestion to you is that your role on the local house board was important because of the
02:17:10 board was important because of the operational responses involved at lachnal yes so the the learning to then be translated into operational performance and how the operational review team observed
02:17:21 the operational review team observed that on the fire ground now you go on to say in paragraph 18 that your first board meeting was on the 22nd of may 2012
02:17:29 2012 and if you look to the next paragraph that pay at this on the same page paragraph 19 uh you say in the third line down there by the time i became a board member there were only a small number of
02:17:40 there were only a small number of actions left outstanding to complete now outstanding actions there are you referring to the 34 lfb pre-lachanel inquest actions i am yes right
02:17:51 inquest actions i am yes right uh if we turn them to page eight of your statement
02:17:55 statement you say it paragraphs 31 to 33 and i'm summarizing them under pre-actioning pre-inquest actions um
02:18:04 um there were a number in which you were involved and summarizing them you were involved in actions 4 6 and 32
02:18:12 6 and 32 yes yes yes four was to complete a sequence of events or a timeline of the latino house fire yes
02:18:19 yes six was was as you say it was to um undertake a review of high-rise policy in order to improve guidance for staff and help them prepare
02:18:30 guidance for staff and help them prepare for the demands of a similar incident you don't say it in paragraph 32 you say it later on is that correct yes but you don't i think suggest that you were involved in the substantive development of the policy
02:18:42 development of the policy but the work as you say in power 32 the work relating to the operational news articles would have come through my team and up to adcb that's as we've seen before is it yes
02:18:53 that's as we've seen before is it yes and then action 32 at the foot of page eight
02:18:56 eight you say i was not involved in the work surrounding this action uh whilst the new policy was still in draft at the date of the grenfell tower fire i should say after the fire brigades union had been consulted i
02:19:08 brigades union had been consulted i decided in the early hours of 14th june 2017 that the lfb's fire investigation team should use the policy to guide their initial actions in the immediate aftermath of the fire i believe the improvements included in the policy
02:19:19 improvements included in the policy greatly assisted the gathering of information and evidence to assist with the investigations that are still ongoing
02:19:29 now that's what you say there so turning against that background to the first of the things i want to ask you about and that's the lindridge review from january 2013.
02:19:39 2013. you cover this on page six of your statement if we go back please at paragraph 20
02:19:46 and then the first line there you say the board minutes dated 7th september 2012 note that i i provided an update that the audit of changes implemented across the brigade as a result of learning from latino is underway
02:19:59 learning from latino is underway and you exhibit dc6 then you say i recall that this was a piece of work that was commissioned by the board to review the actions that had been identified by the board and to indicate whether they had been satisfactorily completed it was work that was being
02:20:11 completed it was work that was being carried out by a member of my team at the time group manager david lindbridge and then if you go to the bottom of the paragraph
02:20:19 paragraph you um you say that at the 17th of october 2012 meeting you provided a further update now just pausing there that was a matter of months wasn't it before the start of the latin house inquest in
02:20:31 the start of the latin house inquest in january 2013. yes it was yes was the intention of the lindridge review to ensure that the lfb was prepared for the upcoming inquest or at least in the
02:20:42 the upcoming inquest or at least in the best position it could be in as i understand it the um the review was to look at the 34 issues that london fire brigade had already internally
02:20:53 brigade had already internally identified and to ensure that steps are being taken to met to meet those that would then subsequently feed into the um inquest
02:21:05 yes and put another way to make sure the lfb was prepared for the inquest and and in the best position it could be to tell the coroner what it had done already yes yes now if you go to paragraph 21 of
02:21:16 yes now if you go to paragraph 21 of your statement on the same page you say at the beginning there my role in this work was to provide oversight as the assistant commissioner but the detailed work was being done by gm
02:21:27 detailed work was being done by gm lindrich what did your oversight involve so subsequently um having made the statement i've then as part of the preparation for coming to give evidence i have been
02:21:38 i have been able to read through a lot more of my emails to understand how this piece of work came about and gary reason identified jim lindrich who wasn't actually in my team at the time i had
02:21:50 actually in my team at the time i had forgotten that when i wrote this statement he was seconded into my team to do this piece of work he was working i believe in the training team at the time and i think gary must have known him he asked him he
02:22:01 have known him he asked him he identified him and asked him to come and do this piece of work he
02:22:05 he was put into my team because i think we were able to use the skill set of the health and safety team who were very familiar with
02:22:16 familiar with conducting investigations especially dr adrian bevan so that we could provide gm lindridge with the support that he might need to undertake this piece of work
02:22:30 right um if we go please to lfb triple zero eight three nine two five please this is the statement to the inquiry of group manager david lindbridge
02:22:41 lindbridge you can see that from the first page it's dated the 18th of december 2019 and if we go to page three paragraph 12 he says this i understood that the purpose of the
02:22:53 i understood that the purpose of the report was to complete an audit of the actions taken to confirm what had been achieved
02:22:57 achieved to achieve this i determined that i would identify the state which existed prior to the latin house fire and determine what changes had been made in the relevant areas subsequently it was not intended to be a qualitative
02:23:09 it was not intended to be a qualitative assessment only a factual review of the actions which had been undertaken therefore i reached no conclusions about whether actions taken were sufficient to meet the expectations of the board i only described what steps had been taken
02:23:21 only described what steps had been taken so that the subject matter experts could make that assessment why was david lindbridge instructed only to undertake what he called a factual rather than a qualitative review
02:23:33 rather than a qualitative review i'm not entirely sure i wasn't present at the meeting where gary reason asked dave linders to undertake the piece of work so i'm not sure what
02:23:44 what or how the request was made or what the details were around that and i was never made privy to that information so i can't answer that i'm sorry
02:23:54 sorry right
02:23:56 right uh
02:23:57 uh can i just show you what gary reason said about that then in light of that answer this is the transcript please for day 180 page 116
02:24:07 page 116 at line
02:24:09 at line 22.
02:24:16 uh he says there that
02:24:21 uh in answer to the very same question i've asked you based on what group manager linderidge has said in his statement that line 22 has the question and his answer at line 25
02:24:32 answer at line 25 is because some of the issues that he was going to review were outside of his sector competence like control he was not a trained control officer so he would not have been able to make an informed judgment
02:24:43 been able to make an informed judgment on the quality of things like training because he wouldn't have experienced the role of a control officer so it was more just to assess whether the actions as defined in the lack of house pre-inquest action plan had been delivered and it
02:24:55 action plan had been delivered and it would have been for officers local to those management teams and functions for the qualitative aspect do you agree with that as far as you can recall it um from reading that yes i don't recall i
02:25:07 from reading that yes i don't recall i wasn't aware of the conversation at the time but i would agree with gary reason's summary there right
02:25:16 right so it wasn't is this right it wasn't your decision to limit lindridge's review only to a quantitative assessment i wasn't part of the conversation between uh dave and gary reason about
02:25:27 between uh dave and gary reason about the aspects of that so no it wasn't my decision right can i just show you a document at lfb00109781
02:25:42 this is an email run from from september 2012
02:25:47 2012 and it
02:25:48 and it if you look at the email itself it's from graham ellis to richard chandler who had responsibility for for among other things control at the time and uh it's copied to you david lindrich and
02:26:01 uh it's copied to you david lindrich and adrian bevin subject latino audit 12 september 2012 richard has discussed earlier operational assurance have been asked to lead on an audit of the actions
02:26:12 asked to lead on an audit of the actions as agreed by the latino board gm david lindrich will be coordinating the audit process david will be assisted by members of ops assurance as well as other audit qualified staff if required
02:26:23 other audit qualified staff if required we have already agreed the scope of the audit with gary reason ac danny cotton and adrian bevin health and safety i understand that gary reason will be writing to all hos to request their full
02:26:34 writing to all hos to request their full support to the audit team now just where he says in the second paragraph there um that you are involved in agreeing the scope of the audit is that right um not that i recall i
02:26:46 is that right um not that i recall i think that it was more that we had agreed that dave lindridge would be reviewing all 34 actions right across different departments in london fire brigade but
02:26:59 departments in london fire brigade but i have no recollection of having any agreement on the scope of the audit and how it would be undertaken you may not have a recollection but can you quarrel with the document which records uh your
02:27:10 the document which records uh your participation in the agreement of the scope of
02:27:14 scope of david lindrich's audit um i think that isn't a very clear statement of the scope of the audit i mean not the necessarily the way the audit be undertaken or um how that would be done so
02:27:24 so i would be guessing to agree what i had seen but i wouldn't i have no i generally don't remember any conversation around whether david linders would just be looking at the facts but that would make sense
02:27:35 the facts but that would make sense bearing in mind that german lindridge was as gary reason said not a subject matter expert across a wide range of those
02:27:42 those 34 items that he wouldn't be able to be a subject matter expert across all of those right i mean did you or did you not participate in the agreement about the scope of lindridge's audit i said i have no recollection of
02:27:54 audit i said i have no recollection of doing that i'm sorry right you don't recall
02:27:56 recall now did you remember whether you or others
02:27:59 others such as gary reason and adrian bevin um considered the possibility of instructing a range of different officers to undertake the review who between them would have been competent to assess all of the pre-actions
02:28:10 to assess all of the pre-actions um as i say i was only aware that uh dave lindrich had been selected once he'd had a meeting with gary reason and i was informed that david lindrich would be the one to be conducting the um audit right
02:28:22 right did you yourself to the best of your election have a recollection have any thoughts about or ask yourself how um the lfb would be prepared properly for the imminent inquest if it didn't know whether all the actions undertaken
02:28:34 know whether all the actions undertaken thus far were any good i think that the um from what i understand from the corporate management board the
02:28:42 board the because they had been supplied with regular updates prior to me joining the board from the heads of the department and the relevant responsible officers discussing
02:28:53 relevant responsible officers discussing that the actions had been completed that this was then an assessment across that piece i think that probably that the corporate management board at the time felt that they had trust in their responsible
02:29:04 they had trust in their responsible offices to updating the action plan and that dave lindrich's purpose was to actually go and because bear in mind the information he would be getting would be from those departments so he would be
02:29:16 from those departments so he would be you know assessing that information i was not aware of any conversations around having a wider team take part in that did you yourself undertake any kind of qualitative assessment
02:29:28 of qualitative assessment uh when you received a group manager lindrage's findings in january 2013. no i didn't why is that because the
02:29:39 audit had been done in conjunction with a wide range of people who were qualified i myself also was not qualified in a number of the areas that were being audited so i wouldn't have the detailed
02:29:51 audited so i wouldn't have the detailed subject matter expert that would be dependent on the people relevant to those departments wasn't it important to you to understand not only whether things had been done but whether the lfb
02:30:02 things had been done but whether the lfb had truly embedded the lessons to be learned from the latino house fire i think that was the purpose of the latino house board they were the ones who were assuring that piece of work right across london fire brigade
02:30:13 right across london fire brigade they were the ones who were receiving the reports and the say all the heads of service of those departments were at that meeting and those were the ones providing that assurance that the work had been
02:30:25 that assurance that the work had been done yes but do you not accept also that the remit of your own responsibility as a coa at the time operational assurance was to assure those parts of the lindridge review
02:30:38 those parts of the lindridge review that fell within that remit so as operational assurances explained my role was around the opera the fire ground assurance of the far ground situation not around the detail of all those actions in that report
02:30:50 those actions in that report yes but for example incident command which would fall within la wouldn't it that would yes yes and was it not your job
02:30:57 job as a coa
02:30:59 as a coa ensure not only that the um the relevant actions in the 34 actions list that fell within your remit had been done but they had been done
02:31:10 had been done but they had been done properly so that the lessons would be properly learned and embedded for those areas of my department yes definitely you did but what did did you do anything
02:31:21 did you do anything to make sure that what had been done actually met what it was that the latino house board was after so i was aware that on the as i say when i joined the board the vast majority of the those actions had been
02:31:34 majority of the those actions had been completed um and so it was picking up previous information from people who've been in charge of that but i was assured that anything that operational assurance were responsible
02:31:45 operational assurance were responsible for had been completed by the members of the team who worked for me yes i mean you told us you yourself undertook no qualitative assurance uh
02:31:54 uh my question really is why not given that some parts of the lineage review fell within the scape of your re uh the scope of your um supervisory role um because at the time um the work that
02:32:07 um because at the time um the work that was being done was ongoing i could see the work because it was my in june day to day work i could see what was going on so
02:32:13 on so i don't think i felt the need to do that um let's look at the linear review specifically this is an lfb triple zero nine four three
02:32:26 another a number of drafts of this document we've looked at with people's comments on them i'm going to show you what i
02:32:32 what i what um i am i believe and i'm told is the final version of the latest version um but perhaps i think for this purpose it doesn't matter if you look at the first page you can see what it is 4th january 2013
02:32:45 january 2013 and if you go to page 4 the paragraph 5.2 under the heading key findings
02:32:55 he says this of the 34 actions see appendix 1 16 have ongoing activities related to achieving the intended outcomes these ongoing activities include those dependent on a future
02:33:06 include those dependent on a future event which cannot be simulated and those which involve influencing external agencies these 16 also include those with an ongoing review of performance levels subsequent to the action being
02:33:17 levels subsequent to the action being closed on the log now just pausing there following that finding did you yourself take any steps to implement any form of tracking or monitoring system to ensure that those continuing activities
02:33:30 those continuing activities were completed satisfactorily no i didn't why is that um because uh and to be fair without seeing the 16 and understand what the detail are um then i i believe that none of those were
02:33:43 then i i believe that none of those were in the area of operational assurance so that would have sat with the subject matter experts responsible officers to understand that because it was
02:33:52 was not something that sat within operational assurance
02:34:02 right we'll may come back to that in a moment before we do let's go on with
02:34:07 with what we see on the screen paragraph 5.3 this review was unable to confirm 13 actions as fully achieving their expected outcome for each of these the actions are either ongoing or dependent on a future event
02:34:20 ongoing or dependent on a future event now again as as ac of operational assurance and as a member of both the latino house board and the odcb did you take any steps to look into those actions and ensure that they were ultimately completed um i think this was
02:34:33 ultimately completed um i think this was raised at the latino house board and that the commissioner used the opportunity to question the head to those department about the um
02:34:45 those department about the um ongoing actions but they were subject to an ongoing report so they were regularly reviewed
02:34:50 reviewed um but that was not something that sort of sat in the operational assurance arena as it were right at all events you were not involved in any continuing monitoring no no no
02:35:02 any continuing monitoring no no no looking at 5.4 a full list of the actions and a brief explanation of the findings is appended to this report listed below are the reviewers key findings specific to 10 actions for the commissioners group's attention
02:35:14 commissioners group's attention and do you know why those particular actions were listed for the attention of the commissioners group no i'm not sure and i've
02:35:23 i've heard previous evidence where there was a conversation about why that said commissioners group i'm not sure that um to be honest with you this report would have been would have gone to both the lack of
02:35:35 would have gone to both the lack of house board and probably to cnb so i'm not sure why the commissioners group is referenced there right
02:35:48 right
02:35:52 and if you uh look at um for example page eight say for example if you look at page eight and look at the 34 actions
02:36:05 eight and look at the 34 actions and the action log feedback there you'll see that
02:36:10 see that the number of actions and their references is listed on the left hand side the department is
02:36:16 is is given there
02:36:20 and the brief action title reported action confirmed activities ongoing and further review activity just looking at for example uh 22 and 24 those are about the
02:36:33 uh 22 and 24 those are about the bridgehead bridgehead information recording and moving the bridgehead so far as moving the bridgehead is concerned in fact both of those there's a yes under activities ongoing
02:36:45 a yes under activities ongoing and you can see that they fall within the op department was that not was that not for you to monitor that was operational policy operational policy certainly but these are
02:36:57 certainly but these are um incident command or fire ground operations matters aren't they i think this was referring to the development and
02:37:07 and production of a policy in those two areas which would have fallen for the operational policy department that would then have been the subject of training and then the intervention of operational assurance would have been monitoring the
02:37:18 assurance would have been monitoring the performance against that policy on the fire ground yes now most of these actions as you can see related to the control room and fsg training do you remember whether you um gary reason or
02:37:29 remember whether you um gary reason or david linderidge had any concerns about the control room and how it had progressed its actions um i don't recall i myself did not um uh gary reason may well have had conversations
02:37:41 conversations um with dave brown about those issues at the commission's board level right and in general terms we can see what's flagged there uh
02:37:49 uh and the reason they're flagged the the fact is that there were some that were flagged for ongoing work weren't there yes there were right whether it was for the commissioners
02:38:00 whether it was for the commissioners group or another board yes yes there were yes
02:38:03 were yes now we can see from uh [Music]
02:38:06 [Music] we can see from lfb3083988
02:38:11 if we go to that please that group manager lindridge produced an updated version of this report in november 2013. and if you go to page four in that
02:38:22 and if you go to page four in that document
02:38:23 document you you come back to the similar section key findings uh and uh you you see there's key findings and then over the page conclusions
02:38:34 conclusions there's no longer an opening commentary that flags particular actions to the commissioners group as we saw in paragraph 5'4 of the january edition of this uh report
02:38:45 edition of this uh report do you know why that element was removed um no i don't um i i ask you because you know don't maybe you don't but confirm for me if you can that by that time november 2013
02:38:57 you can that by that time november 2013 not all the actions had been fully addressed had they um not from this report no no for example fsg refresher training had suffered from a number of problems and
02:39:08 suffered from a number of problems and wasn't being rolled out in accordance with the recommendations yes i understand was do you know whether um group manager language lindridge was asked to update
02:39:19 language lindridge was asked to update those items so that they no longer appeared outstanding or complete as i believe i think from reading email correspondence preparation for this that um
02:39:30 that um group manager lindbridge met with ac brown on a number of occasions between
02:39:37 between march
02:39:38 march and the subsequent updating of this in october i think and he received the updates from ac brown around areas in relation to control right
02:39:48 right do you
02:39:49 do you do you know group manager lindrage's november 2013 report does not update those items uh
02:39:58 uh or rather
02:40:01 does doesn't show them as still outstanding or complete um he would have been working on the information supplied to him by ac brown right did you get any sense that the idea was to somehow to sanitize the report's
02:40:12 to somehow to sanitize the report's findings before it was presented to the latter house board or the latin house working group as it later became no
02:40:19 now gary reason gave evidence that the latin house board never formally received the lingerie report um that's what he told us at day 180 page 130 lines 14 to 18. there's no need
02:40:31 page 130 lines 14 to 18. there's no need to
02:40:31 to turn that up but do you have any recollection about why that was um no i don't so it wasn't until i did my preparation for this that i saw how many sort of iterations it had been
02:40:42 many sort of iterations it had been through and then i believe it was ultimately presented to a commissioner's group but i think the issue may have been that the latino house board wasn't sitting during that period
02:40:53 wasn't sitting during that period because the inquest had started well the national house board the inquest ran from january to march 2013 and the lack of house working group was established in the
02:41:05 working group was established in the spring of 2013 about may time yes the lachlan house working group was the elected members group yes that was obviously separate for this and that was in response directly to the
02:41:16 in response directly to the coroner's recommendations this obviously was the reports the relation to the internal investigation that london fire brigade had taken that the local house board had sat with and i think the
02:41:27 board had sat with and i think the lachlan house board as i understand it and as i remember stopped sitting at the point when the lache house inquest started and then um subsequently house working group was established to address
02:41:39 working group was established to address the recommendations from the coroner just just help me with this the the lindridge review took place between september and december 2012.
02:41:51 december 2012. yes that's correct resulting in the report in its first draft or first edition
02:41:56 edition or in on the 4th of january 2013 a a few days before the start of the inquest whose eyes was that document for if not the latino house board it was for the
02:42:07 the latino house board it was for the lacking house board yeah so why does is the fact that the inquest was sitting and was always going to be sitting for for three months or so uh representing the first quarter of
02:42:18 uh representing the first quarter of 2013 any reason why it wasn't received by the latino house board i'm saying i'm not sure the lack of the house board met during that period i i haven't i don't recall but the i think the reason was that the board hadn't met
02:42:29 that the board hadn't met why would that make a difference why not circulate it to the members of the board so they could think about it but it was circulating the members of the board hence they've seen the several copies with different comments was because the members of the board
02:42:40 was because the members of the board that was shared with them it was just that the fact the final document was not then given to the house board right let's go to the minute of the meeting of the latter board on the 30th of september 2013. now
02:42:52 board on the 30th of september 2013. now this is at lfb triple zero eight four zero four eight
02:42:59 uh latino board meeting 30th of september 2013
02:43:05 2013 i think this overlaps this is the period where the latino house board and the lachenal house working group coexisted side by side yes it was a period and this helped me if i'm with this was was
02:43:16 this helped me if i'm with this was was during that um
02:43:18 um period yes i believe so co-regnum if you like uh and you could see that you were a member of the board you're identified as such as the last name on the list in paragraph one yes i am yes yes and if we
02:43:30 paragraph one yes i am yes yes and if we go down to paragraph uh five actions are rising from minutes and you can see item 5.4 the post-incident audit report for outcomes of the latin investigation has not been signed off by the board
02:43:43 signed off by the board now given that the board is meeting here uh
02:43:47 uh in september 2013 why not why why hadn't it not been signed off by the board um i'm not sure and i don't appear to have been attended to this meeting so i don't recall why right
02:44:00 do you did you see the minutes at the time even though you weren't in attendance um i don't recall but i would i imagine i would have been sent them as a board member i would have yes i would have been yes so it looks it looks
02:44:11 have been yes so it looks it looks as if the lachenal board received uh
02:44:15 uh did not receive as a board the uh or sign off the january edition of the lindridge review i suspect that
02:44:26 i suspect that as a result of this this is why i imagine that that's why conversations were had and a subsequent edition was produced in october [Music]
02:44:37 [Music] because i suspect that realization was had that they hadn't seen the audit report formally at the board so they were asked it was asked to be brought to the board and therefore david linders was asked to update that
02:44:48 david linders was asked to update that um and hence the then october edition of it well just look at what's just below what i'm showing you action involved tc that's tim cut bill to arrange further meeting to discuss post-incident audit
02:44:59 meeting to discuss post-incident audit report
02:45:02 we know from other witnesses that that meeting the further meeting did not happen are you able to tell us why not no sorry
02:45:12 no sorry is it the case that the latino board did not sign off on or even receive and sign off on either the january or the november 2013 lindridge reports
02:45:23 or the november 2013 lindridge reports i'm not sure whether the lachlan house board sat again after the september whether there was a further meeting or not
02:45:30 not um in which to receive it but i know the report did then subsequently go to i believe the commissioners group right let me try it this way do you remember
02:45:39 remember whether you as a as a member of the latino house board ever signed off on either the january or the november 2013 editions of the lingeridge report no i
02:45:52 editions of the lingeridge report no i don't remember that
02:45:55 now can we go please to ron dobson's first witness statement at lfb triple zero three two one five seven page ten paragraph thirty eight
02:46:10 uh he says under action points uh as follows as commissioner i had overall responsibility for ensuring the actions identified following the lack of house fire
02:46:22 following the lack of house fire were implemented and in 2012 i instigated a review of the latino action plan to date to be carried out by the operational assurance division that review was carried out by the head of operational assurance danny cotton and group manager dave lindbridge
02:46:35 cotton and group manager dave lindbridge this review is intended to confirm the actions that had been completed and to identify the actions that remained outstanding or where further work or resources were required this review was reported to the commissioners group in january 2013
02:46:48 commissioners group in january 2013 at this meeting head of operational assurance danny cotton was tasked to discuss the findings of the review with each head of service in relation to each of the actions in the action plan for which their department was responsible
02:47:01 which their department was responsible now we know that the january 2013 meeting of the commissioners group did not go ahead and we understand it from ac reasons written evidence to the inquiry that the november 2013 updated lingerie
02:47:15 november 2013 updated lingerie report was considered by the commissioners group at the end of that year so i think you've hinted at can you summarize what was reported to the commissioners group when the lingerie review updated report was
02:47:27 lingerie review updated report was discussed in late 2013 um
02:47:31 um i can't recall the detail but i know that the report that was going to be presented had been shared with all of the directors and the commissioner prior to
02:47:42 directors and the commissioner prior to that meeting and they'd had sight of it and then i believe
02:47:46 believe that
02:47:47 that dave lindridge and i attended that meeting and david linder has presented the findings that he has reports including the updates that he'd made subsequently
02:47:58 the updates that he'd made subsequently in october so even though your department wasn't necessarily involved in the outstanding actions as we've seen is it right as he says
02:48:06 says that you would you were tasked to discuss the findings of the review with each head of service in relation to each of the actions in the action for which their department was responsible is that correct no because the meeting he's
02:48:17 correct no because the meeting he's referring to didn't happen so i think potentially the commissioner has um has uh maybe an incorrect recollection it was a long time ago but um we didn't have that meeting in january 13 so he
02:48:28 have that meeting in january 13 so he didn't task me with those things very very well and in which case was there a meeting but at a different time of uh in that year or only in november when it was or the end of the year when
02:48:39 when it was or the end of the year when it was finally presented to the commission's group as a complete report so to be clear your your recollection is that you were tasked to discuss the findings of the review with each head of service but only in the november of that
02:48:51 service but only in the november of that year no i wasn't tasked in november that in november it was presented as the report was there was no further conversation about reviewing it so the last uh
02:49:00 last uh sentence of what i've read to you there from ron dobson is something you disagree with i do yes i see
02:49:10 so you you never therefore discussed the findings of the review with each head of service no i didn't did anybody um i'm not to the best of my knowledge right do you know why to the best of
02:49:21 right do you know why to the best of your knowledge nobody did um no right
02:49:30 did you and gary reese never have a discussion about why that had never happened no i believe that uh gary reason i know gary reason was talking regularly
02:49:41 i know gary reason was talking regularly to the other directors about aspects of the report and that he was speaking to dave lindrich but that's as much as i know
02:49:52 lindrich but that's as much as i know gary reason also told us that the lintridge review was never in either report was never taken to or even provided in fact to the latino house working group
02:50:04 latino house working group do you agree i don't believe it was do you know why that was the case um no i have no idea that would have been a decision taken by the corporate management board at the time
02:50:15 management board at the time you said that would have been a decision taken by the corporate management board at the time so um let's see at the time that would have been
02:50:22 been uh the commissioner ron dobson rita dexter yes yes gary reason yes yes and super suburban and that's it and there were other members
02:50:34 members direct they head for strategy and performance and the head for information management sat on the board at that time as did
02:50:40 as did uh james douglas as the head of hr yes not you though no no no no
02:50:47 no is it
02:50:48 is it is it right just looking at all the evidence
02:50:50 evidence so far as you recall it that beyond group manager lindridge's collec collection of data from the various heads of service there was never any scrutiny or qualitative
02:51:01 qualitative evaluation of the work undertaken uh the 34 actions undertaken uh for example to ensure that they had the desired effect not somewhere and where no why is that
02:51:14 not somewhere and where no why is that i'm not sure
02:51:17 something that was something of a missed opportunity would you accept yeah i would think so i think that's um and whether they had a conversation at the cmb or the commissioners group about that i wouldn't have been aware but um i
02:51:28 that i wouldn't have been aware but um i would say that was a missed opportunity
02:51:32 can i then turn to your role in the latino 1843 monitoring which took place after the inquest and indeed the rule 43 recommendations
02:51:43 and indeed the rule 43 recommendations we've already touched on this miss cotton but the latino house inquest ran from january to march 2013. and during that period you were still assistant commissioner for operational assurance i was yes yes and at the end of the
02:51:54 was yes yes and at the end of the latinal inquest hearings the coroner sent the nfb and others uh what was known as a rule 43 letter which contained her recommendations arising from the evidence yes yes
02:52:05 evidence yes yes and we can look at that it's lfb triple zero three two one five eight
02:52:11 there it is 28 of march 2013 addressed to ron dobson uh and uh the title is latin house fire third july 2009 and in the
02:52:22 and in the last paragraph on page one she says this before i set out my recommendations i acknowledge the london fire brigade have already undertaken extensive work to learn from their experience with the fire at lachnal
02:52:33 experience with the fire at lachnal house have introduced new policies and have reviewed existing policies in respect of a number of matters of significance including
02:52:41 including and then she sets out a list if you turn the page to page two you can see it there a list of ten bullet points uh including uh as you can see from the third one down 72d
02:52:53 third one down 72d uh visits
02:52:55 uh visits she calls them awareness of fast bread communication between control and the incident ground and also the handling of fsg calls
02:53:06 and also the handling of fsg calls those are some of the ten and she then goes on to set out her five recommendations which we can see from the headers in italics you can see them if you scroll a bit lower down the page public awareness of fire safety
02:53:18 public awareness of fire safety visits may proceed to 72d and then and then continuing incident commanders and then continuing over the page page three brigade control communications and then
02:53:31 communications and then before finishing with the heading response at the bottom and that stipulated the time frame in which she wanted the lfb to respond to her letter i've shown you that now we'll look in detail at the coroner's recommendations
02:53:43 detail at the coroner's recommendations a bit later in your evidence but just for the moment i just want to look at paragraph 24 of your statement please page seven your first statement
02:53:55 um you say there
02:54:00 uh under post of the heading poster lack of house require inquests following the conclusion of the latter house inquest on 28 of march 2013 the coroner issued
02:54:11 on 28 of march 2013 the coroner issued recommendations under rule 43 of the coroner's rules 1984 to the lfb and other bodies the lfb then took the recommendations and identified a number of actions for the nfb to consider in
02:54:22 of actions for the nfb to consider in relation to each can we take it from that that it was the lfb's intention fully
02:54:31 fully to carry into effect all of the coroner's rule 43 recommendations directed at it yes yes we heard from gary reason when he gave evidence that he was instructed to
02:54:42 evidence that he was instructed to establish
02:54:44 establish an action plan to respond to these recommendations and that he did so from april 2013 by meeting the heads of service including you as head of operational assurance
02:54:56 assurance do you agree yes and that he was uh he instructed heads of service to draft
02:55:02 draft individual action plans relevant to their
02:55:05 their department do you agree with that yes yes
02:55:08 yes and he told us that ultimately those action plans were taken to the commissioners group and used to inform the drafting of the lfb's response to the coroner's rule 43 letter can you confirm that i believe so i
02:55:20 can you confirm that i believe so i don't recall the detail but i do believe that happened i will come back in uh in due time to your role in the drafting of the lfb's response to the rule 43 recommendations but just for the moment if we go to page 9 of your statement
02:55:33 if we go to page 9 of your statement paragraph 34 you'll see you say there as explained above my team is responsible for tracking the progress of the actions arising out of the rule 43 action plan but i do not
02:55:44 the rule 43 action plan but i do not believe any of the actions were allocated to me now on the question of tracking we could pick that up a little earlier in your statement at page seven of paragraph 25 you say there
02:55:55 you say there at a meeting of the odcb dated 3rd of june 2013 an action was assigned to me to take the actions that have been identified from the coroner's recommendations and to produce an action plan so that progress against the plan
02:56:07 plan so that progress against the plan could be considered at each meeting of the odcb
02:56:11 the odcb uh and you go on at the time the nfb was already considering rule 43 recommendations made by the coroner following the deaths of two firefighters in a fire at shirley towers hampshire and said the action plan for those rule 43 recommendations
02:56:24 plan for those rule 43 recommendations was also discussed at that meeting the first version of the latino house rule 43 action plan was circulated and discussed at an odcb meeting on 4th july 2013
02:56:35 2013 and you exhibit it uh
02:56:38 uh you've referred to two exhibits in that paragraph
02:56:42 paragraph uh dc10 and dc11 let's look at dc10 that's at lfb triple zero three two seven three zero
02:56:57 uh and um you can see that this is uh a minute of the odcb meeting on the 3rd of june
02:57:03 june 2013. we can see two thirds of the one third of the way down the list of names that you were present as ac of oa yes yes
02:57:12 yes and if we go to uh page four in the middle of the page we can see item seven coroner's rule 43 letters
02:57:21 and the text says this the letters for latin house and shirley towers were considered it was agreed that acoa would develop an action plan for the lachenal letter the lachenal and shirley tower's action plans will then be combined into
02:57:32 action plans will then be combined into one document following the format of the si s-a-i action plan monitoring report at first draft of the action plans will be considered at the next odcb meeting
02:57:43 be considered at the next odcb meeting and therefore they will be reported at the same time as the sai action plan monitoring report and we can see that you are the person to whom the action is allocated yes yes why were you assigned
02:57:56 allocated yes yes why were you assigned the responsibility for developing the action plan um because within the health and safety department we already had the what's described there as the sai action plan which was where we had any
02:58:07 action plan which was where we had any significant major events in london fire brigade that were investigated and an action plan would then be devised to address the issues raised so
02:58:18 devised to address the issues raised so those were normally issues of significant firefighter injury or significant failure of operational equipment and the um i believe that gary reason
02:58:30 and the um i believe that gary reason the commissioner decided that the format that was used for that would be a useful format to follow um for considering the recommendations from the rule 43 additionally we were already
02:58:42 rule 43 additionally we were already considering the rule 43 shirley towers as part of that reporting process so it meant that it would sit in the same reporting format which was already familiar with odcb
02:58:53 familiar with odcb and that it would be monitored in the same way
02:58:56 same way what was your role in in relation to considering the lessons to be learned from the shirley towers fire so it was the role of operational assurance
02:59:04 assurance to
02:59:05 to take those actions and then to format them into a table and then individual subject matter expert heads of department would be allocated tasks so
02:59:15 so one of the recommendations was the risk of entanglement from fallen cables because the firefighters had tragically become entangled so that was then given to the operational policy
02:59:27 given to the operational policy department to ensure that we had a policy um around cable entanglement and subsequent training that came from that so it'd be to identify the recommendations in rule 43 letters were made to other fire and rescue
02:59:39 were made to other fire and rescue services and to translate those into seeing how london fire brigade performed against them was that a common practice at the time yes it was so you did go about identifying fires from which lessons could be learned even though
02:59:50 lessons could be learned even though they were outside london yes that were where rule 43 recommendations were made because the coroner would send the rule 43 recommendations to every fire and rescue service but is is is it only where rule 43 recommendations were made
03:00:01 where rule 43 recommendations were made yes that's right i see rita dexter told us that when you became acoa she asked you to do a piece of work to consider whether the odcb was having regard to the best available range of
03:00:13 regard to the best available range of information or whether there were more things that could be taken into account do you remember being asked to do that piece of work yes that was i referred to earlier when the depth commissioner said to me i
03:00:24 the depth commissioner said to me i don't know what i don't know and where else could we find information from it's a very broad sweeping kind of statement that she just wanted to
03:00:32 to make sure that she was appraised as much information operationally as possible there wasn't a specific remit for that and that would include things like the rule 43 or where we had identified um
03:00:44 rule 43 or where we had identified um anything but that was mainly the function of seafarer to bring those to our attention right so that wasn't lacking all specific no no not at all and and i think you told us earlier you
03:00:55 and and i think you told us earlier you didn't actually in the end produce a written report no we didn't mr chairman is that a convenient moment we are mid-topic but there's no useful landing really no better place than is it we're not near shore so yeah all
03:01:06 it we're not near shore so yeah all right thank you well i think we should stop at that point then uh this cottonwoods break now so we can all have some lunch we'll resume please at two o'clock and again please don't discuss your evidence or anything to do with it
03:01:17 your evidence or anything to do with it with anyone else over the break thank you so all right thank you very much
03:01:30 thank you very much two o'clock please
03:01:40 you