Danny Cotton, former London Fire Commissioner, gives evidence about the Rule 43 action plan process, the Lakanal House case study development, her role as commissioning officer for incident command training, and the TCAP process she found 'endlessly frustrating'.
00:00:32 would you ask this cotton to come back in please
00:00:47 right mr scotland ready to carry on yes sir yes thank you very much when you're ready mr phil thank you mr chairman miss cotton can we please look at lfb triple zero eight nine one two seven
00:01:02 this is a consolidated rule 43 action plan prepared for the subsequent adcb meeting on the 4th of july 2013 which you may recall was this the regular format of the
00:01:13 was this the regular format of the action plan considered by the odcb at the time yes it was let's go to the minute of that meeting at lfb triple zero 32729 please
00:01:27 uh first page of it is uh there and you can see that halfway down the list of attendees your name is there ac operational assurance yes yes so if we go to page three item six third item from the bottom
00:01:38 from the bottom you will see that you were instructed to circulate an amended version of the action plan taking account of the nine items listed above it yes yes that's correct yes now um let's
00:01:50 yes yes that's correct yes now um let's just see what you say in your statement your first statement please page seven paragraph 26 you say
00:01:59 you say uh a member of my team at the time group manager max dissoniaki was responsible for keeping the action plan up to date now why did you delegate that work to max to signiaki do you remember um yes
00:02:11 max to signiaki do you remember um yes because max was already doing all of the updates on the previous rule 43 and the sai action plan which is where we've had the previous firefighter
00:02:22 where we've had the previous firefighter injuries and the action plans that flowed from that so uh he was already undertaking that role so it was ideal for him to carry on with that i see when did he start that role
00:02:32 role oh i i can't remember it was a very he'd been working the health and safety department for a very long time well i was going to ask you which department he was in health and safety yes is the case as he says in his
00:02:43 yes is the case as he says in his statement but so you delegated it to him um
00:02:47 um when you did so did you provide him do you remember with uh either a list of the 34 pre-inquest action items or
00:02:58 action items or i or the um the january 2013 edition of the lindridge report no i didn't the briefing that i had been given
00:03:08 given by
00:03:09 by gary reason who was my manager at the time was that he wanted that actually it had been agreed at the commissioners either see and build commissioners group that um
00:03:21 that um the rule 43 actions would be included in the same way as their rule for three action plans and that we would follow that format so i was working to the brief of using the coroner's
00:03:33 the brief of using the coroner's recommendations um exactly as that so that was the work i undertook i followed was there a sense in which you regarded this task
00:03:44 essentially taking on the version of the action plan at least in respect of the nine items as something of a clean start uh yes it was very much so that this the
00:03:55 uh yes it was very much so that this the the way this was going to be presented to otcb was as the coroner's recommendations i see
00:04:02 just panning out for a moment and asking a more general question was there any thought given at the time to
00:04:10 to making a smoother transition from where you'd got to uh with lindridge on the 34 action 34 actions pre-inquest and the rule 43 actions
00:04:22 and the rule 43 actions as a result of the rule 43 letter i'm not sure if any conversations were held by the um cmb or the commissioners group i wasn't made aware if there were any
00:04:33 wasn't made aware if there were any right so
00:04:35 right so did nobody at the time take any of the rule sorry any of the 34 actions
00:04:42 actions which remained relevant in light of the rule 43 recommendations see what had been done thus far and therefore see whether that informed what needed further to be done
00:04:55 informed what needed further to be done in the light of the rule 43 recommendations um i wasn't aware if that happened right why is that um i'm not sure um that would have been a decision that would have been taken by
00:05:07 a decision that would have been taken by cnb if that was to happen i would think yeah and you'd know about it if it had been if it had been decided if it had been decided it would have been uh given to me by gary reason yes right okay um let's see how to see if that
00:05:19 okay um let's see how to see if that comes back later in the questions but can we go to max to sneaky statement please this is at lfp triple zero eight six two four nine
00:05:29 uh and if we go to page three please in that statement let's look together at paragraph thirteen it's at the bottom of page three
00:05:39 he says i compiled the action plan from reviewing the updated information provided to me by all the owners of action points as listed in the in the relevant column of the action plan the initial draft of
00:05:50 of the action plan the initial draft of the action plan was provided to me by adrian bevin head of health and safety i believe the action plan was drafted for the director of operational resilience and training gary reason i was given existing material to work from
00:06:03 existing material to work from and then if we move uh to
00:06:05 to paragraph 15 on the next page page four he says
00:06:11 he says the process of review of the action plan was that approximately three weeks prior to the board meeting i would send a request for updated information to all owners of action points as listed in the relevant column of the action plan
00:06:23 relevant column of the action plan and then if we look at paragraph 17 at the foot of page four he says
00:06:28 he says once the information had been collated usually one or two weeks prior to the board meeting i would review the amended document and if necessary refer to the owner of an action point for further information or clarification
00:06:39 information or clarification approximately one week before the odcb meeting i would send the amended action plan to shireen malcolm for distribution to the members of the odcb by the agreed deadline which was approximately one
00:06:50 deadline which was approximately one week prior to the board meeting but first what was your role in overseeing that work um
00:06:57 um so
00:06:59 so look at this it seems quite complicated and confused but basically max worked directly to dr adrian bevin who led the health and safety department
00:07:10 who led the health and safety department and said that agreed format for using that information was something that had been going on for some time quite regularly gary reason would be the one who would be
00:07:21 would be the one who would be assisting in updating various actions and there would be direct communication between adrian bevin and gary reason i would normally be copied in on the
00:07:32 i would normally be copied in on the emails
00:07:33 emails but not necessarily be the one where the information was passing to and from now as assistant commissioner for operational assurance did you ever challenge the updates that were received from the other departments so for
00:07:45 from the other departments so for example where departments had not completed their actions in time or up to a satisfactory standard so if um group manager dysgn yaki was having issues with getting information in a timely fashion
00:07:57 in a timely fashion then i would send an email that would either come from myself or from david archer requesting the updates and if that we still weren't getting any joy then i would speak to gary reason who would
00:08:08 would speak to gary reason who would then email the other directors directly as it were for them to contact their heads right so your your role as um acla
00:08:19 acla uh if i can put it that way uh was is this right to um essentially ensure
00:08:26 ensure proper collation as opposed to quality assure it yes that's right now what about in your capacity as a member of odcb by which i mean did you or
00:08:37 or as a member or did the board in general ever challenge an update because for example the work was inadequate or incomplete yes the ogcb would
00:08:48 yes the ogcb would challenge information in the updates especially if somebody had information that they believed the update wasn't correct or that there was missing information or that it was ambiguous
00:09:00 ambiguous then there would be challenge provided can you give us an example um
00:09:05 um try and think of one where
00:09:10 so um i think that the the deputy commissioner was quite rigorous in her challenge quite regularly and if she thought that somebody was being
00:09:22 somebody was being overly ambitious in what they'd stated that so they thought work had been progressed further than it had she would ask them to provide the evidence for that
00:09:30 that can you give us an example of a specific no sorry i can't think of a specific one that's about if i were to look back at minutes and updates of those i would possibly be able to find one let's look then at the
00:09:41 then at the latin house working group and the strategy committee and what i might call the bevin review gary reason told us that the latino house working group was established to
00:09:52 house working group was established to provide political oversight scrutiny and accountability of the lfb's responses to the latin house fire and he was responsible for providing the latino house working group with the with
00:10:04 latino house working group with the with regular uh monitoring reports in other words updates uh on the lfb's progress as against the rule 43 action plan that's what he told us do you agree yes
00:10:15 that's what he told us do you agree yes that is correct now the first iteration of the rule 43 monitoring report as opposed to the action plan is that lfb triple zero
00:10:26 is that lfb triple zero six seven eight two zero
00:10:34 it's dated monday 30th of september 2013 and it's the note of a meeting or item one is note of a meeting of the 28th of august 2013.
00:10:47 and if you go to page 11 we can see the monitoring report attached to this agenda
00:10:56 agenda there it is and it runs for a number of pages thereafter um it's it's it's a separate document isn't it as we've seen from the rule 43 consolidated action plan presented at the meeting yes it is yes
00:11:08 the meeting yes it is yes um
00:11:09 um were these whether the two updates the updated action plan and the updated monitoring report kept separate because it suggests a reason because unlike the odcb the latin house working group was
00:11:20 odcb the latin house working group was focusing exclusively on the latino rule 43 recommendations that's correct and what was the odcb focusing on as well uh that was focusing on the rule
00:11:31 as well uh that was focusing on the rule 43 from shirley towers where the two firefighters had lost their lives
00:11:42 um gary reason also told us that he would he would take your latest update to the odcb and put that into the monitoring report for members um because as he said it was ostensibly exactly the same information just in a
00:11:54 exactly the same information just in a slightly different format for members consumption would you agree with that yes
00:11:58 yes now let's look at your statement um your first witness statement page 8 paragraph 28
00:12:06 uh you say there uh at a meeting of the elvipe strategy committee on 12 november 2013 director gary reason introduced a report
00:12:17 director gary reason introduced a report entitled latin house monitoring report and action plan and i will return we'll we'll turn to that report in a moment it's just a few months on from the first version of the monitoring report we've just seen
00:12:30 monitoring report we've just seen but let's stick first with the rest of your paragraph you say this having reviewed it i note that that report is in my name because i was the head of the relevant department however it was drafted by the head of health and safety
00:12:42 drafted by the head of health and safety adrian bevan the report included an action plan monitoring report which was presented by gary at regular meetings of the working group given that the report was going out in your name did you check its contents
00:12:54 your name did you check its contents um i would have seen the report but um i very much relied on dr adrian bevin for completing the details working very closely with um gary reason
00:13:08 i see so what was your role other than a conduit
00:13:14 conduit merely as a conduit merely as a conduit what was the point of being a conduit i couldn't gary reason do that um i think because the um reports the rule 43
00:13:26 reports the rule 43 updates came through the operational insurance department i think it was just felt
00:13:31 felt for it to line up that they would have it as a report in my name as head of operational insurance but as head of operation and operational assurance
00:13:40 assurance your domain was rather narrower wasn't it than the full width of the rule 43 uh action plan and related reports yes but because the health and safety team
00:13:52 but because the health and safety team were the ones who were responsible for providing the updates through jim just dysanaki that's how it came to be i think i see i think we're getting the picture of one of in essentially functionality but because
00:14:05 in essentially functionality but because of the system that you adopted from the health and safety department max disagne adrian bevan it came through you yes that's right gary reason that that
00:14:16 yes that's right gary reason that that may explain what i'm going to show you next can we go to lfb triple zero eight nine zero nine five this is an email dated the third of october twenty thirteen from gary reason
00:14:27 october twenty thirteen from gary reason to max
00:14:29 to max and you copy to adrian bevan subject re authority forward program ccg4
00:14:37 ccg4 and
00:14:38 and he
00:14:39 he talks about and i think i can summarize it
00:14:43 it preparation for the forthcoming 12th of november strategy committee and the dates by which things have to go in and to the cmb uh and in the second paragraph in the
00:14:54 uh and in the second paragraph in the last
00:14:55 last half of it he says it'll be for us to produce it and needs to be in the same format that i recently produced for the latino house member working group lhwg see attached copy of the action plan that we use for the lhwg earlier in the
00:15:07 that we use for the lhwg earlier in the week
00:15:08 week that was the september version we saw the 30th of september date on the meeting notes remember and the version that was produced there then he says this given the above it's clear that we need to crack on with preparing the covering report so i get a
00:15:20 preparing the covering report so i get a chance to see it before the dispatch date for the cmb on the 17th we also need to ensure that the updates to the wider rule 43 are consistent in the latino specific update that goes to odcb and the one i take to members
00:15:33 odcb and the one i take to members through the lhwg nb members are were very challenging regarding the lateral rule 43 so it may be helpful if i give you some feedback on this before we submit the rule 43 update to the next odcb meeting
00:15:47 update to the next odcb meeting what feedback did gary reason give on that subject i don't recall specifically and i'm not sure whether he gave the feedback uh directly to max um and adrian or whether
00:16:00 directly to max um and adrian or whether i was including that i don't recall how are the el fipa members quotes very challenging on quotes as he says in relation to the latino rule 43 actions so um i think um
00:16:12 so um i think um what he's referring to is the fact that quite rightly uh the members of elfipa um provide a robust challenge to the officers who attended the lachlan house working group
00:16:23 working group to ensure that they were giving full and proper updates into the work that was being undertaken now as we touched on a moment ago the drafting of the covering report was allocated to adrian bevan uh as you told
00:16:36 allocated to adrian bevan uh as you told us i think now let's look at see what adrian bevin says in his statement about this lfb triple zero eight nine zero eight nine eight nine zero eight nine
00:16:48 eight nine zero eight nine that's the first page of his statement there
00:16:51 there 29th of january 2020 is his statement if we go to page 4 paragraph 17 he says this at 17 and 18. i'll read both to you in october 2013 i was asked to draft the covering note
00:17:03 i was asked to draft the covering note of the monitoring report and action plan which is contained at pages one to three of the exhibit in which i will refer to as the covering note in this statement i will distinguish the covering note from the table contained
00:17:14 covering note from the table contained in the appendix to the document which i will refer to as the action plan i was assigned the task of drafting the covering note by the director of operational resilience and training gary reason and ac operational assurance
00:17:27 reason and ac operational assurance danny cotton as stated above danny cotton was my immediate line manager at that time i cannot recall the date when i began the task but i have reviewed my calendar records and i believe it may have been assigned to me at a meeting on
00:17:38 have been assigned to me at a meeting on 8th october 2013. now
00:17:42 now you can see that mr bevin exhibits a calendar invite there as he refers to let's look at it it's at lfb triple zero eight nine zero nine two
00:17:55 there it is and you can see that uh gary reason sends the invitation to you uh to uh
00:18:01 uh uh adrian bev and max de signing and david lindbridge do you remember the meeting no i don't recall i'm sorry have you any recollection or impression of a
00:18:12 recollection or impression of a recollection of what was discussed at the meeting um no i'm i'm not even sure from this whether i attended the meeting that was a meeting invite but i would have to be able to
00:18:21 able to access my diary to see if i actually attended is there any reason why you wouldn't have done apart from unexpected personal things if well if i'd been on leave or if i'd been on an operational incident or if i'd been at
00:18:32 incident or if i'd been at already at a different scheduled meeting then there could be a number of reasons now the finalized report to the strategy committee which we saw referred to a little bit earlier for the 12th of november 2013 meeting is that nfb triple
00:18:45 november 2013 meeting is that nfb triple zero eight nine one one seven if we go
00:18:49 if we go to page one of that you can see what it is
00:18:54 blacknell house monitoring report and action plan to the two elements identified in the report titled there date 12 november 2013 report by assistant commissioner operational assurance as you
00:19:06 assurance as you as you say you put your name to it we've seen that from your statement and
00:19:11 and if you look at the summary
00:19:16 summary it says on 20th of june 2013 the authority was presented with a paper that discussed the outcomes from the coroner's inquest into the fire at lack lachen house on third july 2009 in which six members of the public tragically
00:19:27 six members of the public tragically lost their lives that paper also described the actions that the commissioner would take in response to the coroner's recommendations at the authority meeting it was agreed that implementation of the actions would be
00:19:38 implementation of the actions would be monitored at both officer level via the operational directorate's coordination board adcb and via monitoring reports presented to meetings of the strategy committee this report responds to the latter requirement for providing a
00:19:50 latter requirement for providing a regular update to the members of the strategy committee so that was the plan that's the idea and if you go please to page two
00:20:01 two you can see paragraph six
00:20:05 six under the heading progress made against the action plan and paragraph 6 says so that members can easily see where the progress of the plan deviates from the time scale commitments included in the commissioner's response to the
00:20:16 in the commissioner's response to the coroner letter dated 23rd of may 2013 refers and we've seen that in in the evidence the information has been color coded only one activity failed to be delivered
00:20:28 only one activity failed to be delivered by the target date which relates to the establishment of the high-rise forum officers had intended to establish this new forum by the end of august but due to the availability of the key stakeholders the inaugural meeting was
00:20:39 stakeholders the inaugural meeting was actually held on the 4th of october para 7 all other tasks are progressing in accordance with the agreed time scales or have been completed
00:20:50 scales or have been completed did you verify that information particularly in paragraph seven uh when you read through dr bevin's draft
00:20:57 draft um no because the information would have been that that was taken from the rule 43 action plan that would have been agreed
00:21:05 agreed by odcb
00:21:07 by odcb well um we tried differently uh this report is going out in your name yes yes so when you when a statement was made by you or under your name to the strategy committee
00:21:17 committee did you check yourself and verify the truth of the statement all other tasks are progressing in accordance with the agreed time scales or have been completed i was aware that adrian bevin and max
00:21:28 i was aware that adrian bevin and max disney would have been working to the information that odcb had ratified which i would have been present at so i would have been content that that information was correct
00:21:38 correct right so the answer to my question is you did verify the information did you when you read through dr bevin's report only by the fact it was the same would correlate with information odcb i didn't have to conduct an independent
00:21:49 have to conduct an independent verification of this table as it was a lift of the information from odcb so you checked that it was the same as what odcb was being told and no more than that yes that'd be it yes i see um
00:22:00 than that yes that'd be it yes i see um now it appears that the next information on which the strategy committee was updated about the work of the black house working group and the rule 43 actions was in the 11th of july 2014
00:22:12 of july 2014 report to that committee the strategy committee
00:22:15 committee let's look at that lfb triple zero six seven eight one nine
00:22:22 uh and uh there it is uh on on the screen latino house working group strategy committee meeting 11 july 2014 report by deputy commissioner and director of operational resilience and
00:22:34 director of operational resilience and training
00:22:36 training uh that's not you that's gary reason that's right why that why had there been a change
00:22:41 a change um i think because gary reason would actually have presented the report and because he was the one who was responsible for presenting all the information to the lack of house working group i think he felt it was more appropriate that
00:22:52 felt it was more appropriate that reports were actually going in his name because he was essentially the responsible officer even though the functional route to reporting to the strategy committee in late 2013 as we've
00:23:03 strategy committee in late 2013 as we've seen had been through you because of the origins of the data in the health and safety or other the origins of the formatting within the health and safety department i think this is because at this time gary reason was working so
00:23:14 this time gary reason was working so closely with dr adrian bevin and max disonike on the updates of the report that
00:23:20 that he felt he had that oversight and therefore the report went in his name right at what point did was the decision made that it should no longer be you who put the name to the report but him up
00:23:32 put the name to the report but him up him and rita dexter i'm not sure that would have been the decision they would have taken i'm not sure when that was taken right but they didn't include you in that decision did they or did they they didn't right and now if we um look please at uh
00:23:44 now if we um look please at uh the
00:23:45 the summary you can see it says that it's the final update to the strategy committee detailing the work that has been initiated and progressed by the latin house working group recommendations one that the work of the latino house working group be noted too
00:23:57 latino house working group be noted too that this report be agreed as the formal conclusion of the work of the latino house working were you aware of that i think you're speaking quite quickly
00:24:08 speaking quite quickly that's me quickly is a new thing so perhaps i think stenographers finding it difficult to follow all right i'm sorry i will slow down i'll say it again so it can be got down
00:24:20 i'll say it again so it can be got down properly recommendations one but the work of the latino house working group be noted two that this report be agreed as the formal conclusion of the work of the latino house working group
00:24:32 the latino house working group now were you aware that at this point in time a number of the rule 43 actions were incomplete
00:24:43 i would have been aware of the updates that were going to odcb yes
00:24:51 my question was were you aware at this point in time july 2014 that there were a number of rule 43 actions that were incomplete
00:25:02 rule 43 actions that were incomplete yes from the same from the from the rule 43 action plan that was going to odcb not from the latino house working group because i wasn't involved in that but through my work with odcbs right
00:25:13 right so the answer is yes yes did you tell gary reason that there were a number of outstanding items from the rule 43 of rule 43 actions gary
00:25:26 from the rule 43 of rule 43 actions gary reason was fully aware because he was a member of odcb and had seen the rule 43 action plan updates did you know that gary reason nonetheless
00:25:38 nonetheless was telling the strategy committee uh that
00:25:44 that this was the formal conclusion of the lack of house working group no i wasn't aware of this
00:25:55 did you see this report before it went no i wasn't parted to the either being at the commissioner's cnb or strategy committee so i wouldn't have seen any of these papers
00:26:08 can i then turn to a different topic which is incident command training now i should say that in the course of examining this topic we will come time and again i think to the action plan
00:26:20 and again i think to the action plan and the updates given to the odcb
00:26:26 let's look at lfb triple zero four three four zero six two
00:26:35 this is a document with which we
00:26:40 examined with gary reason when he gave evidence and this was referred to as the lfb's rule 43 pro former do you recognize this document i believe i was shown it i wasn't i
00:26:52 i believe i was shown it i wasn't i didn't i don't remem recall taking part in filling it in i think that was the comms department right when did you first see this document do you think um i don't recall i have seen it in my preparations to
00:27:04 i have seen it in my preparations to come here but i don't recall the time when i first saw it
00:27:09 do you think you saw it at the time from april or may 2013 um i i would be guessing i don't remember i would imagine i would have seen it but i don't recall seeing it
00:27:21 seen it but i don't recall seeing it it
00:27:21 it i think we can proceed and correct me if i'm wrong about this that this was an internal working document created in about april 2013 and intended to scope out potential ways in which the lfb
00:27:32 out potential ways in which the lfb could respond to the lack of house rule 43 recommendations yes i believe so now the incident command section of this document starts at page 11. can we
00:27:43 document starts at page 11. can we please go to page 11.
00:27:47 now that there is the subject incident commanders and you can see the box arrangements there
00:27:53 there and
00:27:56 and before we look at the detail um let me ask you this gary reason told us that you were the head of service responsible for the response to the coroner's incident command recommendations is that right that's correct and
00:28:08 is that right that's correct and therefore you were responsible for the content of this part of this document um interestingly i was responsible for part b definitely part a was undertaken
00:28:21 was undertaken was a piece of work that was being done by ac dave brown in conjunction with the operational policy department because the the wider document that talked about
00:28:33 the wider document that talked about attendance at operational incidents was subject to operational policy on that but it was a larger piece of work that dave brown was also working with the fire brigades union on about the changes
00:28:44 fire brigades union on about the changes in officer level so section b was mine but dave brown and op were doing section a now i'd like to focus on the second recommendation there which is b which you yourself pointed out let's just look
00:28:55 you yourself pointed out let's just look at that it says it is also recommended that consideration be given to training of ics and potential ics to enhance their performance in relation to the following and then there are seven
00:29:07 the following and then there are seven incident command topics i'll read them to you although we can find them in the rule 43 letter itself but it's worth under just reminding ourselves of what they
00:29:17 they are one use of the dynamic risk management model and other management tools to enable ics to analyze the situation and to recognize and react quickly to changing circumstances
00:29:28 quickly to changing circumstances two
00:29:29 two to recognize when to escalate attendance by a more experienced ics three
00:29:35 three to anticipate that a fire might behave in a manner inconsistent with the compartmentation principle four to be aware of the risks to those above and adjacent to the fire flat
00:29:47 above and adjacent to the fire flat five handover from one ic to the next and effective deployment of outgoing ics six the collection of information from all possible sources seven use of methodical search patterns
00:30:02 seven use of methodical search patterns now when you first saw this uh
00:30:06 uh whenever that was did you think that there was anything unclear or confusing about any of those recommendations no no let's go
00:30:17 let's go to see what ron dobson told the coroner about incident command and some of these recommendations can we please go
00:30:27 to pages 13 to 17 of this self-saying document which sets that out
00:30:34 now i'm not going to read this all to you
00:30:37 you but can i take it that you're familiar with this part of the document this is uh commissioner ron dobson's evidence uh
00:30:45 uh to the inquest in answer to questions asked by mr james maxwell scott yes i've seen this yes um and if we go to page 19 i think we can pick it up
00:30:56 can pick it up just
00:30:57 just scrolling down page 19
00:31:01 what is said there's a lot of it runs over to page 20 and 21. if you just scroll gently through that
00:31:12 this is about embedding the performance review of command notification of monitoring an incident the role of an officer at uh um incidents and the carder and then if we
00:31:24 incidents and the carder and then if we go to page 21 we can see more of the same
00:31:28 same and then page 22
00:31:32 we can see on page 22 the the two items a and b
00:31:36 a and b which are the proposals to address uh everything that had come out of the inquest
00:31:42 inquest you've referred to a um just looking at b it says this the lfb will engage with our training contractor to ensure the points specifically listed in recommendations one to seven
00:31:55 in recommendations one to seven are addressed in the current review process of incident command training this work will aim to ensure that the training provided enhances performance across the range of required skills and knowledge needed to support effective
00:32:06 knowledge needed to support effective incident command the brigade will also introduce a case study which will incorporate the learning outcomes from latin house and from other high-profile high-rise incidents such as shirley towers
00:32:17 incidents such as shirley towers hampshire and harrow court hertfordshire now gary reason told us that that proposal
00:32:24 proposal would have was put together by you and your incident management training team and that you would have i think is how he put it have been comfortable with those proposals before they were presented
00:32:35 before they were presented to the commissioner to the deputy commissioner rita dexter and the various directors that's that's what he said at day 180 page 169 line 25
00:32:46 line 25 to 170 line 5 do you agree yes
00:32:54 that being said how did you arrive at that training proposal the one identified in b um that was a result of a conversation with
00:33:04 with um other senior operational colleagues and with
00:33:08 and with james douglas who was in charge of hr training and with gary reason about the best way forward to address the issue
00:33:19 right were there formal meetings at which that was discussed and minuted i believe that was discussed at our director at management board meetings which gary reason would chair where
00:33:30 which gary reason would chair where peter cowop from operational policy and james delgalesh and
00:33:35 and graham ellis would be there as well so be colleagues who would have the relevant information
00:33:42 right did you yourself have do you recall specific input into the into that wording the language i've read to you and b
00:33:52 and b i don't recall but i think the other person who was heavily involved in this was dac tim cut bill who had been the lfb lead for the investigation
00:34:05 lfb lead for the investigation into lachlan house and the work throughout with the coroner's inquest he was the one who had the detailed information so i know that he was working very closely on a lot of these
00:34:17 working very closely on a lot of these recommendations as well so i don't recall the specifics of how the wording came to be but um i believe those people were involved in it and i know that dac cut bill had a lot of involvement with that
00:34:30 lot of involvement with that yes and in that connection then let me just show you a document to fix it in your your mind and that of others lfb3091864 please
00:34:47 this is an email from you to uh
00:34:51 to uh graeme ellis adrian bevin and michael curran
00:34:55 curran the 19th of april 2013. uh if we go uh to the text of it you can see it it
00:35:06 to the text of it you can see it it starts hi folks i attended the meeting below about the rule 43 from lachnal and we have been given a piece of work to do to respond to the leadership element i had a quick chat with graham yesterday but ideally i would like to meet with
00:35:17 but ideally i would like to meet with all of us on wednesday if everyone is free i'm awaiting some further info from tim cut bill including the commissioner's statement and the detailed questions that the commissioner wants answering but to give you an early
00:35:28 wants answering but to give you an early heads up we need a draft response by first week of may and if you look down the screen you can see that this tops an email or overtops
00:35:39 see that this tops an email or overtops an email from tim cut bill to you among others you can see that the 16th of april um attaching a rule 43
00:35:51 attaching a rule 43 uh and a proposal for discussion about how you might organize the response that's what he sent you does that
00:35:58 does that email change so far as i've read it to you
00:36:01 you assist you in your recollection of your involvement yes it does yes now then let's move on in time a little bit to may 2013 can we please go to nfb triple zero eight five three five
00:36:13 to nfb triple zero eight five three five six
00:36:16 six this is an email of the third of may 2013.
00:36:23 uh if we can have that expanded please
00:36:28 it's not terribly easy to see but it says
00:36:31 says from you third of may 2013 to gary reason steve churick and dave brown and james knighton pro former for rule 43 responses incident command response dc
00:36:43 incident command response dc can you see that uh yes yes he says hi folks please find attached oas first draft of the response to the rule 43 for today's meeting very much a
00:36:54 rule 43 for today's meeting very much a work in progress we have included the relevant parts of both the commissioner's written and verbal submissions for reference thanks danny does that
00:37:05 does that tell us i can show you the attachment perhaps i should show you the attachment before i ask my question it's at lf b three zeros eight five three five seven
00:37:23 and you can see the first page of the attachment there
00:37:30 and if you scroll down over the next few pages you'll see the outtake from the transcript of the uh
00:37:38 uh of the inquest ron dobson's evidence and then if you go uh to page seven
00:37:46 seven you can see uh the current position and then you've got in the box with regard to part b of the recommendations the seven recommendations there
00:37:57 recommendations there uh and then if you go to page nine you can see the proposal
00:38:02 proposal uh under
00:38:03 uh under a little that little a we propose to address the rule 43 recommendations by the following actions and you can see the text um was that drafted by you
00:38:15 um was that drafted by you given the email i've shown you which covered it so a
00:38:20 a probably not because that was the issue i was referred to earlier relation to dave brown and operation policy about the changing of officer level thresholds if it goes on
00:38:31 officer level thresholds if it goes on to section b then if i could see that well it does go on on page 10 if you turn the page thank you to
00:38:44 cover um in the fourth line a planned review of training provided for offices in the areas listed in be one to seven to ensure that the appropriate training is provided and
00:38:55 appropriate training is provided and assessment of competence in these areas and then it goes on to say we're proposing to introduce a case study which will incorporate the learning outcomes not only from lack of house but also shirley towers and harrow court
00:39:08 also shirley towers and harrow court etc that looks like your area yes so i think this this response here would have been a combined response from a number of departments but looking at
00:39:19 but looking at that text if nothing else in this document and the covering email of the third of may 2013 can we take it that you were involved in yourself in the drafting of some elements of the rule 43
00:39:31 elements of the rule 43 action plan yes i was yes at least in respect of b and in the respect we've seen thank you now can we then turn against that background to the next thing which is the lack of house
00:39:43 next thing which is the lack of house case study which
00:39:46 which came
00:39:47 came to
00:39:48 to fruition
00:39:50 fruition as such through something called tcap0153
00:39:55 tcap0153 and i want to ask you about that um can we please go to that tcap at lfb triple zero 67857
00:40:08 this is the first page of one five three uh and if we go to page as well you can see the title is latino training case study and if we go
00:40:19 training case study and if we go to page four please of that tcap form we can see
00:40:23 can see the title latino training case study and then under paragraph 1.2 name of commissioning officer and their department ac cotton operational assurance
00:40:33 assurance and dave brown is the client as you can see from the next paragraph yes correct now um in module 5 of this inquiry peter groves told us that the commissioning department would have
00:40:44 commissioning department would have primary responsibility for the training package and its training needs and learning objectives is that pausing there is that correct um in the main it's correct i think there
00:40:55 in the main it's correct i think there was a slight difference in the case of the um two tea caps relating to lachenal because um although and i think as pete mentioned as well
00:41:06 and i think as pete mentioned as well although a name of the commissioning department officer will be put on there um the detail of it is uh normally completed by somebody else and in this case the lead officer was uh dac tim cut bill because of his involvement in
00:41:19 bill because of his involvement in the latin investigation and his involvement throughout the process he was the most detailed officer and subject matter expert right across the case for lacking all so this was something that he was
00:41:32 all so this was something that he was involved in commissioning and involved throughout and in fact subsequently was the person who produced and delivered all of the senior officer aspect of this training package
00:41:44 aspect of this training package now to be fair to you it was indeed ac tim cutler who signed this off in may 2016 in fact we can see that later in the document we'll come to that
00:41:55 later in the document we'll come to that but on the basis of what we see on page four
00:42:00 four it looks like you were the commissioning officer
00:42:02 officer that's another thing of a name only yes it was my department and um indeed group manager mike curran had also worked with tim cuthbill closely on the lachenal house
00:42:13 lachenal house investigation who was then had returned and was working health and safety worked alongside tim cut bill and others on the development of this package right you say in name only
00:42:25 you say in name only did you
00:42:26 did you as the commissioning officer identified as such on this page have any involvement in the development of this tcap no i didn't
00:42:38 could you just explain why that is given that it is your department that was the commissioning officer or rather the commissioning department yes because operational assurance was given
00:42:49 because operational assurance was given the role of the commissioning department because these were aspects in relation to incident command which clearly came in to my
00:42:57 in to my department but because dac tim cutsville was the very much agreed subject matter expert and had been working directly to the commissioner ron dobson on this issue
00:43:08 commissioner ron dobson on this issue it was agreed a very early stage that he would be the one that would be the lead authority subject matter expert and responsible for the development of this package
00:43:19 package right
00:43:20 right subject matter expert i understand but would would it not be necessary for your department as the commissioning department and you as the commissioning officer nonetheless to keep
00:43:31 officer nonetheless to keep oversight supervisional responsibility for the development of this tcap so the oversight was conducted by the liaison between tim cutville and mike curran
00:43:44 between tim cutville and mike curran the and the fact that it was such a very specific subject on a case study around la canal there it was decided that tim couple who was also a very senior
00:43:55 tim couple who was also a very senior officer would be the one who would be leading on this to whom was tim cut bill responsible in his line of reporting in respect of this tcap gary reason
00:44:07 tcap gary reason and gary reason [Music]
00:44:09 [Music] to i suppose for the commissioning group commissioner and cnb yes so
00:44:17 so does that mean that you were not in the reporting line at all in respect of this tcap so
00:44:23 tcap so assistant commissioners weren't generally in the reporting line of tea caps once a commissioning department and the officer once this teacup had been completed
00:44:32 completed there would then be a dedicated group of people involved in that including people from the commissioning department but then working very closely with the learning and development team nick
00:44:43 learning and development team nick markwell's team and then the team from the babcock's external training provider so those people working together on the development of the package i was aware of updates clearly because
00:44:55 i was aware of updates clearly because tim cuthbert brought those to the directorate management board because we were in the same directorate so i was aware of the progress it was making and sometimes frustratingly slow progress but i was not the person who had the
00:45:07 but i was not the person who had the day-to-day oversight of it and in fact assistant commissioners didn't have day-to-day oversights of tcaps
00:45:17 so you not just see if i can draw the threads together on where we are so far neither you as the commissioning officer nor your department as the commissioning department were in
00:45:29 as the commissioning department were in the line of supervision of the development of this tcap members of my department where yes members of your department yes absolutely but those members of your department
00:45:40 but those members of your department including tim cut bill reported out of your department in respect of it so sorry tim cupple wasn't in my department he was in my director sorry it's very confusing right okay so gary reason was our director in charge of us uh a number
00:45:51 our director in charge of us uh a number of us sat underneath him in our departments including myself and tim cutball and peter cowart and peter groves and james delgalesh gleash will sat underneath gary um
00:46:02 sat underneath gary um so tim would report into gary as his line manager um i would report to gary as my line manager yes so coming back to the the words of the document yes i think i'm right on tai that all
00:46:15 i think i'm right on tai that all members of your directorate would
00:46:19 would report in respect of this development of this but not your department no some members of my department were directly involved as part of the stakeholder group development developing
00:46:31 stakeholder group development developing this package so mike curran who worked for dr adrian bevin
00:46:36 bevin therefore for me was in the stakeholder group but they didn't report up the department they reported out of the department so um in the development of tcaps people didn't
00:46:47 the development of tcaps people didn't report through into the top of the commissioning board um it's quite complex quite difficult to explain this process because i found it endlessly frustrating myself trying to understand and get to grips with the
00:46:59 understand and get to grips with the tcap process it was a very i think unnecessary burdensome and complex process to develop training that involved a number of different people at different times
00:47:11 people at different times so there
00:47:12 so there there wasn't a situation where you would sit down and have a commissioning department's discussion around that tcap that wasn't the process that happened so it would be
00:47:23 so it would be then on to the management of the learning management strategy in people in that team to manage the ongoing progression of the tcap until it was developed into a product which would then be reviewed and ultimately signed
00:47:34 then be reviewed and ultimately signed off
00:47:36 off but not signed off by you no this was signed off by uh ac tim cut bill it was but not and not you even though you were the commissioning officer no this was a anomaly with this specific um tcap
00:47:48 anomaly with this specific um tcap because of the nature of it right let's try dave brown ac brown he's the client and his department is apr as we can see
00:47:56 can see what was his role can you tell us in
00:48:00 in the um
00:48:01 the um any input into the content of this document or its oversight and supervision the same he wouldn't have had any he was just the client for it but he had a member of his team who i believe was deputy assistant commissioner adrian
00:48:13 deputy assistant commissioner adrian fenton who was involved in the stakeholder meetings around this subject right
00:48:19 right now well let's let's see how we go with the document against that background um if we can go please to page four uh at the bottom of the page you can see section 1.6
00:48:30 you can see section 1.6 which has now come into view um
00:48:34 um background context uh it says
00:48:39 uh members of the public lost their lives at lachnal house incident this was subject to detailed investigations and recommendations under rule 43 of the coroner's rules and then if you turn the page please to
00:48:50 and then if you turn the page please to page five
00:48:53 page five the particular importance of applying policy and training appropriately at this type of incident has been highlighted by these investigations the learning outcomes from this incident needs to be shared with operational
00:49:05 needs to be shared with operational staff to inform and influence their approach dealing with this type of incident
00:49:10 incident the lfb is seeking a training case study that focuses on the learning outcomes listed in section 4.1 with the coroner's seven recommendations considered
00:49:21 seven recommendations considered throughout the training as they also relate to the learning outcomes as mentioned the purpose and main objective of this tcap is to share the learning outcomes from the latino incident not to develop another high-rise training pack
00:49:33 develop another high-rise training pack this training must be consistent with existing training and policy and signpost existing training and policy where relevant
00:49:44 what was meant well let me ask you a prior question um when this document was created apparently in your name did you see it um no i don't believe i did don't
00:49:55 um no i don't believe i did don't believe you did would it be normal for the commissioning officer and the commissioning officers department not even to see a tcap in this form i would say quite normal for the
00:50:07 i would say quite normal for the commissioning officer not to see it but not for the commissioning officers department not to be involved and i saw as you scroll down there that um there were two people in my department who were involved in this
00:50:19 who were involved in this uh i i
00:50:21 uh i i when i scrolled down i'm not sure what i scrolled down past but maybe page four if we get back to it where you see a list under paragraph 1.4 of the stakeholder group members we've got tim cut bill and nick markwell
00:50:34 cut bill and nick markwell adrian and adrian bevin and then you have neil withers as well who was the uh graham ellis's deputy in instant command i see uh can you help us nonetheless even
00:50:46 uh can you help us nonetheless even though this document appears to be fairly alien to you but can you help us with what was meant by the intention to share the learning outcomes from the latino incident um
00:50:57 um exactly that that the purpose of this was to have a training package that was focused on la canal
00:51:03 la canal and the outcomes and therefore the coroner's recommendations from that incident right was it in your mind at the time when you say that the training package was to be
00:51:14 that the training package was to be focused on lachenal but it would tell the story even by way of an abbreviated timeline of what actually happened at the incident yes that was the idea that was the idea was it
00:51:26 it now we've seen the coroner's rule 43 recommendation uh containing seven specific areas where incident command training could be improved
00:51:35 improved do you know why it was that the training package didn't seek to make those improvements but was in was tied instead to existing training and policies
00:51:44 um i don't believe it was well if we look over back at page five help me with the and maybe you can't given your relative unfamiliarity with it but
00:51:55 relative unfamiliarity with it but in the third paragraph in the last sentence it says this training must be consistent with existing training and policy and signpost existing training and policy where relevant
00:52:07 where relevant why
00:52:08 why because we had an existing high-rise policy an existing policy on a number of other which i think you'll find are listed below and what that means simply is that
00:52:19 and what that means simply is that the relevant policies and procedures must be followed in this training package not that it is simply to deliver a training package on those it's to deliver on lacanel but ensuring the high-rise policy that the
00:52:31 ensuring the high-rise policy that the on arrival tactics policy the dynamic risk assessment policy are all adhered to in that because those were existing policies for london fire brigade why was it necessary for the training
00:52:42 why was it necessary for the training the new training which was to learn the lessons in those seven respects to be consistent with existing training and policy because if we didn't make it consistent
00:52:53 because if we didn't make it consistent with existing policy then we would be um confusing all of our instant commanders who are trained to the existing london fire brigade policies if we went outside of
00:53:04 brigade policies if we went outside of that policy and told them to do something different they would quite rightly question that because we have an existing suite of operational policies well i have to say i find that a little puzzling because
00:53:15 puzzling because one conclusion might have been that the existing policies were not adequate and and you're right sir but i think what this intended to do the the intention of this was that it would describe the lack of
00:53:26 describe the lack of house fire step by step with what happened and then make reference to the policies and i think potentially i know a number of the policies have been reviewed and i know you've been
00:53:37 been reviewed and i know you've been detailed through a number of those and
00:53:41 and i think sometimes it's not the policy that's at fault it's the application of the policy or potentially the understanding of the policy and by having a case study i think that the vast majority of firefighters really
00:53:53 vast majority of firefighters really understand a case study because you have a picture you have a building you build a story up and then you build the training into that story so it's it's a real life experience as opposed to just sitting down with a list of things that
00:54:05 sitting down with a list of things that you have to adhere to it kind of combines them in a real life experience for them
00:54:09 for them yeah all right thank you
00:54:17 on the language as it stands in this tcap though was there not the risk that consistency with existing training and policy would be prioritized over development of
00:54:29 would be prioritized over development of policy and training as recommended no i don't believe so because this was a such a specific subject matter lacking house that we'd
00:54:40 matter lacking house that we'd obviously had such detail on that the the focus of this training package was to relate the story of the lack of house fire
00:54:49 fire now the learning outcomes that are referred to in the background text i think appear at page nine of this document if we can go to that please
00:54:58 please and we see there that again the
00:55:01 the uh
00:55:02 uh outcomes are listed at one to seven verbatim
00:55:07 verbatim and do you agree that that would suggest that the case study was intended to address each of those recommendations yes definitely yes
00:55:18 yes definitely yes and how would the the the package provide meaningful improvements in those seven areas if the tcap had to be consistent with existing training
00:55:29 existing training uh given there's there might be a risk that they were contradictory so um
00:55:34 so um none of those um issues list in 107 were in any way contradictory to existing london fire brigade policy and procedures um they were
00:55:45 um they were all a part of the existing suite of policy and procedures we had and the the idea of the lachenal case study was to go through step by step the
00:55:56 was to go through step by step the progression of the fire at la canal and then to break and have conversations um with the people that were being trained together whether that was senior officers or fire station watch based staff about the specific issues in there
00:56:10 staff about the specific issues in there in relation to how they related to lack of house i've seen so this at this point uh 2013 the aim was as you've just put it to go through step by step the progression of the fire at lachnal and
00:56:23 progression of the fire at lachnal and then to break and have conversations yes that's the idea and then that enabled discussion so for instance you would break and say at this point the watch manager was being given information from a member of the public
00:56:34 a member of the public from here and from there how would you collate that information how would you share that information how would you make sure you're getting the best out of it that kind of thing so it would be that discussion point then where people could then chip in and
00:56:46 could then chip in and have a conversation about that
00:56:50 it looks from this document that somebody has essentially cut and pasted
00:56:54 pasted the as learning outcomes the seven
00:56:58 the seven recommendations yes that's correct yes can you just help me uh did anybody actually sit down and work out what trainees would have to learn in order to achieve
00:57:08 achieve uh
00:57:09 uh for example five handover or six collection of information from all possible sources or seven use of methodical search patterns um i believe um that i've seen a
00:57:21 um i believe um that i've seen a document that is actually a table where these seven items are taken and then they are mapped against current policy and which uh what um
00:57:33 and which uh what um both firefighters and officers would need to do to understand that the reason i asked the question in the way i did was because items one to four are outcomes uh they are things that you would expect
00:57:45 uh they are things that you would expect you would train someone to do uh
00:57:49 uh use recognize anticipate be aware but five six and seven aren't outcomes they're just functions aren't they i think the reason they're worded like that is to be very specific and not
00:58:01 that is to be very specific and not dilute the intent of the coroner in the recommendations she made so to make it explicit that those were the outcomes required from the training and i think if you
00:58:11 if you reword them you potentially risk losing the essence of what they were at that time i believe that's why it interrupted you mr william but i have difficulty
00:58:22 difficulty in understanding the approach of the lfb to coroner's recommendation number two which is all concerned with the experience of the incident commander
00:58:34 the experience of the incident commander and um
00:58:36 and um i don't have her words on the screen and i can't remember them specifically but i think what she recommended was that the lfb give consideration
00:58:47 consideration to the way in which incident command moves from one officer to another
00:58:54 really strictly in accordance with seniority at the scene or the number of fire appliances sent to the scene now
00:59:03 i'm not sure that uh
00:59:07 uh this formulation actually addresses her concern and the answer to her concern may have been it's that we've got the best system we could have anyway um and i think so from recollection um that the
00:59:19 i think so from recollection um that the commissioner's response was that um there were a number of steps in place that london fire brigade believed to address that and also the addition of changing the thresholds of command
00:59:30 changing the thresholds of command so instead there being such a rapid handover because it changed at four pumps six pumps eight pumps to actually increase the gap between them so that officers were responsible for a greater number of fire appliances reducing that
00:59:42 number of fire appliances reducing that handover process but
00:59:45 but simply cutting and pasting parts of the coroner's letter into this document doesn't necessarily address the point that she was trying to get out no no i agree with that stuff
00:59:56 no i agree with that stuff all right thank you yes mr sorry's interrupted thank you now we also heard from peter graves when he gave evidence that the commissioning department would have been i think is what he said
01:00:07 would have been i think is what he said involved in the development of a training package and its content and would ultimately be required to sign off that content before it's released do you agree with that uh in the normal run of events yes i said
01:00:18 in the normal run of events yes i said and this one was slightly different in that dsc tim so ac tim cutball was the one who was um very heavily responsible for the development of it right so in the normal run of events you
01:00:29 right so in the normal run of events you would have been the person responsible for signing off this tcap uh yes i would have been but in this case it didn't happen it was tim cut bill for the reasons you've explained
01:00:40 yes is it right that the training which was developed under this tcap consisted of a cbt study package for those ranked firefighter up to watch manager
01:00:53 firefighter up to watch manager and for those ranked station manager and above a half day case study facilitation delivered by way of a presentation from d from ac cup bill um
01:01:04 um sorry the the cbt package was an interactive video presentation where the
01:01:11 where the video played of the progression of the fire at la canal there were voice overs from the incident commanders who had been actually at la canal relaying information
01:01:22 information about what they were told at the time what they'd seen um and then there were um
01:01:29 um the video would then pause once all the information had been and then there were some
01:01:33 some questions posed about uh what would you do with this information could you now do a line drawing to demonstrate what the information you've been given is so it was a combination so
01:01:45 so it was a combination so cbt package it was a very interactive video package that involved directly the incident commanders who had been there on the at the latino fire when you say it was very interactive
01:02:01 could you just explain what you mean by that well in that it wasn't just um sometimes cbt packages were um
01:02:11 would you call them video i can't think of the word like not cartoons but you know they were images they weren't real people these were the real people who had been involved in lacanal
01:02:21 lacanal who were giving a voice over to the real fire that was happening so they played timed slots of the fire developing and they stopped it and demonstrated so it was actually the real building that was on fire with real timelines of it
01:02:34 was on fire with real timelines of it and the actual incident commanders relaying the story of what happened to them and then stopping it to be able to pose the questions for staff to
01:02:42 staff to discuss various aspects of it we'll look at it in a moment before we do can i just ask you uh it's right i think from what you've told us that even though this was an interactive cbt
01:02:54 though this was an interactive cbt package
01:02:55 package watchmen crew managers and watch managers only received that and didn't get any teacher-led training they had a trainer's guide that came with it that
01:03:06 trainer's guide that came with it that was quite a comprehensive document for them to follow as they went along they didn't receive any additional one-to-one training for it no do you know who decided that they should have interactive cbt as opposed to
01:03:18 interactive cbt as opposed to trainer-led presentations um
01:03:22 um i don't know i imagine that would have been a decision reached potentially by the
01:03:27 the the group who put the package together i wasn't aware of that given the
01:03:32 given the apparent importance of this training uh in order to carry out the recommendations of the latino culinder coroner do you know what
01:03:43 latino culinder coroner do you know what the rationale for the training being in the form it was
01:03:48 was uh was as opposed to teacher-led so
01:03:52 so i'm not 100 sure but knowing what i know about delivering training so bearing in mind there are 440 different workplaces that the training
01:04:03 different workplaces that the training would need to be delivered in to have delivered that as a trainer-led training would have been a very resource-intensive very time consuming and would have taken far longer to roll out that training
01:04:14 far longer to roll out that training program
01:04:15 program to those individual watches whereas a cbt
01:04:18 cbt can be sent out as a package which they can then all access immediately it wouldn't be dependent on having a trainer arrive at their place of work to deliver the training to them or getting them together at one venue to
01:04:29 or getting them together at one venue to see the training given that crew managers and watch managers were invariably first responders at a fire and would have to make decisions very quickly if the fire developed beyond the
01:04:40 quickly if the fire developed beyond the compartment of origin or there was a sudden impending growth of fire why is it that they only got computer-based training um i wouldn't say it's an only computer-based training it was a very
01:04:53 computer-based training it was a very comprehensive say an interactive and and received very good feedback from the crews they like the visualization of being able to see an incident and hear the people talking about it as i said that would have been the same issue i
01:05:04 that would have been the same issue i believe that um from crew manager up to senior officers this was um approximately 1700 people that needed this training as officers so to be able to do that with trainer-led
01:05:15 to be able to do that with trainer-led training would have been would have caused a great uh further not greater further delay in being able to get the training out to the individuals now let's look at
01:05:27 now let's look at the training guide for station-based staff
01:05:31 staff issued by babcock in august 2014 baby
01:05:37 baby please
01:05:49 now um first you can see at the very foot of the page the date of 22nd of august 2014 and you can see at the top of the page that it's called training guide station
01:06:01 that it's called training guide station based training and then it in the box lacking all house case study yes yes uh
01:06:09 uh do you agree well are you familiar with this document i've seen it in preparation for coming to give evidence i didn't see it at the time you didn't see it at the time no i didn't uh
01:06:20 didn't uh do you agree as a document point that the training guide covers the key interactive slides from the cbt package but not the slides which contain the videos or graphics which explain the full factual narrative of the latino
01:06:31 full factual narrative of the latino incident yes yes and those 95 slides for your reference members of the panel are at bab6045 can i just ask you whether those 95
01:06:42 can i just ask you whether those 95 slides in the full cbt package were ever presented to station based staff um i believe so but i couldn't confirm that i'm not aware
01:06:54 now if we look at page seven
01:06:58 of this document this relates to section 72d visits and information gathering
01:07:06 and if you look at the question
01:07:12 of page seven you've got task one
01:07:16 uh as as a task one is i mean there's a graphic there i think but there's also things to consider and then policy 800 information gathering and contingency
01:07:28 information gathering and contingency plans
01:07:29 plans and then if you move to page 8
01:07:34 it asks questions on the purpose of section 72d as you can see there's the question
01:07:40 question and page nine question what information can you gather and record that would be relevant to crews attending an incident
01:07:51 relevant to crews attending an incident like this
01:07:53 like this and there are some pra sheets at appendix 3. and then page 10 you look at that asks delegates the question
01:08:02 question what actions would you take if you discover building defects how is this information shared and there are some sections identified from policy 800 and then if you look at pages 11 and 12
01:08:14 and then if you look at pages 11 and 12 there's further discussion uh of
01:08:17 uh of or points for a group discussion on 72d visits
01:08:21 visits it's it's headed things to consider and further discussion 72d visits are a legal requirement who do you think is responsible for carrying out 72d visits etc do the 72d
01:08:32 carrying out 72d visits etc do the 72d visits you carry out serve any other purpose
01:08:35 purpose these visits should be used to gather information on risks to firefighters hazards beyond normal expectation all those that are less obvious control measures tactical plans and then for visits high rise premises
01:08:46 and then for visits high rise premises do you consider fixed installations floor stroke floor numbers layout of the flats where the door numbers are flat entrances and escape routes how are these best documented and so you can see those there now just
01:08:57 and so you can see those there now just pausing that it looks as if this training on information was just simply to remind trainees what the statutory obligation was under the 2004 act
01:09:08 2004 act and the contents of policy 800 but not much more than that i think
01:09:16 potentially the area that says for visits at high-rise premises do you consider
01:09:23 consider and that was in relation to the fact that
01:09:26 that the
01:09:27 the layout of the flats at lacanal house was a complicated scissor layout and was not necessarily as you would see it you wouldn't necessarily expect the
01:09:38 you wouldn't necessarily expect the flats to be laid out like that so
01:09:41 so and talking about the flat entrances and escape routes obviously one of the issues at
01:09:46 issues at lachen house was understanding the fact that there was an escape balcony at the back of all the premises that wasn't clearly understood so i think that um
01:09:55 um those are made reference to specifically because of the latino house fire right
01:10:01 right i mean just on what i've shown you pages eight nine and ten and i appreciate it is just a selection from a relatively long document a 23-page document but this looks just like a refresher calls on the on the legal requirements and the
01:10:13 on the on the legal requirements and the lfp policies in this respect there's no link across to the latin house incident itself
01:10:18 itself so i think that if you and i don't know because i couldn't access it i think if you watched the video and they talked about the complexities and understanding the layouts of the floors that that would
01:10:30 layouts of the floors that that would then lead to that conversation around the fact that you need to understand where the flash entrances are which floors they're on and that kind of thing i think that that's why they are talking about those issues
01:10:42 about those issues and and it is part of the latino house case study so there would be that understanding that those were the issues and i'm sure that the voice over from the initial crews and the crew management watch manager would
01:10:54 the crew management watch manager would discuss the complications of understanding what what flaws were and missing flaws numbers and that kind of issue when you're trying to identify where you're going
01:11:05 whether was there any study of the ways in which information about latino house specifically had been obtained by the lfb
01:11:12 lfb and in which way it was defective and could be improved on for the future um i don't remember but there it would have been looked at because they would have considered what information
01:11:24 what information london brigade had in relation to lack of house before the fire i i'm slightly struggling with this training guide not least because we can't see anything in it that innovates or identifies the
01:11:35 that innovates or identifies the mistakes at lac and all which should be cured
01:11:38 cured can you can you help us with that i think you would need to see the video and the voiceovers to understand because i think that's where it says do you consider um and those were some of the areas
01:11:49 um and those were some of the areas where they were identified as issues so when you're talking about the um you know the the door numbers and the layout of the flats and the floors and things were those were some of the areas
01:12:00 things were those were some of the areas of confusion at lacanal so i think that does relate to them
01:12:06 but as i say i um i i wouldn't be able to do that without having seen the video and listening to the voiceovers right
01:12:18 in general terms i mean have you presumably seen the videos and heard the voiceovers yourself no i haven't seen them you haven't no i just i've seen the script of the audio inputs so the document that's got and it
01:12:30 inputs so the document that's got and it wasn't a complete script it was an early version of it that's got a script of some of the audio inputs that talks about um the initial incident commanders and then talking about the incident right so when you say you have to see
01:12:42 right so when you say you have to see the whole package of course one would naturally yes but you haven't seen the whole thing now i haven't right now i take it from me that this training at least this uh this document
01:12:53 least this uh this document which is the analysis training guide doesn't cover the identification of or treatment of external panels facades or modern methods of construction during a
01:13:04 modern methods of construction during a 72d visit do you know why that is no i don't and more generally there's nothing in this
01:13:11 this training on external flame spread either do you know where that is no i i presume um though i don't know i think from anything that it is it's played in the video because
01:13:22 it's played in the video because obviously it demonstrates external flame spread and that would then be a subject to a conversation but i i can't see it in this document no no and
01:13:31 and do you agree that external flame spread was considered to be one of the factors that made latino house such a significant incident yes it wasn't uh it was a factor in the fire i think
01:13:42 uh it was a factor in the fire i think wasn't it
01:13:43 wasn't it yes the um fire loading of the flat of origin which was a significant fire loading the weather on the day the coanda effect of the taking keeping the heat and flames
01:13:55 the taking keeping the heat and flames close to the building open windows because it was summer and high winds on the day all combined to make it um yes very rapid external fast spread yes and given
01:14:06 given that external flower spread was one of the factors that made latino such a significant incident are you able to explain why that significant factor was not part of the training package designed to educate
01:14:18 the training package designed to educate officers on it i'm not sure that it wasn't i haven't so so without being able to see the video and the voice over i couldn't say whether it was or wasn't in there right well there's nothing in this document on it so
01:14:28 it so using that as a as a a a basic uh departure point can you explain why that factor doesn't appear in this document no as i say i wasn't um part of
01:14:39 document no as i say i wasn't um part of the team that put together so sorry i can't help with that uh there's nothing in this training package at least in relation to this document on the dynamic risk management model or dmm
01:14:50 model or dmm uh or on fires behaving in a way inconsistent with the compartmentation model which were two of the seven topics identified by the coroner do you know why they were omitted from this document
01:15:02 why they were omitted from this document um i believe on an earlier slide you showed me the dmm was there the one you showed me early on with the picture of building a small building on the left-hand side i think i think that might have been page seven sorry can you show me that again
01:15:15 nope there was another one that actually had the dmm i'm not sorry we've looked at a number of documents but there was a view of the dmm at one point so um i can't miss document we were just looking at but um i i don't know without being able to see
01:15:27 i i don't know without being able to see the rest of the thing i'll tell you whether it's not in there but um and no i don't know why
01:15:34 well i don't want to mislead you about the content of the document and trying to work out what it was that you might have seen there was something where it was it wasn't it wasn't in bold it was a kind of lighter color underneath something we were just looking at but it might not be this training guide it
01:15:46 might not be this training guide it might have been a it was something to do with a case study we've looked at a number of documents sorry um yes
01:15:54 [Music] behaving in a way inconsistent with the compartmentation principle then taking that one can you explain why that isn't covered in this training package so i believe it is covered in the narrative i
01:16:07 believe it is covered in the narrative i believe that there is a conversation around the fire spread through grills and vents
01:16:12 and vents and
01:16:13 and spreading from um
01:16:16 um through flats because their alterations have been made i'm sure that's covered in the uh voice over it's it it might not be i think this analysis training guide doesn't give you a full picture of
01:16:28 doesn't give you a full picture of what's in the actual package itself right now when you say the actual package you mean the 95 slides yes some voiceover yes and i have so i have
01:16:39 some voiceover yes and i have so i have not seen sight of the 95 side sorry um i i understand that but given perhaps you can't help me with this but given the importance of
01:16:48 of things like external flame spread fire behavior inconsistent with the compartmentation principle why are they not in this document which is the training guide which one would have
01:16:59 training guide which one would have thought was the more important document rather than being buried away in 95 pages of slides um i'm not sure um yes they are very relevant important points
01:17:11 relevant important points i mean on the face of this document do you accept that this case study on the face of this document and making all allowances for what you say about the 95 slides doesn't properly disseminate key lessons from the latin
01:17:22 disseminate key lessons from the latin incident to those officers most likely to need training as incident commanders namely crew managers and watch managers on the face of this document absolutely but i do believe there is further
01:17:33 but i do believe there is further information in the the presentation itself let's then turn to the station-based training and mr chairman that's probably a convenient moment for the break yes well i think it probably is so we'll
01:17:45 well i think it probably is so we'll have a break now it's cotton we'll come back please at 25 to 4 and again i have to ask you not to talk to anyone about your evidence yes while you're out of the room of course all right
01:17:55 right please
01:18:03 thank you very much 25 to 4 please
01:37:06 would you ask this cotton to come back in please
01:37:20 all right ready ready to go on thank you very much yes mr village yes mr chairman thank you we've looked at the station-based training i'd like now please to look at the training guide for the senior officers at lfb triple zero
01:37:31 the senior officers at lfb triple zero three double zero four four
01:37:41 as you can see from the foot of the screen this is also dated the 22nd of august 2014. the interac this is also called latin house case study and as you can see from the top of the screen it says senior
01:37:52 the top of the screen it says senior officer training if you turn to page seven the interactive slide start and run through to page twelve on page seven uh you can see um there is the topic of
01:38:03 uh you can see um there is the topic of 72d addressed as conducted by lower rank officers
01:38:09 and on page eight
01:38:12 it focuses on assessing and prioritizing information as an incident commander nine
01:38:19 nine identifying flats and how line drawings might help and and on that you can see specific flats four specific flats that lack north
01:38:29 north 57 68 79 and 80. and then at page 11 you've got
01:38:42 questions about relocation of the bridgehead and implementing and communication communicating the plan and the page 12 questions on search and rescue methods
01:38:52 uh as with the package for station based personnel we've seen no mention of external flame spread facades compartmentation or the dynamic risk management model again do you accept
01:39:03 management model again do you accept that going on the basis of this document at least
01:39:07 at least it failed to disseminate key lessons from the latino house to senior staff i can see now where i was referring previously to the dmm it's on the left hand side on
01:39:18 to the dmm it's on the left hand side on the slide at the bottom it's underneath the writing there so i'm presuming by the fact that that's included there and on every one of those slides that it makes reference to that
01:39:29 slides that it makes reference to that when the conversation um which is was this presentation was led by dac tim cuthbill he was the one who delivered this training senior officers so i'm presuming and i'm only presuming
01:39:41 so i'm presuming and i'm only presuming that the ref the reason that is there is because that was referenced throughout the presentation i see uh and i follow so are you referring
01:39:52 i follow so are you referring to
01:39:54 to the colored boxes yes yes underneath the drawing of the building there's a second box which i'm sorry i can't read the detail off from here but there are colored boxes which
01:40:06 colored boxes which i believe to be an illustration of the decision-making model i see let's just try that a little bit more then can we go to page seven
01:40:19 uh the difficulty i think is with this we can't blow it up but if we go to page seven you can see there's the same multi-colored box and arrow uh
01:40:27 uh graphic on the left hand side there under analysis section one can you see yes okay and if you go to page eight the same
01:40:35 the same seems to be underlying some text yes i i would i imagine as i say i am only imagining that um as one of those boxes is information um about the
01:40:46 boxes is information um about the instant information gathering that that would be the context in which that would be discussed because this is talking about information then how you deal with that information um so when it says about um
01:40:58 um so when it says about um how do you balance discrepancies between the information the situation and that's all part of the decision-making model so i i would imagine and i'm sorry so i'm just i don't know this is a fact that
01:41:09 just i don't know this is a fact that that's what that was there for as a reference point i mean certainly looks on the face of it would you agree that the decision-making model if that's what it is is lurking obscurely beneath the surface of other texts um
01:41:21 texts um yes i wouldn't describe it as lurking but um it would be a doc something everyone was familiar with so by having it lurking it would be in people's minds because they would be familiar with not just muddle
01:41:32 familiar with not just muddle on the face of one of the slides and say this is the decision-making model here it is this is how you operate it in the context of lachnal and i'm not sure um and forgive me i'm not sure if you played the slideshow whether it would
01:41:44 played the slideshow whether it would then bring the decision-making model to the fore when you were discussing that point um it's very hard to see when all you have is a kind of listed training guide in front of you yes i understand that now
01:41:56 yes i understand that now we heard from gary reason that the training package was launched for station based staff in august 2014 as the date rather signifies but the final sign-off for the tcap
01:42:07 the final sign-off for the tcap which we've looked at earlier only took place in may 2016 when you were director for safety and assurance
01:42:14 assurance do you remember that no i don't i have seen that as part of the um
01:42:19 the um the documents i've seen to prepare myself for this it seems like a terribly long period of time when the training started in 2014. i'm not sure about that why that date's included it indeed let's just
01:42:31 included it indeed let's just nail the date down to the document can we go back to the tcat form please at lfb triple zero six seven eight five seven
01:42:39 seven uh if we go to page 37 in that document you'll see the sign-off page there's ac cut bill yeah see that yes i do head of uh can you see what it says head of sog
01:42:51 uh can you see what it says head of sog sognor so special operations group and operational resilience 17th of may 2016. d.a.c fenton you mentioned his name earlier we're familiar with him from phase one same day and the next day
01:43:02 phase one same day and the next day peter groves 18th of may so there's the there's the timing on it uh are you able to explain why the tcap form was not signed off as closed and completed until
01:43:14 signed off as closed and completed until may 2016 when it was apparently being rolled out to station staff and senior officers in august 2014. no i have no idea i'm sorry it seems very bizarre to be signed some two years
01:43:27 very bizarre to be signed some two years later yeah
01:43:31 um can we go back to the rule 43 letter then at lfb triple zero four two zero eight nine page six
01:43:48 in the last line
01:43:51 on that page uh it says that the brigade's work on incident command including the case study training package uh was estimated to be completed by december 2013.
01:44:03 december 2013. now this was um this is in the uh letter sent by uh the lfb to the coroner in may
01:44:15 sent by uh the lfb to the coroner in may 2013 so you can see from page one take that from me do you know what the original basis of the estimate of december 2013 was um no i don't and i would say that would have been a very optimistic estimation
01:44:28 have been a very optimistic estimation of a date at best right
01:44:32 gary reason told us that the training package was not evaluated during his tenure as director of operations resilience and training and that that might have happened after his retirement he couldn't tell us whether that was
01:44:44 he couldn't tell us whether that was through the odcb diat or the operational review team attending high-rise incidents to see whether the training had been embedded properly can you help us with that um
01:44:55 um no i can't formally say how it was assessed um obviously
01:45:01 obviously any issues arising out of attendance at high-rise incidents of operational crews would have been picked up by the operational review team and therefore would have been subject to scrutiny by
01:45:12 would have been subject to scrutiny by odcb and through the diop process but that's not to say that that was a formal um assessment of the sort of embedding of this training with cruz to your knowledge was
01:45:24 training with cruz to your knowledge was this training package or these training packages ever evaluated
01:45:29 to the best of my knowledge i don't think it was and in with the benefit of hindsight and reviewing some of this training i think that is an area where there have been
01:45:40 that is an area where there have been deficiencies in london fire brigade throughout a number of training interventions that i'm not sure that we they london fibroid ever go back and fully
01:45:52 fully review how well training has been embedded
01:45:55 embedded and how it's embedded ongoing i think that's a gap it's a gap and do you know
01:46:04 have you given us the benefit of your evidence and and your view about it being a gap do you know whether before you
01:46:10 you left the lfb that had been identified as a gap
01:46:14 a gap no i don't believe so it wasn't something that um i don't think i had considered or anyone else it's only in reviewing this and considering the issues that we're looking at here that
01:46:26 issues that we're looking at here that i think that what happens is that a piece of training takes place there is
01:46:34 there is reviews that the training's taking place because that's registered on the step process so you can see the percentage of staff that have undertaken it and then i don't think that anything then goes back to see how well that's been embedded because invariably with a
01:46:47 been embedded because invariably with a large organization like london fire brigade something else comes along and i know that whilst we were developing this we had another fire that resulted in some very serious injuries to firefighters
01:46:59 very serious injuries to firefighters that then became the focus of developing another training package so i think part of the problem is is the continual development of new training in response to either
01:47:09 to either national policy a national event or something like this and i think as a result of that that can sort of completing of that circle to discover whether or not something's been fully embedded
01:47:18 embedded isn't something that happened given the significance of the latino house incident uh given the num the amount of resources devoted to
01:47:29 num the amount of resources devoted to identifying actions and their cure given the recommendations and then the efforts put into addressing those and given the fact that this training package or these training
01:47:40 this training package or these training packages were the result of that surely it was essential wasn't it to evaluate whether they were any good yes
01:47:49 yes and was that not at the heart of your department's function um no the
01:47:54 um no the i don't think that was ever fully considered by anybody including myself and i think it should have been that it was
01:48:02 was it would have been the responsibility of a number of us um not least of all the large number of um highly experienced operational officers that were
01:48:11 that were you know um took part as part of odcb which is i think where it should have sat and i think that was something that we failed to do yes but for your part as
01:48:23 failed to do yes but for your part as acoa do you accept responsibility for your part in that gap yes i do thank you now let's then turn to babcock and babcock's review of incident command training as against the
01:48:35 training as against the coroner's seven incident command training recommendations uh you're familiar with the other tcap you mentioned tcap0124 yes yes i am now let's uh look at the
01:48:47 yes yes i am now let's uh look at the incident command rule 43 pro forma at lfb
01:48:52 at lfb 0034062
01:48:55 and go back to point b
01:48:59 page 22 please
01:49:05 now as i say gary reason dated this at about may 2013
01:49:10 may 2013 at day 180 page 160 lines 1 to 11. and if we look at the first half of b it says the lfb will engage with our training contractor to ensure the points
01:49:22 training contractor to ensure the points specifically listed in recommendations one to seven are addressed in the current review process of incident command training this work will aim to ensure that the training provided enhances performance
01:49:34 training provided enhances performance across the range of required skills and knowledge needed to support effective incident command i've read that to you before i re-read it now because i'm going to focus on that first we heard evidence from peter
01:49:46 first we heard evidence from peter groves
01:49:47 groves on the problems that the brigade experienced when asking babcock to develop incident command training and he put it down to a lack of subject matter experts
01:49:58 matter experts in babcock or available to babcock that ac reason gary reason agreed with that in his evidence my first question to you is do you agree absolutely you do that being so
01:50:10 that being so was any consideration given that you can recall to undertaking this rule 43 request internally for example within your own operational assurance department as opposed to by babcock
01:50:23 department as opposed to by babcock i would love to have done unfortunately two things prevented that one was the fact the details of the outsourced training contract did not provide for london fire brigades
01:50:34 did not provide for london fire brigades to
01:50:35 to conduct its own training across there were that whole range of training that was past the contract that meant that we weren't
01:50:45 weren't allowed to develop our own training not least of all because we had disbanded the training department as part of the outsourcing of the contract my team would simply not have been able
01:50:57 my team would simply not have been able to do that the size of the team and the amount of other work requirements but the frustration that i know that i felt along with a number of other colleagues about the speed with which we were able to develop any incident
01:51:09 were able to develop any incident command training was a constant subject of conversation between myself and gary reason subsequently myself and james darglich because it was so frustratingly slow and we were
01:51:21 so frustratingly slow and we were devoting
01:51:22 devoting a lot of time and resources from my department my team for people trying to support that because of the lack of expertise they had within babcock's
01:51:35 you weren't involved i think in the negotiation of the babcock contract no i wasn't
01:51:40 wasn't um nonetheless are you able to give us any sort of insight about why when the babcock contract was signed off there was no exception made for
01:51:53 there was no exception made for doing anything within the brigade by way of response to the then impending inquest um unfortunately not so i think that that would be a matter for ron
01:52:05 that that would be a matter for ron dobson or someone from cnb um to answer um it it was something that we felt quite keenly as a something that obstructed our ability to progress
01:52:16 obstructed our ability to progress certain items very quickly because of having to go through the external training provider now the frustration you've just uh that's the right word you just expressed was that something that you
01:52:27 expressed was that something that you yourself or to your knowledge others expressed to the cmb before the babcock contract was signed off or was it something that you experienced only after it was signed uh it was only after we weren't aware of how much it
01:52:39 after we weren't aware of how much it would impact and i don't think anyone anticipated the huge impact and delays it would bring by having an external training provider
01:52:52 going back to the pro forma we were told again by peter groves and gary reason that the reference to the do you see it says current review process of incident command training
01:53:03 process of incident command training that was a reference to babcock's review of incident command that was intended to be completed in april of 2015 taking three years from april 2012. do you agree with that yes i do that's what that means we also heard from them that
01:53:16 that means we also heard from them that the intention was to work those seven recommendations into the ongoing bad court babcock incident command course review do you agree with that yes i do um in fact i think it's right isn't it
01:53:27 um in fact i think it's right isn't it that although it was intended to finish in april 2015 that review was still continuing as at the date of the grenfell tower fire wasn't it yeah i believe so yes am i right in saying that as acoa with responsibility for incident
01:53:39 as acoa with responsibility for incident command
01:53:41 command and subsequently director of safety and assurance from january 2016 you yourself were heavily involved in the incident command course review um i'm not heavily involved i was
01:53:52 um i'm not heavily involved i was involved not as i wasn't able to commit as much time as i would have liked to it because it was something that was very important to me but definitely when i was the assistant commissioner of operational assurance
01:54:04 commissioner of operational assurance i met regularly with babcocks with colleagues to discuss the progress of it because of how frustratingly slow it was yes and can we take it that you were therefore even if not heavily or not as closely
01:54:17 even if not heavily or not as closely involved as you would have liked you were involved from the reviews inception in 2012.
01:54:23 in 2012. um yes so initially so um when babcocks one of the unfortunate things was when babcock's first took over the training for london fire brigade is as part of
01:54:34 for london fire brigade is as part of the initial plan that was part of the tender is that there was due to be a year where there would be effectively london fire brigade training working alongside babcock training so a
01:54:45 working alongside babcock training so a year of handover process of all of the training the trained materials and everything else working alongside each other and unfortunately due to
01:54:56 unfortunately due to political reasons it was decided that it would be a drop dead start date for babcocks so they started and were completely responsible from day one for all of the training but as part of that they had undertaken to review
01:55:09 they had undertaken to review all aspects of training which incident command was one of the first key reviews they were undertaking but i think that fell into the same problem areas as developing instant command training in
01:55:20 developing instant command training in that they had a lack of subject matter expertise in the area right well we'll come to look in a little bit more detail in a moment about about some of that but can we take it that you were involved
01:55:31 can we take it that you were involved from the start and were still involved up until your appointment as interim commissioner in january 2017. yes yes was the intention at the time of the this pro forma in may 2013 to put the
01:55:45 this pro forma in may 2013 to put the coroner's rule 43 recommendations and indeed babcock's own excuse me own findings to the extent that they existed in current training at the center of the um the ic course review yes it was it was now we know
01:55:58 review yes it was it was now we know that the lfbs work on this rule 43 recommendation was overseen at least so it appears by the odcb and
01:56:06 and the
01:56:07 the lachenal house working group gary reason told us that the information gathering for both of those entities merged into one as he put it because he would use the updates given to the odcb
01:56:19 would use the updates given to the odcb in other words provided by your team do you agree yes you told us that earlier and he said that he was entirely dependent on the updates sent through to the od odcb that was day one eight one lines uh page
01:56:32 that was day one eight one lines uh page 48 line 19 to 49 line 3 for our references do you agree with that i would say that gary had a far better understanding than that because it was a conversation that was
01:56:44 conversation that was explored at both our directorate management board and in one to one meetings gary reason is probably one of the most detailed people i have ever worked for
01:56:57 detailed people i have ever worked for in that he was definitely not the sort of person who would just accept what was given to him on face value he would explore the detail and dig down into that
01:57:08 detail and dig down into that he had a great fondness for a red pen on his report um and was very fond of uh and quite rightly of challenging and asking for detail so a number of
01:57:19 a number of ways in which he would explore what was put in the reports and then ultimately it would go through odcb with that layer of discussion and challenge as well right
01:57:30 right is that a fact let's have a look and see what he says can we look at the transcript please for day
01:57:37 day 181
01:57:38 181 page 48.
01:57:46 see what you say about what he says page 48 line 19.
01:57:54 now
01:57:57 the question you should see at line 12 is as follows can you explain why you didn't make it clear to the latter house working group that in fact babcock's conclusions as you agreed with me earlier were that the existing incident command training was
01:58:08 existing incident command training was at times implicit not tightly focused and uneven in the sense that any given individual might or might not get that training depending on their rank answer at line 19 well i was very much
01:58:20 answer at line 19 well i was very much dependent on the updates i got through odcb obviously if i felt they weren't robust enough or i needed more information then i think you've probably seen emails from me that pushed back on some of the updates that we got during the life of this particular committee
01:58:32 the life of this particular committee because i was the one that had to face members and answer the questions and if we turn the page uh he says so again i hadn't seen that tcap response i would have been taking my cue from the information i was given
01:58:45 my cue from the information i was given now
01:58:47 now can you comment on that is that correct to the best of your knowledge uh the fact that um gary reason would push back and ask for further information definitely i said he was um very strong in that respect of wanting
01:58:59 very strong in that respect of wanting to
01:58:59 to find out detail and answers and i think the fact that at the directorate management board the relevant staff who worked including myself
01:59:09 myself peter groves and james douglas who were all very heavily involved in updates regarding instant command training and the frustrations with babcocks uh meant that we we had a lot
01:59:21 babcocks uh meant that we we had a lot of conversations around this and we raised a lot of concern around the delays
01:59:26 delays let's look on um question at line four i mean had you seen that tcap response can we take it that you would not have allowed the text such as this to appear in the in this action update uh i would answer i would probably have
01:59:38 uh i would answer i would probably have been a little bit more careful about expressing it slightly differently yes can we take it that you never yourself took steps to verify the findings of babcock's rule 43 review or ask anybody
01:59:49 babcock's rule 43 review or ask anybody in your own directorate to do so as against what commissioner cotton was giving you or assistant commissioner cotton yes as she was then assistant commissioner cotton that was the job of the commissioning department i wasn't going to check on every piece of work
02:00:01 going to check on every piece of work i mean i had a big job and i was like all top managers very busy and you know we relied on our heads of service and they're teams that work for them to do this work and i had no reason to doubt based on my meetings with ac cotton and
02:00:13 based on my meetings with ac cotton and what i saw was going on at my level that this was being progressed appropriately do you agree with that that's the general summary of the way you worked or he worked yeah i agree um that gary
02:00:24 he worked yeah i agree um that gary reason had a very big job and a large directorate but i would also say that he was very well informed because of the one-to-one meetings and the directorate management board meetings where we raised concerns
02:00:37 where we raised concerns and the
02:00:38 and the delay in babcock's training was a subject that was um i would suggest on most of the agendas for those meetings in general where he says at line 20 i had no reason to doubt based on my
02:00:50 had no reason to doubt based on my meetings with ac cotton and what i saw was going on at my level that this was being progressed appropriately to your recollection did it did
02:00:57 it did uh
02:00:58 uh ac reason ever challenge you on what you were telling him um i wouldn't say he challenged me we just had open conversations about the progress that wasn't being made or was being made was frustratingly slowly so
02:01:11 being made was frustratingly slowly so i wouldn't say he was challenging me we just had
02:01:15 just had conversations around how the work was going and what the issues were let's then look at the monitoring reports to the lhwg on on this topic which is the development of the incident command course review we start with the
02:01:28 course review we start with the first monitoring report in august 2014 uh 2013 which we saw earlier lfb triple zero six seven eight two zero
02:01:38 you can see the first page we saw this before this is for monday the 30th of september 2013 note of the meeting of the 28th of august 2013 and if we go please to page 11 we can see the beginning of the
02:01:50 11 we can see the beginning of the monitoring report there it is note the color coding red overdue amber action being taken to address green on target blue completed just note that there
02:02:00 there and on the right hand side you can see that it says action update update august 2013.
02:02:06 2013. uh if we go please to page 13 we can see that the update for recommendational incident command starts at the bottom of page 13. do you see and there is b review
02:02:19 do you see and there is b review in the second column from the left review incident command training to ensure the seven points are adequately covered
02:02:25 covered uh and that's the seven points isn't it from the um recommendations by the coroner and if you look at the last column on the right hand side it says this
02:02:34 this babcock have recently completed a full review of incident command training at a draft course review report was received by officers on 2nd of august 2013. this is now being considered and will inform
02:02:46 is now being considered and will inform revisions and improvements to the suite of incident command training solutions officers also instructed babcock to confirm that all seven incident command related recommendations are sufficiently
02:02:58 related recommendations are sufficiently and
02:02:59 and if you turn the page comprehensively covered within the existing suite of training courses babcock has confirmed that all seven issues are covered in the existing suite of command training albeit that there
02:03:11 of command training albeit that there may be opportunities to emphasize the latino event during some inputs this will be discussed at the next incident command forum meeting which is scheduled for the 5th of september 2013.
02:03:24 for the 5th of september 2013. gary reason told us ms cotton that babcock's confirmation would have been given to your department the oa department is that right um i believe it was given to peter
02:03:37 um i believe it was given to peter groves because peter gross was the interface between london fire brigade and the babcock training contract and therefore
02:03:45 therefore his department was overseeing all of the reviews that babcock were involved in and reporting back through him um clearly the information would have been shared with the my department since uh overall in charge of instant command
02:03:57 uh overall in charge of instant command but peter groves's team was the one working with babcocks on the review right across the piece because they were the
02:04:04 the sort of area that worked most closely with babcock so it was that team that were sharing that information right but was it not you who put
02:04:15 but was it not you who put the sentence babcock has confirmed that all seven issues are covered into this document um not to me personally i'm not sure whether it was someone from my team or someone from peter grove's team i see can you tell us
02:04:26 peter grove's team i see can you tell us when or how babcock provided the brigade with the information no the confirmation sorry now unfortunately why in the course of my preparing for this i can't find any
02:04:38 preparing for this i can't find any evidence of how that information was shared
02:04:42 shared do you know how babcock conducted its rule 43 review no i'm unaware i know that they were looking at all of the incident command training and looking at all of the um
02:04:56 training and looking at all of the um tactical decision tds exercises and things and
02:05:01 they had as part of their staff two or three retired officers from london fire brigade who were assisting with that review process um so i i would guess although i can't
02:05:13 um so i i would guess although i can't confirm that they were involved in that
02:05:17 do you know what the methodology was used by babcock to conduct that review no i'm unaware
02:05:28 you don't know do you know how bangkok
02:05:33 bangkok assured itself that the existing suite of command training really did get to grips with the coroner's recommendations not least given that they weren't subject matter experts um no they had subject matter experts
02:05:44 um no they had subject matter experts within their team as i said the retired senior officers from london fire brigade would be considered subject matter experts because they had not long retired and were experienced senior officers
02:05:54 officers so that i i presume although i can't say that they would have been working on that but i i can't confirm that do you yourself have any input into or oversight over the um the review
02:06:07 the um the review no because that was a specific review to be conducted by the external training provider which didn't have a london fire brigade input into it so that it would follow from that that nobody else at the lfb had any input into the review either not
02:06:20 had any input into the review either not as far as i'm aware no no do you know that when that the results of that review were received anybody asked babcock how do they go about doing it um i'm not sure what i i'm not sure about is whether or not
02:06:32 i'm not sure about is whether or not anyone from peter grove's team as the interface team was involved in the design of any of those um reviews i'm not sure but they would have been the people who who if anyone was involved
02:06:45 people who who if anyone was involved would have been did you or anybody else ever since check babcock's conclusions i didn't personally i'm not sure if anyone else did right let's look at their conclusions please and we'll start with the tcap zero two form
02:06:58 with the tcap zero two form at lfb403716
02:07:05 is it right that this document being a tcap
02:07:08 tcap entitled enhanced incident command training based on latino inquests rule 43 recommendations was the document and indeed the process that facilitated babcock's rule 43 review yes yes
02:07:21 babcock's rule 43 review yes yes uh on page three if we go to it please it we can see from the version control table that this
02:07:28 this form was first raised as version 0.1 on the 3rd of june 2013 by mike curran as a first draft you can see that and if you go to page 5
02:07:39 and if you go to page 5 and it evolves until august 2016. if you go to page five of this tcap form background stroke context is set out there as you see and uh if you
02:07:50 and uh if you cast your eyes down to the bottom of the page bottom of the screen underneath the seven uh
02:07:56 seven uh incident command items that come from the
02:07:59 the rule 43 recommendations there's a paragraph that says this with respect to the points specifically listed above in one to seven these need to be addressed to ensure the training provided enhances
02:08:11 to ensure the training provided enhances performance across the range of skills required in particular recently published straight revised policies below
02:08:18 below babcock are expected to provide a proposal detailing the changes to courses to achieve a greater and enhanced level of incident command training than is already delivered based on the points one to seven above
02:08:31 on the points one to seven above now again why were babcock only asked to make a proposal which covered changes to existing courses as opposed to creation of a whole new training course or exercise focusing on
02:08:43 training course or exercise focusing on the points that arose from lachlan i don't know but if i were to make my best guess on it i would suggest that the idea of teacup 0153 of the lachman
02:08:55 the idea of teacup 0153 of the lachman house case study was that that was a completely new case study training package that would also encompass those seven points and that the points raised here were
02:09:06 and that the points raised here were that at every opportunity of instant command training um
02:09:11 um that these points should be included and
02:09:16 and that that babcock says the training provider should ensure that they are front and foremost um in a range of instant commanding command interventions so that it wouldn't just
02:09:27 interventions so that it wouldn't just be a a one-off intervention and when people went for instant command training from crew manager up to senior officers that these points would be addressed
02:09:40 but that's a guess that's an educated guess yes yes
02:09:48 now the the proposal document that came with this tcap is that lfb triple zero three eight one seven zero if we can just please look at that
02:10:00 uh the file information tells us that this document was generated on the 19th of september 2013 and called tcap number 0124 enhanced
02:10:13 and called tcap number 0124 enhanced incident command training based on latino inquests rule 43 recommendations that's the file information take that from me miss cotton if you would um just looking at the document on the
02:10:24 um just looking at the document on the screen it's entitled tcap number zero one two four enhanced incident command training etc uh have you seen it before do you recall this documentary um i was i didn't see
02:10:35 this documentary um i was i didn't see it at the time i have seen it in my preparation before giving evidence now gary reason told us that it would have been the job of the commissioning department in other words your department i think to evaluate and sign off any proposals like this from babcock
02:10:47 off any proposals like this from babcock do you agree in conjunction yes with the team of people who devised tcap so it was never solely the responsibility of a commissioning department it would have been done in conjunction with the
02:11:00 have been done in conjunction with the team from peter groves's department who are the ones who worked on all of the tea caps so i think that was supposed to be a safeguard to ensure it wasn't just one person or one individual right signing
02:11:12 person or one individual right signing the document off it was a it was the group of people who developed it um and who were the subject matter experts who would sign off right so you weren't involved with this
02:11:23 right so you weren't involved with this document at the time no i wasn't and you didn't see it at the time no i didn't right
02:11:30 right we have peter graves's evidence about it and gary reason's evidence about it and its contents i don't think i need to trouble you with that but can i just ask you if you go to page three
02:11:39 three just to help me with one part of it uh which is the second paragraph below the table
02:11:45 table under the heading training proposal it says
02:11:47 says tcap0124 requires enhancements to incident command training based on latino inquests rule 43 recommendations the seven recommendations relate to areas of incident management training
02:11:58 areas of incident management training that all they currently deliver through existing training require enhancement to meet the tcap requirement and the rest of the the document goes on particularly at page 14 to to detail the
02:12:09 particularly at page 14 to to detail the proposal for the enhancement namely to develop some cdes command decision exercises which would specifically address each of the seven recommendations made by the coroner
02:12:20 recommendations made by the coroner that's right i think isn't it yes we can look at the document
02:12:26 why enhancement why not recreation
02:12:32 potentially that is because of the length of time it takes to develop a new training package right from scratch and that may well have been as a response to the frustrations that i know
02:12:44 response to the frustrations that i know that were
02:12:46 that were shared at gary reasons the directorate level with babcocks as a training provider in the delay it took to develop anything so it may well be that it was deemed more appropriate to
02:12:57 it was deemed more appropriate to attempt to enhance an existing training package to include those points rather than to go back to the beginning and start on what would inevitably a two to three year process to develop a
02:13:08 two to three year process to develop a new training package but i'm not sure that's the reason but i know at the time there were concerns around every new tcap and the delay and length of time it was taking to develop it now
02:13:19 of time it was taking to develop it now we'll come back to the command decision exercises in due course more likely tomorrow but for the time being let's just go back if we can to the august 2013 monitoring report update provided
02:13:30 2013 monitoring report update provided for the monday 30th of september 2013 meeting we saw earlier lfb triple zero six seven eight two zero page fourteen
02:13:51 if you look at the right hand side of the document the second line down it says as i've shown you babcock has confirmed that all seven issues are covered in the existing suite of command training
02:14:03 existing suite of command training albeit that there may be opportunities to emphasize the lack of event during some inputs now
02:14:11 now when we put this wording to gary reason he suggested that the wording could have been more as he put it explicit and suggested that he was very much dependent on the updates that he got through odcb in
02:14:23 updates that he got through odcb in other words from you we've seen that before
02:14:28 can you tell us why you didn't make it clear in your update either to the odcb or to gary reason that babcock's ultimate conclusion was that the lfb's training required enhancement and refinement in order to
02:14:40 enhancement and refinement in order to meet the coroner's rule 43 recommendations um
02:14:44 um once again i didn't word this so i can tell that because it's exceptionally poorly worded in my opinion
02:14:51 opinion and i'm surprised that passed through odcb with wording in such poor manner because that would not normally have happened so
02:15:00 so no i can't confirm that because i think it should have been made far more explicit about what babcock said and i think just using the word lack on the event is a very poor choice of words
02:15:12 the event is a very poor choice of words indeed did you not see this though at the time
02:15:15 the time i
02:15:16 i i can only think i would have done as part of the odcb reporting process and which is why i'm surprised that it is worded in such a fashion
02:15:25 a fashion that's why i'm asking you can you explain given your role on the edcb at the time anna's acoa at the time why a wording like that went past you and no i can only apologize it's very poor wording it should never have
02:15:36 poor wording it should never have happened
02:15:42 did that presumably that didn't give you cause for concern at the time because you didn't spot it uh no it would have given me cause concern if i'd spotted it and i would have made sure it had been reworded
02:15:51 reworded so obviously it uh and and and i'm very surprised that it it got through the scrutiny of everybody especially including
02:16:02 everybody especially including the deputy commissioner and gary reason both of whom were very particular in uh wording that was used in documents and especially with wording that was going to be
02:16:14 wording that was going to be shown to
02:16:15 shown to members of the lockhart house working group
02:16:19 group can i then take this on [Music]
02:16:21 [Music] and
02:16:23 and look at the development of the command decision exercise particularly holcroft house
02:16:31 mr chairman this is a a new topic or sub-topic but and i may or may not finish it by 4 30 but i quite like to make a start on it that's all right yes uh thank you um can we go
02:16:42 can we go back then to babcock's proposal to develop command decision exercises in order to meet the coroner's seven incident command recommendations and i'd like to start with the with lfb 001 5289
02:16:57 like to start with the with lfb 001 5289 this is the covering email to the babcock proposal we've just seen created in september 2013 we looked at uh uh it's an email of the 19th of
02:17:08 uh uh it's an email of the 19th of september
02:17:09 september 2013 from doug massey of babcock to stephen green who's in the lnds that's the learning and development strategy arm of the training department i think as gary reason told us
02:17:22 i think as gary reason told us and what he says is this steve thanks for your time this morning i've had a go at laying out a table around the issues we discussed i haven't found it as straightforward as i thought it would be so we need to kick this into
02:17:33 it would be so we need to kick this into shape between us if we can i've added what has already been shared with lfb after the table to give context by way of explanation my definition of a command decision exercise is a minerva
02:17:46 command decision exercise is a minerva type exercise to ensure maximum consistency this proposal is to develop a sufficient number of exercise scenarios we have identified 16 that are suitable to start
02:17:57 identified 16 that are suitable to start with i anticipate ultimately the number needed will be well into double figures and as explained in the proposal the idea is to give each role cm to dac plus
02:18:08 idea is to give each role cm to dac plus two exercises each working in syndicates of three or four people the first cde is common to all the second is different scenario to each syndicate shared learning and debrief as
02:18:19 syndicate shared learning and debrief as we discussed the cde will be delivered in syndicate rooms with a trainer present and facilitating
02:18:27 now mr massey refers there as you can see
02:18:30 see to us developing a sufficient number of exercise scenarios with with 16 already having been identified as suitable and sufficient as he says
02:18:41 as he says do you know how many command decision exercises babcock or the lfb initially envisaged creating in response to the coroner's recommendations
02:18:52 recommendations no i don't but the um to set some context to that the the issue is that you couldn't just have one command decision exercise because
02:19:04 decision exercise because inevitably uh with the way of any large organization and london fire brigade is no different once a number of um officers and or crews had gone through that command decision they would then
02:19:16 that command decision they would then have had a conversation with other officers so that anyone turning up for the training would effectively uh understand what the injects would be and what the process would be and therefore
02:19:26 therefore the testing of their ability would be tainted as it were and we were familiar with this as a process from promotion processes where despite saying to the candidate when you leave the room
02:19:38 to the candidate when you leave the room please don't discuss this it's not in your interest with someone else to understand what exercise it is inevitably they would share it with someone who would share it with somebody so we would have to have a large number of different exercises to
02:19:49 large number of different exercises to be able to ensure that it was rigorously testing officers in their ability to respond so i'm not sure that anyone came up with what would be a perfect number but it would have to be
02:20:00 a perfect number but it would have to be a large number of varied exercises to ensure that we gave each person a fresh experience and it wasn't just a recycled exercise right would that large number be more than 16 do you think he says
02:20:12 be more than 16 do you think he says well into double figures ultimately yes it would have to be especially if that was going to be used in ongoing training because you wouldn't want to repeat the same training intervention for somebody in two years running and if you're
02:20:23 in two years running and if you're talking about having syndicates of four people in a room if you had that maths across it it would be you know you'd have to have a number of different interventions to ensure that people weren't having a repeat of
02:20:34 that people weren't having a repeat of the same exercise now let's go to lfb double uh lfb triple zero three eight one seven zero
02:20:44 can see the suitable exercises the 16 suitable exercises set out in babcock's proposal document here
02:20:51 here and if you go please in this document to page 16
02:20:55 page 16 this is the september document of 2013 on page 16 is section 6 existing training which says the following table lists current incident management training
02:21:07 current incident management training exercise scenarios that encompass all seven rule 43 recommendations each exercise scenario will develop deliver the requirements of all seven recommendations as a core activity of delegate participation additionally a
02:21:20 delegate participation additionally a range of supplementary exercise injects will allow training staff the flexibility to emphasize the requirement of one or more of the rule 43 recommendations by configuring the development of the exercise scenario as
02:21:32 development of the exercise scenario as it progresses aligned to delegate need and or lfp requirement and then there's a table below that the first column in the table is entitled incident management training
02:21:44 entitled incident management training minerva stroke command decision exercise number and title and the second column contains the scenario description first did you ever look at these training courses to satisfy yourself
02:21:55 training courses to satisfy yourself that they would address what had emerged from the lack of house incident from the coroner's findings in her rule 43 recommendations no i didn't why is that because there were a dedicated team of
02:22:06 because there were a dedicated team of people working on it you just saw steve green from the learning development strategy he was a very competent operational officer along with doug massey who was one of the recently retired senior officers
02:22:17 recently retired senior officers and
02:22:19 and to not put to find a point on i would simply have not had time to go through those individually and myself but these were a large majority of these were existing
02:22:30 a large majority of these were existing london fire brigade training scenarios that were handed over to babcock so they weren't ones that babcocks have developed i believe did anybody to your knowledge did anybody actually do the exercise i've just put to you namely sit down
02:22:42 just put to you namely sit down look at these exercises analyze them and ask themselves the question do they satisfy what emerges from the incident from the coroner's findings and her rule 43
02:22:54 coroner's findings and her rule 43 recommendations um i think that's what doug massey was referring to in the email to steve green that that's what he was trying to map out and it was more complex than he thought
02:23:06 not specifically in relation to these but i was
02:23:10 but i was met with a number of the individuals in the babque training team around instant command
02:23:15 command where they had fleshed out the contents of a number of instant command training interventions and had printed them out on sheets of paper that covered the wall of an entire office where they tried to do the breakdown of what each
02:23:28 do the breakdown of what each individual training exercise covered and what areas it covered so i do know it was a very complex piece of work um that took some time and was indeed far more
02:23:39 took some time and was indeed far more difficult than i think was initially anticipated doug massey was he an ex-lfb firefighter or senior officer yes he was and even he found it difficult yes indeed right
02:23:50 indeed right so
02:23:50 so your answer i think is the exercise was done but not by you no let's then look at the next iteration of the monitoring report at lfb triple zero
02:24:02 the monitoring report at lfb triple zero 67832
02:24:05 67832 we saw the monitoring report for of august for september this is the version for november and the meeting of the lhwg on the 14th of november 2013 as you can see item
02:24:18 of november 2013 as you can see item four in the agenda there is the action plan monitoring report you see that yes and uh if we go to page 25 we can see the beginning of that document
02:24:31 and there on the right hand side you can see action update november 2013 and in the far right column under that we can see the first two paragraphs of the update are the same as the previous
02:24:43 the update are the same as the previous update from the august of that year weren't they yes now yes let's let's then look at the third penultimate paragraph down the third one which is penultimate and it says it says
02:24:55 which is penultimate and it says it says this the babcock incident management suite of training interventions specifically relevant to high-rise scenarios
02:25:01 scenarios are regularly monitored by the operational assurance department through direct observation through the operational review team ort officers that attend training events and command assessments this has confirmed that the
02:25:13 assessments this has confirmed that the seven icy related issues are fully embedded within all incident command training exercises now the operational review team sat within your department didn't it um
02:25:25 within your department didn't it um they sat within it for responsibility but i didn't own the operational review team officers they were eight officers that belonged to different departments predominantly in dave brown's operations
02:25:36 predominantly in dave brown's operations world so they may well have been borough commanders or somebody in the regulatory fire safety team but they were senior officers who had an additional role of a tag of being an operational review team
02:25:47 team you say they sat within it for responsibility does that mean you were responsible for them in this context only in the context of their additional ort tag not for their
02:25:58 ort tag not for their normal management or their normal day-to-day job this was a specific role that entire enabled them to carry pages and they would be mobilized to incidents of six pump fire and above to carry out the quality assurance so from
02:26:10 carry out the quality assurance so from the overarching part of that ort yes but
02:26:14 yes but not unfortunately i didn't own them and i didn't have say over their day-to-day work
02:26:22 uh right i'm breaking that up a little bit if i can then the um
02:26:30 it says that the monitoring is done regularly by the operational assurance department that's you yes um
02:26:37 yes um what i think this is trying to say but once again i think actually gary worded this
02:26:42 this is that the where they could the operational review team would attend training events and instant command assessments to observe that training but it was not
02:26:54 to observe that training but it was not every training event because there were only eight of them and they had a day job as well but where possible they would attend to perform some quality assurance but it was not every single event by any means i would
02:27:06 every single event by any means i would probably guess they attended one in every six to eight training events simply because of the volume of training that was going on and the additional responsibility they had for their day jobs
02:27:16 jobs did the operational review team as referred to here at least begin regularly attending incident command training and assessments after the coroner's 43 rule 43 recommendations
02:27:29 the coroner's 43 rule 43 recommendations in order specifically to review its compliance with those recommendations only where possible it was um ad hoc because of the limited number of them and as i say and their day job requirements and their
02:27:41 their day job requirements and their operational cover requirements you say only ad hoc if only ad hoc how could it be
02:27:46 be reliably the case that the ort could as it says confirm that the seven incident command related issues are fully embedded within all incident command training exercises um i don't think that's an accurate reflection of what
02:27:57 that's an accurate reflection of what happened right so to that extent this update to the lateral house working group was overstated and misleading yes and i'm also
02:28:08 also somewhat bemused confused by the fact that it's marked complete because it clearly wasn't and that was my next question and that was also overstated and misleading yes yeah and i have no idea why anyone would consider
02:28:20 have no idea why anyone would consider that to have been complete because at this stage we were very far from completing the enhancement that babcock's going to undertake to embed fully those seven recommendations so it was in no way complete
02:28:32 so it was in no way complete thank you very much mr chairman is that a convenient moment yes it's suitable first as far as your concern i hope we will come back first thing tomorrow morning to continue this theme with this next set of documents but it is
02:28:44 next set of documents but it is convenient for the time being right thank you very much well that's a good point at which to close for the day we'll finish there i'm afraid i'm gonna have to ask you to come back again tomorrow but i think you were expecting that anyway yes sir and again
02:28:56 expecting that anyway yes sir and again i'm going to have to ask you not to talk to anyone about your evidence or anything relating to it over the break and we'll resume please at 10 o'clock tomorrow morning thanks all right thank you very much we'd like to give the
02:29:07 you very much we'd like to give the usher please
02:29:14 [Music] thank you mr millet 10 o'clock tomorrow morning thank you thank you very much mr chairman
02:29:30 you