Gary Reason, former London Fire Brigade Assistant Commissioner, testifies about the brigade's response to the Lakanal House coroner's recommendations on incident command training, revealing significant gaps in how training packages addressed external fire spread, compartmentation failure, and dynamic risk assessment.
00:00:35 good morning everyone welcome to today's hearing
00:00:39 hearing today we're going to continue hearing evidence from mr gary reason formerly of the london fire brigade so if the reason is there would you ask him to come in please
00:00:52 good morning mr reason yes please sit down make yourself comfortable thank you
00:01:08 all right we'll let you get organized and then
00:01:10 and then we'll start
00:01:17 okay thank you thank you very much yes mr miller when you're ready yes thank you very much mr chairman good morning and good morning members of the panel um good morning to you mr reason uh yesterday when we finished for the day
00:01:28 yesterday when we finished for the day we were looking at the training delivered to the station based officers which was developed and published in april 2014. now i'd like to look at the training guide for the senior officers please and that is lfb303044
00:01:51 you can see from the foot of the page that it's dated the 22nd of august 2014 and we can go to page seven please
00:02:03 and we can go to page seven please and look at those and those are the interactive slides and they start there and they run through to page 12. if we look at page 7 while it's on the screen
00:02:15 while it's on the screen you can see that it focuses on checking 72d visits conducted by lower rank officers and then at page eight if you go to page eight you can see that
00:02:26 if you go to page eight you can see that that focuses on assessing and prioritizing information as an incident commander page nine on identifying flats and how line drawings might help
00:02:38 and then page 10
00:02:40 page 10 asks questions in relation to responding to fsg calls and you can see some of the details there call slips helping on the command unit casualty information sheets etc and then
00:02:54 casualty information sheets etc and then page 11
00:02:55 page 11 is about asking questions about the location of the bridgehead things like when would you move it what would you need to consider before relocation of the bridgehead
00:03:06 relocation of the bridgehead and implementing and communicating your plan
00:03:09 plan and on page 12 if we can look at that those are questions about search and rescue operations implementing controlling and evaluating searches etc now that's a very quick
00:03:22 searches etc now that's a very quick tour of this document as with the package for station based personnel there's no mention here we've been able to find of the risks of external flame spread facades facade fires compartmentation
00:03:35 facades facade fires compartmentation loss of it as a result of facade fires or the dynamic risk management model none of that appears to be the subject of this
00:03:44 of this training package do you accept first of all that is the case uh
00:03:50 uh same answer as i gave yesterday for the station-based package the i accept the the first one that the dynamic risk assessment element is missing from this package but the whole concept and
00:04:02 package but the whole concept and content of this training solution was to disseminate information to senior officers around the unusual and potentially rapid fire spread in high-rise buildings right and do you
00:04:13 high-rise buildings right and do you accept that to the extent that it failed to disseminate key lessons about dynamic risk management model uh that was a failure um
00:04:24 um and to disseminate lessons from the latino house incident again a similar answer or same answer is yesterday these packages tend not to be used in isolation so this is the
00:04:36 used in isolation so this is the storyboard if you like of the lachen house fire and there is other training on the big learning system and probably would have been discussed at this senior officer training session around dynamic risk
00:04:47 training session around dynamic risk assessment yes you said that yesterday and i was
00:04:51 and i was wondering about that in mechanical terms as you say there's other training on the big learning system those are hyperlinked i think is that right from this training package yes i
00:05:03 right from this training package yes i believe so yes so it would require either a station-based officer or a senior officer under this program to operate the hyperlink and go and look at the policy or process
00:05:14 and look at the policy or process is that right uh yes that would be true would they get any guidance during the training sessions
00:05:20 about which policies they should look at which parts of the policies they should look at
00:05:24 look at well the dynamic risk assessment policy is quite a succinct policy from my memory
00:05:30 memory and it would have been i suspect i wasn't at any of these senior leadership sessions uh training sessions but it would have been i would suspect a
00:05:40 suspect a core discussion point during the presentation these uh sessions were obviously delivered by i think initially deputy assistant commissioner tim cutball who had been
00:05:51 commissioner tim cutball who had been the lead officer for the investigation intellect and also had a huge amount of knowledge about this particular incident and he was supported by officers from the incident management training team
00:06:02 training team when they were delivering this package because we recognised that senior officers would be obviously interested in the incident itself and how it developed but also some of the more issue
00:06:12 issue more significant issues for command and control for senior operational staff right but by putting all the hyperlinks to all these policies in this training package
00:06:23 these policies in this training package you were is this right leaving it to the individual officers whether station based uh for their package which we saw yesterday or for more senior officers for this
00:06:34 for more senior officers for this package
00:06:35 package really to do their own homework uh and
00:06:39 uh and find the time to self-study using the big learning package as a resource yes i'd accept that right when would station-based staff just going back to them
00:06:52 going back to them find the time to to do that or the inclination to do that
00:06:56 that well station-based training is managed by the watch manager for the respective watches at station as i think you've already heard from other witnesses there is a core program
00:07:07 other witnesses there is a core program of training across the risk critical areas which includes incident command and it would be for the watch managers to decide based on their own training needs analysis of their own teams uh
00:07:18 needs analysis of their own teams uh when and how that training should be delivered and then what frequency right so that would um just thinking about that answer would that mean that the frequency
00:07:29 that mean that the frequency and intensity of using big learning at station based level would be uneven across london it could be uneven but that's not necessarily a failure it might be
00:07:41 necessarily a failure it might be a facet of the local risk environment in which those watches are likely to work in so one of the things that we encouraged station-based staff through the
00:07:52 station-based staff through the management structure within service delivery which was dave brown's directorate was to look at local risk and that informed the borough training plan and then the management structures from the borough commander down to the
00:08:03 the borough commander down to the station managers and watch managers at station to tailor their training programme uh in addition to the quarries critical which is mandated through a policy
00:08:13 policy to link to the local risks within their local communities so would it work this way and indeed both at station based level and officer level i call it officer level um
00:08:24 officer level um senior officers senior officers senior officers are slightly different because senior officers uh by definition there's a lot less senior officers than there are frontline firefighters at fire stations
00:08:35 stations and depending on what qualifications and what we call attributes if they've got specialist skill set like press liaison or fire safety they could be covering in effect the whole of london
00:08:46 in effect the whole of london so
00:08:47 so they would undertake personal development across the whole suite of incident command training policies to maintain their proficiency in being deployed at that level
00:09:03 yes that i
00:09:06 that i understand but are you telling the inquiry that in fact at what at station level
00:09:13 level it was left to the individual watch managers or station managers to decide which elements of big learning in the training package would be used to a certain extent um i know you've
00:09:24 to a certain extent um i know you've heard about the operational directorate coordination board work which often led to a station training support package in a particular theme or issue they were mandated so that wasn't left
00:09:35 they were mandated so that wasn't left to the local managers that was something that the organization decided was a an issue that we wanted to either highlight or we wanted to improve performance in that area
00:09:45 that area but there is not it's not just the watch managers working in isolation they have a
00:09:50 a senior officer station manager who looks after the whole station so he's managing across all four watches at that station and then above that person there is a borough commander all of those have uh responsibility for
00:10:04 all of those have uh responsibility for managing training and the performance of their staff and
00:10:07 and dave brown will be able to talk in more detail about the quality assurance processes in place but there was an independent quality assurance process within service delivery
00:10:17 delivery so each fire station would be visited i think at least once a year by an independent audit team and one of their key focuses would be the training activity at that station
00:10:28 the training activity at that station both in terms of what's been recorded and what's being planned and how that training is being delivered
00:10:36 right but we may pursue that a little bit further later with you or with with um
00:10:41 um ac brown when he comes to give evidence can i just ask you though based on your second witness statement um you say that you say if we can go to the second witness statement lfb
00:10:53 witness statement lfb 3067846 please uh at paragraph 55 page 27 page 27
00:11:03 you say this
00:11:10 you say in addition to the above over a two week period between 20th and 30th of may 2014 the watch managers who were filmed and appeared in the case study delivered the case study package to their respective watches i'm not aware
00:11:22 their respective watches i'm not aware that any further revisions to the case study were made as a result of these sessions however i believe that prior to its release tim cut bill also delivered the case study package to the senior management team which included the
00:11:33 management team which included the commissioner deputy commissioner and directors i would have been in attendance for this presentation but cannot recall the exact date do you remember whether um any comments or concerns were raised at that stage
00:11:46 or concerns were raised at that stage either by you or the commissioner or deputy commissioner when the case study package was delivered to you um
00:11:54 um no i don't remember any uh issues being raised i think we were as a group i won't speak for the others but i was certainly impressed with both the content the style and the approach taken in the case study because it was
00:12:06 taken in the case study because it was very interactive which is obviously a much more engaging training development tool than just watching a powerpoint right did nobody ask why it didn't cover the full range of the coroner's recommendations no i don't recall anyone
00:12:18 recommendations no i don't recall anyone raising that issue why didn't you yourself at that stage raise the package's failure to incorporate things like the dynamic um risk assessment um i don't remember the the specific
00:12:31 um i don't remember the the specific meeting itself um but again similar to the answer i gave before i'm aware through my own self-development and training that i've done is
00:12:42 training that i've done is dynamic risk assessment is really at the core of what you do as an incident commander so it features in virtually every incident command training course when you do events and training sessions is the core
00:12:54 and training sessions is the core element that informs your decision making process so it's it's very well embedded within the organization as a as a process to manage incidents but we've seen what the
00:13:05 incidents but we've seen what the coroner said about it the question is at this stage this is late 2014 um it was one of those things that was not present in the package and therefore not reinforced so it's what you're saying that it
00:13:16 so it's what you're saying that it didn't need the brigade are taking the decision that it didn't need to be or you were satisfied that it didn't need to be i don't think it was a conscious decision not to include it and this case study was just one component of a
00:13:29 case study was just one component of a range of training solutions that were developed in the immediate aftermath of the latino house fire so
00:13:35 so [Music]
00:13:37 [Music] once we acknowledge that it is one of the seven specific issues the coroner raised there was other training solutions that have been rolled out before this package was delivered to stations and to senior officers which
00:13:48 stations and to senior officers which would have also covered the dynamic risk assessment issue did anybody gather all these training packages up together
00:13:57 together at this point or indeed any other point and ask themselves the question do all these training packages taken together cover
00:14:05 cover properly
00:14:07 properly all of the coroner's recommendations i certainly wasn't aware that that process as you described was undertaken but
00:14:17 but i think everyone was alive to the issues in the coroner's rule 43 for obvious reasons
00:14:23 reasons and
00:14:23 and there was a significant body of work done both in terms of policy development development of new training development of new equipment and new procedures to
00:14:34 of new equipment and new procedures to address all of the issues that were identified by the coroner
00:14:42 so the answer to the question is no i don't think it was done but there is a the context is it was in the context of there was a lot of other training solutions and other policy and equipment developments that been
00:14:53 equipment developments that been happening in the immediate aftermath of the latino house fire
00:15:00 yes but would you accept that as you put it there was the significant body of work being done in terms of policy development development of new training new
00:15:11 development of new training new equipment and new procedures wasn't all being done by one department or one person it was being done by different people in different departments across the brigade yes i'd accept that but you'll also recall that
00:15:22 accept that but you'll also recall that there was the lack of house board in the initial aftermath of the fire which was chaired by the commissioner which would have uh the attendees at that board would have covered all of the um
00:15:33 would have covered all of the um departments that were working on uh you know organizational improvement and looking at new equipment so there was a a
00:15:41 was a a forum where if there was any concerns that what one department was doing was not quite covering uh what someone else was expecting them to cover then it would have been raised through the lack of
00:15:52 have been raised through the lack of house board and possibly subsequently at the lakme house working group well that's the point lachlan house board predates the recommendations yes yeah uh it's only the lack of house working group that is there
00:16:04 group that is there to
00:16:05 to over essentially oversee the carrying into effect of the rule 43 recommendations isn't that right that is correct yes and therefore the only oversight being given to holistically to all of the
00:16:16 given to holistically to all of the recommendations is through that process the latino house working group and it's reporting that's not strictly true because the
00:16:27 that's not strictly true because the rule 43
00:16:29 rule 43 pro forma that was created to share with elected members at the latino house working group also was reviewed by the operational director at coordination board
00:16:40 at coordination board again the constituent members of that board covered i'm just checking that i'm being accurate here but yeah they did cover all the heads of service that we're working on aspects of this rule 43
00:16:51 we're working on aspects of this rule 43 yes it's the pro formas we're going to come to we've already seen it before um but that's the only am i right in thinking that's the only holistic oversight yeah odcb was was
00:17:03 holistic oversight yeah odcb was was where we'd agreed corporately that we would review the rule 43 developments yes
00:17:09 yes and that would then be reviewed and turned by the latter house working group yes so that everyone's clear about these these labels yeah now let's look at paragraph 61 of this same witness statement if we can mr reason please if
00:17:20 statement if we can mr reason please if we go to page 28 we can see that at 61 you are answering the question in italics whether the training was evaluated and if so where what when and you say this beyond the
00:17:32 what when and you say this beyond the business usual training processes that i've detailed in paragraph 13 31 i don't recall this case study training package being specifically evaluated prior to my retirement in january 2015.
00:17:43 retirement in january 2015. however
00:17:44 however under any underperformance in relation to high-rise incidents and training involved involving high-rise scenarios would have been picked up in the six monthly odcb reports produced by the
00:17:56 monthly odcb reports produced by the operational assurance department high-rise incidents and high-rise related training scenarios were not uncommon so any underperformance would have been picked up through the odcb monitoring process
00:18:08 monitoring process now given the significance of the latino health incident do you know why consideration was never given to evaluating the training package or otherwise ensuring that operational staff had learned and embedded all the
00:18:21 staff had learned and embedded all the lessons of lachenal including external fire spread risks risks of failure of compartmentation and the dynamic risk management model um
00:18:30 um well as the paragraph 61 says the the training was rolled out starting in i think it was july and august 2014 i think we gave stations and senior
00:18:42 i think we gave stations and senior officers approximately three months to complete
00:18:45 complete the case study and then there's always a a kind of legacy period where you then start to see whether the investment in this training has delivered the desired outcomes in terms
00:18:57 delivered the desired outcomes in terms of
00:18:58 of performance at high-rise incidents and as it says there high-rise incidents sadly are not unusual particularly in london so we do get a quite a body of evidence in terms of
00:19:09 quite a body of evidence in terms of performance any incident high rising fires that have escalated beyond the initial attendance the normal predetermined attendance would be attended by the operational
00:19:21 would be attended by the operational review team which is a dedicated carder of officers that look at the performance and this would have clearly been a focus for the operational review team to look at high-rise incidents once this body of
00:19:32 at high-rise incidents once this body of training had been implemented to see if it had started to have the desired effect right i think the is the answer to the question then in fact you retired essentially too soon after the rollout
00:19:44 essentially too soon after the rollout to see this this is the evaluation uh intelligence coming from the the body of information that we captured about our performance incidents and training uh it was probably too early for me to
00:19:55 uh it was probably too early for me to see that coming through to odcb i see now
00:19:59 now as i've shown you in the second part of the paragraph you go on to say that any underperformance would have been picked up in the way you say um in summary are you telling us that the
00:20:10 in summary are you telling us that the case study wasn't subject to a specific evaluation exercise per se but if there had been problems with its content or problems with it with
00:20:21 or problems with it with carrying its uh content into effect then those would have become clear via the odcb and diot mechanisms well i think there's a stage before that so
00:20:31 so as you know from evidence you've heard already the this tcat was subject to a training commissioning process
00:20:38 process with a commissioning department and in fact dac tim cutler was heavily involved in in developing the content with this with babcock because of his subject knowledge of the incident itself
00:20:49 knowledge of the incident itself and therefore um in essence the signing off process of the tcap is an assurance process in itself that it's actually that the training is delivering
00:21:01 actually that the training is delivering what the learning objectives were set out in that particular tcap
00:21:06 tcap obviously the kind of level three level four evaluation as i call it uh is can you measure that the intended outcome has been embedded within the staff that this is this package was
00:21:18 staff that this is this package was aimed at and then the kind of that's a level three which is what the assurance process in dave brown's directorate would have been aiming to achieve across all training but of course including high-rise related issues and
00:21:31 including high-rise related issues and then the level four is really where the odcb
00:21:34 odcb management information is used to see if the design you know if it's been embedded in the staff is it having the desired outcome when we're actually attending high-rise operational incidents um two things flow from that
00:21:46 incidents um two things flow from that the first is you refer to the tcap commissioning department and the sign-off um that's a paper exercise isn't it or is there a pilot uh there's my understanding is always a pilot and i think as i said earlier in
00:21:58 pilot and i think as i said earlier in this statement i was i'm aware that the officers that were involved at the incident some of the junior officers saw an early pilot of the case study
00:22:09 pilot of the case study and they delivered it to their teams who would have been at lachnal house via most of them and that was part of an additional process we did for this because there had been so much
00:22:21 had been so much input by the state you know the station staff and the people the junior officers that attended this incident they were very passionate about making sure that their colleagues in other parts of london would learn from this package and again i don't know if
00:22:32 this package and again i don't know if you've seen the package but i think all of the insta commanders write up to assistant commissioner steve chirik who was the the final incident commander of this large fire they all contributed actually as a talking head uh video clip
00:22:45 actually as a talking head uh video clip on the package um and and that was something that we hadn't previously done i don't believe and that's because the people are involved in lacking all so passionate about making sure their colleagues from other parts of london
00:22:56 colleagues from other parts of london who may not have been aware of the detail of the incident other than what they've seen on telly that they could learn from from the officers that were there as its own experience
00:23:07 experience yes um the second thing that plays i think from what you just said is you refer to level three and level four evaluations i think mr gross told the inquiry that those were not done uh in relation to this package
00:23:19 uh in relation to this package do you know are you able to help with that or was that after your time um
00:23:24 um i can tell you what was in place when i was head of training so we we used the kirkpatrick model of evaluation which is a level one level three level four level five we never achieved level 5 because
00:23:35 five we never achieved level 5 because that's societal improvement which was very difficult to measure but i certainly believe that we had a level 3
00:23:45 level 3 evaluation which is linked to the assurance processes which i've touched on dave brown will be able to provide you with much more detail about the insurance processes for training that was going on within his directorate
00:23:58 was going on within his directorate and the level four i believe given the principle of what level four evaluation is trying to achieve is looking at organizational improvement which is what the function of odcb was
00:24:15 now the final sign off of the tcap if we go
00:24:21 if we go to
00:24:23 lfb 306 7857 please we can see the date
00:24:31 the date you just have that up there's the first page of it but if we go to page 37 we can see the final date of the sign off of this tcap was there it is may 2016. you can see
00:24:42 was there it is may 2016. you can see the signatures uh there's a ac cup bill uh signing it on the 17th of may
00:24:50 of may um d.a.c fenton uh uh on the same date and some further signatures below that uh and babcock i think on the 31st of
00:25:01 uh and babcock i think on the 31st of may 2016.
00:25:03 may 2016. so that's about 18 months after the date of the package that we saw and and in fact uh two years after the station-based package april 14.
00:25:14 14. now let's look at your first witness statement
00:25:17 statement uh you say at page 17 in that that's nfb3032747 paragraph 51 you say in the penultimate sentence
00:25:29 you say in the penultimate sentence um in paragraph 51 that the training package was launched for station based operational staff in august 2014. we've seen that are you able to tell us why
00:25:40 seen that are you able to tell us why the tcap form wasn't signed off as closed and completed as at that date august 2014 and why there was a delay until may 2016 no i
00:25:51 no i as i said yesterday i wouldn't have seen the tcap when i was working i've only subsequently seen it in preparation for giving evidence you see going back to what you told us earlier when i asked you
00:26:02 earlier when i asked you whether um the odcb and diot mechanisms would have been the mechanisms through which any problems with the content or delivery would have become clear you said there
00:26:13 would have become clear you said there was a stage before that which is the tcap commissioning and sign-off but it looks from the chronology that this station the station-based training april 2014 and the office of senior
00:26:25 april 2014 and the office of senior officer training august 2014 happened two years and 18 months respectively before
00:26:31 before the tcat commissioning sign-off so it wasn't a stage before that this was just looks like a stage after that are you able to help well in terms of the chronology of the administration
00:26:42 the chronology of the administration yeah i can't disagree with that because that's what the dates say but i can reassure the inquiry that uh and and tim cupple used to work for me before i retired that he
00:26:53 to work for me before i retired that he was heavily involved in this um as a subject matter expert for the lack of house fire the training did get delivered on the dates that i put in my statement i checked that obviously before
00:27:04 before producing my statement and so the uh evaluation of the improvement that was intended would have started to flow through you know three months after
00:27:15 three months after staff had started to clean so this probably isn't you know i don't know i'm only presuming this is probably an administrative issue rather than a an issue that has indicated that the training wasn't delivered right so
00:27:26 delivered right so um between april 2014 and
00:27:30 and january 2015 when you left for the station-based training and august 2014 and january 2015 for the senior officer training would i be right in thinking that any problems with that training
00:27:42 that any problems with that training package as it became rolled out and embedded um would have would have become obvious or should have become obvious to the operational assurance department um who were to pick up um poor
00:27:54 um who were to pick up um poor performance trends in training uh training incidents yeah but i'm talking really about the training and how this package was was being received so would i be right
00:28:06 was being received so would i be right in thinking that during that period the odcb's impd report would feature any trend in
00:28:15 trend in failure by station-based staff for officers to to learn from the package yeah that's that's how that process works so uh that report you've just described is informed
00:28:26 report you've just described is informed by a whole raft of uh intelligence and management information including direct observation from offices that have attended and the operational review team that uh assessed performance yes uh so it would have it would have featured if
00:28:38 it would have it would have featured if if there was any issues that had been captured right and you sat on the odcb i think at this time uh yeah up until the date i retired i sat on yodcb from the whole period i was assistant
00:28:49 whole period i was assistant commissioner from 2008 to the time i retired in 2015. well were you aware of any impd reports um being produced by or for the odcb which identified a trend
00:29:00 for the odcb which identified a trend either among station-based staff or officers of any problems with embedding these training packages not at the time by the time i'd retired high-rise issues had been highlighted i
00:29:12 high-rise issues had been highlighted i think i put that in my one of my statements uh over the life since odcb had been created which was 2006 from memory uh high-rise and high-rise related issues
00:29:23 high-rise and high-rise related issues had featured you know not regularly but periodically during the life of that process but certainly in respect to this particular piece of training uh it wouldn't have really uh
00:29:35 wouldn't have really uh there wouldn't have been a body of evidence built up by the time i retired now can i then turn to babcock's review of incident command training against the seven uh incident command recommendations we
00:29:47 uh incident command recommendations we saw those listed in the the rule 43 letter yesterday yeah um can we go to the pro forma please which is lfb3034062
00:29:58 page 22.
00:30:04 now we looked at this i think yesterday this is the document that you'd received uh
00:30:11 uh from
00:30:13 from uh
00:30:14 uh i think is this right from is it tim cut bill
00:30:18 bill no this is the you recall yesterday we discussed this this was the working draft
00:30:24 draft that i i facilitated to be produced for the commissioner so that he could respond to the coroner's rule indeed and i thought you told us yesterday it was it was given to you collected up by uh by uh assistant commissioner cut bill
00:30:38 uh by uh assistant commissioner cut bill in there no it was um sorry the the the person that pulled the information together from the heads of service was glenn seabright who was the head of communications right now um looking at a
00:30:49 communications right now um looking at a and b on this page page 22 looking particularly at b uh you said that we the lfb will engage with our training contractor to ensure the points specifically listed in recommendations one to seven are
00:31:01 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 incident
00:31:12 needed to support effective incident command the brigade will also introduce a case study which will incorporate the learning outcomes from lack of house and from other high-profile high-rise incidents such as shirley towers
00:31:23 incidents such as shirley towers hampshire and haruko hertfordshire
00:31:27 now if we go to your first witness statement uh
00:31:35 uh you tell us well before i ask you that can i just confirm something um peter groves told us that the reference there to current review process was a reference to babcock's three-year initial course review process or icrp is that right
00:31:52 yes yes now let's go to your first witness statement please page seven and let's look together at paragraph 28 if we can
00:31:59 we can you say there towards the bottom of your screen
00:32:02 screen that at the inaugural meeting of the nhwg the latin house working group was held on the 24th of july 2013 at this meeting the initial work program as outlined below was agreed the names in
00:32:14 outlined below was agreed the names in the brackets indicate the officer who had responsibility for leading on the item and then you set them out there and
00:32:21 and you could see that the
00:32:24 the first one was ongoing updates on the progress of the latin house review also victim support both of those were yours and then at the foot of the screen for the page incident
00:32:35 foot of the screen for the page incident command developments you were also tasked with reviewing all the developments relating to incident command
00:32:42 command that the brigade had implemented following the latin house fire do you remember why that was identified as one of the six priorities for the working group's work program because the primary function of the and
00:32:56 because the primary function of the and focus of that working group was to look at the brigade's response to the specific
00:33:01 specific elements of the rule 43 plus other issues that the the group eventually wanted officers to look at and report on you you told us earlier i think that it was your responsibility to provide the
00:33:12 was your responsibility to provide the members of the latter house working group with a rule 43 monitoring report at every meeting um the the first iteration of that action plan monitoring report was i think
00:33:22 think is this right prepared for the latin house working group september 2013 meeting
00:33:28 meeting yeah if that's the inaugural meeting then that would have been the first meeting i took that report too yes well let's see let's look at the document and see
00:33:35 see see what you recall of it it's it's um it's within the agenda pack for the september 2013 meeting and it's at lfb3067820
00:33:45 if we can go to that please page 11. we'll start with page one just just to identify the documents
00:33:56 this is latin house working group it's your exhibit 32 monday 30th of september 2013 and now item three update on progress with the brigade's rule 43 action plan
00:34:09 with the brigade's rule 43 action plan action plan and covering note director of operational resilience and training that's you and if we go to page 11 which sits within that item here we see
00:34:20 here we see uh what we call the pro forma and we looked at this i think yesterday action update august 2013 you see that yes in the far right
00:34:31 yes in the far right um
00:34:32 um and if we start at page 13 i think i'm right am i in saying that this is the the update in respect to the actions intended to address the coroner's recommendations on incident
00:34:43 coroner's recommendations on incident command yes uh
00:34:46 uh yes uh and on the left hand side of the page under item 3
00:34:51 item 3 you can see the text which says this the brigade review its policies and procedures concerning incident command having regard to whether it is effective for the choice of the ic to be tied closely
00:35:03 the choice of the ic to be tied closely to the number of or types of appliances attending an incident and be given and training be given to ics to enhance their training in relation to the following
00:35:12 following uh and then um if you um turn over to
00:35:20 to page 14
00:35:21 page 14 please uh you can see that uh on the right hand side in the column we've got the brigade rule 43 actions
00:35:32 43 actions and i just want to focus it on the action in the bottom row and go back to page 13.
00:35:42 um in the bottom right page 13 there's a b under lfb action review incident command training to ensure the seven points are adequately covered you see that yes and in the last column the august update
00:35:54 in the last column the august update says this still on page 13 babcock have recently completed a full review of incident command training and a draft course review report was received by officers on 2nd of august
00:36:05 received by officers on 2nd of august 2013 this is now being considered and will inform revisions and improvements to the suite of incident command training solutions they're just pausing there
00:36:15 there this is am i right this is the reporter rising out of babcock's three-year course review relating to incident command that is correct right um now we'll come back to the babcock
00:36:26 um now we'll come back to the babcock incident command course review shortly but just sticking now with the august 2013 monitoring report delivered to the national house working group
00:36:37 working group at the 30th of september 2013 meeting sticking with this um
00:36:43 um the remainder of the update if we go over the just at the bottom of the page to start with and then we'll go over the page offices also instructed babcock to confirm that all seven incident command related
00:36:55 that all seven incident command related recommendations are sufficiently and return the page comprehensively covered within the existing suite of training courses
00:37:04 courses babcock has confirmed that all seven issues are covered in the existing suite of command training albeit that there may be opportunities to emphasize the latino event during some inputs this
00:37:15 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. now
00:37:28 first do you remember how when and how babcock gave you that information gave you the confirmation that all seven issues are covered in the existing suite of command training
00:37:40 of command training i haven't got the date and i wasn't the officer that received that report and i think i've seen uh uh certainly a document that reflects uh i think the
00:37:51 document that reflects uh i think the work that babcock did in preparation for this but it wouldn't have been a document i would have seen it would have gone to the commissioning department who who had put that action in the uh the original rule 43
00:38:03 action in the uh the original rule 43 response to the coroner was that glenn seabright or was that somebody else no glenn seabright was really the kind of administrator and or not the author he was just pulling the information
00:38:14 was just pulling the information together from the heads of service and commissioning department so okay so who was it incident command sat within ac cotton when she was uh head of service for operational assurance so we're looking are we for a confirmation
00:38:26 we're looking are we for a confirmation by babcock to ac cotton
00:38:29 ac cotton that
00:38:31 that uh all seven issues have been covered in the existing suite of command training yeah or someone in ac cotton's department that was managing this piece of work right i follow thank you do you remember whether the rule 43
00:38:43 you do you remember whether the rule 43 review
00:38:44 review was documented
00:38:49 what this piece that responding to the seven items specifically yes yes i i've seen a document in uh reviewing information for this for preparing
00:39:00 information for this for preparing myself which was a a similar table to this but with um a list of all the courses where babcock covered the seven items and i assumed that someone in ac
00:39:12 and i assumed that someone in ac cotton's department would have assessed that for you know currency suitability and completeness before getting before i was given this update yes i think i know what you're referring to we may we maybe come to it i think
00:39:23 to we may we maybe come to it i think that's babcock's proposal is that right it may be that document yes right well we'll look at that shortly um we'll come back to that then um now mr groves told the inquiry that babcock had
00:39:36 groves told the inquiry that babcock had often had difficulties delivering incident command training due to a lack of subject matter expertise
00:39:44 first of all would you agree with that observation um there were difficulties with um design and development around certain curricula and incident command was one of those in the early days of the contract yes i agree with that that that
00:39:56 contract yes i agree with that that that being said was any consideration given by you or or at odcb level or indeed at lhwg level to undertaking a
00:40:08 or indeed at lhwg level to undertaking a review
00:40:09 review internally either within the training department or the operational assurance department or perhaps a combination of the both well in effect the way the commissioning process worked was the
00:40:21 commissioning process worked was the operational assurance department would have assured themselves that the seven items as detailed by the coroner's rule 43 recommendation were covered in existing and to what extent they were covered and i think the
00:40:33 extent they were covered and i think the mention of the incident command forum was something we introduced not long after the contract was awarded which was a kind of another meeting but it was specifically around discussions
00:40:46 it was specifically around discussions around incident command to try and assist
00:40:49 assist babcock
00:40:51 babcock so there wasn't a view corporately or even by myself that we should uh do a further piece of work with babcock because i would have expected and i i do believe
00:41:03 i would have expected and i i do believe uh that there was evidence provided to the brigade through that um that by the virtue of that update has been given to me that that piece of work had been done by the ops assurance department which was the commissioning
00:41:15 department which was the commissioning department for this piece of work just a couple of things that flow from that uh
00:41:21 that uh if we can go back a page please just to page 13.
00:41:24 page 13. um i'm just focusing on what's said there babcock has recently completed a full review of incident command training uh my question was was any consideration
00:41:35 uh my question was was any consideration given
00:41:36 given to undertaking that review within the lfb either through the training department or operational assurance or both that was my question
00:41:47 assurance or both that was my question no not at that time right so how did the lfb have oversight of or involvement in babcock's rule 43 review that's referred to there
00:41:58 that's referred to there the course review element of that or the response to the seven items being covered in existing training which which element are you well i'm referring to the recent completion of the full review of incident command training
00:42:10 of incident command training we we wouldn't have had direct involvement because in in the contract as i think mr um
00:42:18 growth covered in his evidence that a part of the contract was for all course curricular to be reviewed within the first three years and obviously instant command was one of the the main course
00:42:29 command was one of the the main course course curriculars that uh we were interested in and i i i saw the second of august 2013 course review report and it was a very comprehensive
00:42:40 very comprehensive piece of work from babcock with i think from memory about 38 recommendations relating to how uh babcock could improve the provision of incident command training and and
00:42:52 of incident command training and and that's what i took to the course review build which i subsequently set up i think in early 2014 right
00:43:00 now let's look at the tcap uh form for zero one two four at lfb four zero three seven one six
00:43:18 tcap0124 the title
00:43:21 the title is enhanced incident command training based on lachnal inquest's rule 43 recommendations uh first is that the document and process that facilitated babcock's rule
00:43:33 process that facilitated babcock's rule 43 review
00:43:35 43 review yes i believe so right and then if we go to page three we can see uh from the version control statement here that it uh was the form was first raised on the 3rd of june 2013.
00:43:47 raised on the 3rd of june 2013. at least that's the date of the first draft yes yes yes and if we go to um item 12 there we can see that the last draft and sign off was on the 10th of august 2016.
00:43:59 august 2016. um now um if we go to page five of the tcat form
00:44:03 tcat form you can see background and context there you see that uh and um the background and context sets out about halfway down your screen the seven recommendations by the coroner for
00:44:15 seven recommendations by the coroner for lfb incident command training yes yeah yes then if we go to the bottom two paragraphs just read with me if we can scroll up it says this after the
00:44:27 can scroll up it says this after the seven item list with respect to the points specifically listed above in one to seven
00:44:34 to seven uh these need to be addressed to ensure the training provided enhances performance across the range of skills required
00:44:41 required in particular recently published stroke revised policies below babcock are expected to provide a proposal detailing the changes to courses to achieve a greater and enhanced level of incident command
00:44:52 enhanced level of incident command training that is already delivered based on the points one to seven above now why would babcock only asked to make a proposal which covers changes to
00:45:03 a proposal which covers changes to existing courses
00:45:08 i only saw this document in preparation for this
00:45:12 for this hearing so i'd probably not the best witness to ask that question of who would be um someone from the commissioning department so maybe ac cotton right i
00:45:24 department so maybe ac cotton right i can answer that ac cotton right um to the best of your knowledge doing the best we can with what you know why was no thought given to creating or instructing
00:45:35 thought given to creating or instructing babcock to create a whole new training course or exercise that focused on uh the specific or each of the specific seven points
00:45:48 or each of the specific seven points i think looking at the seven points uh in detail obviously i'm i'm well aware of what they were and are
00:45:56 and are as it says there they that the initial review
00:45:59 review and our understanding was that they all of these issues have got training solutions embedded within incident command training or other training solutions
00:46:07 solutions so there wasn't anything new in the seven points that we weren't already providing training so there wasn't an absence of training in any of those areas so the focus
00:46:19 so the focus was i suspect what can we do better in terms of the existing training provision to embed the issues that have been highlighted there with the seven points that were raised by the coroner
00:46:33 what wasn't there a problem with that and although one can understand that you wouldn't want as it were to reinvent the wheel wasn't the problem that the
00:46:44 wasn't the problem that the coroner had identified through his recommendations that the wheel wasn't working
00:46:49 working and therefore you needed a new wheel i don't necessarily accept that's what the coroner was recommending this is one fire
00:46:58 fire in amongst you know probably hundreds of fires relating to high-rise around that period obviously not all as tragic as lacking thankfully so
00:47:08 so it may reflect that the officers in attendance at lacanal given the nature and the challenges they faced uh
00:47:16 uh you know
00:47:17 you know didn't perform as we maybe would have liked against these seven or because of the nature of the fire was different to what we'd seen previously were caught slightly unawares
00:47:29 were caught slightly unawares i don't think there was a systemic problem across these seven issues and that comes from me as being a the director level but also as a a very experienced operational incident
00:47:40 experienced operational incident commander for 30 odd years um you know there's always lessons you're going to learn incidents particularly the ones that are the outlier incidents that are you know are very challenging and unusual
00:47:52 and unusual but i certainly had a sense uh both corporately and personally as a professional fire officer that we were doing all of this stuff and and of course there were lessons to be learned because of the scale and nature of the
00:48:04 because of the scale and nature of the lack of fire that we wanted to share with other colleagues um you say at the start of that last answer that the latino house fire was
00:48:15 the latino house fire was one fire
00:48:16 one fire in amongst probably hundreds of fires relating to high rise around that period
00:48:23 that can't be right can it it this was a particularly uh
00:48:29 uh a particular fire which had caused the death of six people an inquest and had been on the face of it taken with the utmost seriousness
00:48:40 with the utmost seriousness by the lfb to the extent that you'd established a working group before the inquest and after the inquest a another working group to uh take into account the rule 43 recommendations we we haven't seen uh
00:48:53 43 recommendations we we haven't seen uh the same
00:48:54 the same exercise given or done in relation to any other fire so would i not be right to say that lachlan house was a milestone
00:49:02 milestone a milestone event uh in the lfb's history
00:49:06 history uh
00:49:07 uh yeah i would describe it as a significant event in the fire brigade's history but yeah i'd agree with the sentiment of that comment yes and given that the
00:49:15 that the coroner had heard two months three months three months of of evidence and produced carefully constructed uh
00:49:23 uh rule 43 recommendations which set out seven
00:49:26 seven specific uh points which were the subject of training to be given by incident
00:49:33 incident of incident commanders and potential incident commanders to enhance performance i come back to my question given that why not just create or think about creating a whole new training
00:49:44 about creating a whole new training course or set of exercises focusing on the kinds of problems which emerged at latino house rather than seeking to improve existing training which as you could tell had not
00:49:57 training which as you could tell had not worked or was defected well the there's two elements to this tcap there's the assessment of how well the brigade was covering these seven issues and we've
00:50:08 covering these seven issues and we've touched on that already and the second part was where we could uh identify new opportunities through
00:50:18 re-constructing some of the existing incident command assessment materials and what i'm talking about there is the command decision making exercises the tactical decision making art exercises
00:50:29 tactical decision making art exercises and the incident command exercises which are
00:50:32 are practical exercises role play exercises and that's part of this solution it's not in this section of the tea cap but it is in this cap and then the final part of the jigsaw which i hope
00:50:44 part of the jigsaw which i hope answers the question is is the lacrimal house case study itself notwithstanding i accept that the dynamic risk assessment element of it wasn't embedded within that case study
00:50:55 wasn't embedded within that case study but there were other materials available for for those sessions uh covering that topic but the case study itself was doing exactly uh what it was designed to do which was
00:51:06 uh what it was designed to do which was to try and cover all of these issues in a practical uh context showing a real incident that you know firefighters and officers had dealt with uh at the latin house fire
00:51:19 dealt with uh at the latin house fire but the case study came later didn't it the cde
00:51:22 the cde came later on i think yeah so that's i think i thought that's what you're going to draw my attention to with the kind of chronology of dates at the start of the document is this was a kind of a work in progress so
00:51:34 this was a kind of a work in progress so the case study was just one element which is why the whole of the tcat probably wasn't signed off until much later because uh some of the tactical decision making exercises and
00:51:45 tactical decision making exercises and command decision making exercises had not been changed at that point and obviously that that was done over a number of months and possibly years to get all of the existing training
00:51:56 get all of the existing training material i think there were from memory i think there's 16 uh tactical decision stroke command decision making exercises that were in the portfolio that babcock offered the brigade at that time and a number of
00:52:08 brigade at that time and a number of those i think from memory and this is from memory so i apologize if it's not exactly accurate i think six of them were chosen which had high rise sort of features and they were the ones we were going to
00:52:19 they were the ones we were going to focus in on to kind of develop a narrative and to kind of explore some of these issues with the with the delegates when they undertook that training nonetheless i come back to my point one
00:52:30 nonetheless i come back to my point one more time
00:52:33 more time given the importance of the fire given the rule 43 recommendations given the structure established in the lfb to carry them into effect why not simply create a whole new training course
00:52:45 create a whole new training course whether or not it used parts of old training that had worked in the past
00:52:49 past um but they're focused on particular things that are at arizona at lacanal rather than seeking to improve existing training
00:52:56 training okay i can only repeat what i've said i i believe the tcap for this particular case study is trying to achieve that exactly what you've just said now let's look at the babcock proposal at lfb3038170
00:53:14 uh
00:53:17 this document is dated uh i can tell you not the 19th of september 2013 uh and
00:53:26 uh and it's called tcap number 0124 enhanced incident command training based on lachlan quest's rule 43 recommendations uh first of all do you remember this
00:53:37 uh first of all do you remember this document i wouldn't have seen this document i didn't see the processes relating and documents relating to tcaps so right i've only seen this in preparation for given evidence today and
00:53:48 preparation for given evidence today and who would have signed this document off
00:53:51 off it would have been you know
00:53:53 you know part of peter groves's team but primarily it's the commissioning department's job to evaluate any proposals from babcock in relation to new training or revisions to training
00:54:05 new training or revisions to training now let's look at the opening paragraph it says this a review of the current incident management training provision directly relating to the areas identified by the 7 rule 43 recommendations has been undertaken the
00:54:16 recommendations has been undertaken the purpose of the review was to confirm current practice and to identify areas for improvement to meet the requirements of tcap 0124 and then um it says the review considered the
00:54:27 it says the review considered the following incident management courses and there are nine set out uh below um covering crew managers through to deputy assistant commissioners and above yes yes i recognize those courses yeah
00:54:39 yes yes i recognize those courses yeah yes and then in the last paragraph on this page just we can scroll down it says this the following table gives a broad overview of the outcomes from the review process in terms of the
00:54:50 from the review process in terms of the areas identified for improvement and the proposed solutions to enhance training and then if you look into the table it says on the left hand side um they're learning outcomes and then as a findings
00:55:03 learning outcomes and then as a findings column existing learning outcomes are in need of revision to ensure the training is tightly focused and addresses the outcomes required for each rule 43 recommendation and then if you look at the second
00:55:14 and then if you look at the second row under action training new learning outcomes have been written for each one each one of the seven rule 43 recommendations
00:55:24 and then if we look over the page
00:55:29 page two but the second page we can see from the first column relate that that relates to training provision and babcock's findings are under the second column as follows existing
00:55:42 second column as follows existing training provision was either explicit or implicat it should be implicit i think across the different roles some receive dedicated theory and practical training for other roles it depended on the exercise scenario they
00:55:54 depended on the exercise scenario they are exposed to as part of the training as to whether or not all areas relating to the rule 43 recommendations were covered and assessed and then the row below that underneath underneath it
00:56:06 underneath it next to the words exercise scenarios on the left hand side it says this as mentioned above existing exercise scenarios were found to be in need of revision to meet all
00:56:17 to be in need of revision to meet all areas of the rule 43 recommendations and then in the column to the right of that it says this suitable exercise scenarios have been identified and core and supplemental sorry supplementary injects written
00:56:29 sorry supplementary injects written aligned to each role and covering the identified lfe policies and procedural notes to ensure delegates knowledge understanding and ability is tested by application in addressing the incident command challenges posed by each of the
00:56:42 command challenges posed by each of the exercise scenarios and i've read a lot of that to you mr reason but in summary and i know you didn't see this document at the time but in summary is this right to the best of your understanding
00:56:53 to the best of your understanding babcock reviewed the incident command training against the coroner's second seven recommendations and discovered that although the content of the recommendations could be said to be contained within the incident command
00:57:04 contained within the incident command training
00:57:05 training it was at times implicit not tightly focused and whether any individual received the relevant training would depend both on their rank and on the exercise scenarios they happen to be
00:57:16 exercise scenarios they happen to be exposed to as part of their training i agree to that summary of what i've just read thank you now if we go to page three of this document in the second paragraph below this table
00:57:28 in the second paragraph below this table uh
00:57:29 uh page three yes thank you page three
00:57:41 uh page three yes thank you page three training proposal in the second paragraph
00:57:44 paragraph in this text it says this um tcap0124 requires enhancements to incident command training based on latin requests rule 43 recommendations the seven recommendations relate to areas of
00:57:56 seven recommendations relate to areas of incident management training that although currently delivered through existing training require enhancement to meet the tcap requirement now again was that
00:58:05 that the same reason namely the training was often implicit not tightly focused and and uneven i think you could make that inference from that statement based on what's gone previously in this document yes yes
00:58:17 previously in this document yes yes thank you now as the rest of this document goes on to detail particularly at page 14. well let's look at page 14 if we can go to that um would you accept that babcock's proposal
00:58:29 would you accept that babcock's proposal for the enhancement was to develop some command decision exercises or cdes which would specifically address uh each of the current of seven areas of
00:58:40 uh each of the current of seven areas of recommended incident command training
00:58:43 i haven't read the whole of that page but right just quickly scan reading it that appears to be what they're proposing yeah yeah decision-making exercises right now let's go back to your
00:58:54 let's go back to your well just before we leave that document you said it was it was signed off by all prepared by the commissioning department um as at this time which is september 2013 just just could you remind me if not tell me who that was it was i see
00:59:07 not tell me who that was it was i see cotton that was ac the head of that department yes now if we go back to august your august 2013 monitoring report prepared for the 30th of september 2013 latino house
00:59:19 latino house working group meeting that's at lfb3067820
00:59:24 um we go back into the the pro forma and look again at it page 14.
00:59:33 page 14. page 14.
00:59:34 page 14. uh yes
00:59:35 uh yes and there we can see uh in the second line in the right-hand column i read it to you before i'll read it again babcock has confirmed that all seven issues are covered in the existing
00:59:47 seven issues are covered in the existing suite of command training albeit that there may be opportunities to emphasize the latino event during some inputs now mr reason having now seen babcock's proposal for
00:59:58 proposal for tcap0124 the 19th of september 2013. would you accept that what you what is said there is not quite accurate babcock's conclusion wasn't that there may be opportunities for emphasis or
01:00:09 may be opportunities for emphasis or enhancement but that existing training requires enhancement so as to meet the coroner's seven recommendations yeah i agree that the wording could be more explicit to reflect that statement yeah
01:00:22 explicit to reflect that statement yeah and therefore as at the 30th of september 2013 when you were providing this update to latin house working group members the training did not in fact cover those seven issues did it well i think it did cover them uh
01:00:35 well i think it did cover them uh what we were saying there is there were opportunities to improve the training to reflect uh and improve the areas of the seven items raised by the coroner so we're not there was as i said earlier there was no absence of training in any
01:00:48 there was no absence of training in any one of those seven areas but clearly it was our intention uh the true babcock contract to improve the training that we already offered but but in fact as we've seen the proposal uh
01:00:59 seen the proposal uh did not say that it was covered for all incident commanders it depended on whether they were exposed to the exercises or not uh i think at every level going back to that listing the tcap uh
01:01:11 that listing the tcap uh there is high-rise exercise for uh crew manager watch manager all the way up to brigade manager and certainly i'd done a few of the exercises and and they did involved high-rise related
01:01:22 they did involved high-rise related incidents so my understanding is that there were training opportunities involving high-rise for all levels of command in the brigade
01:01:33 command in the brigade yes but just because it's a high-rise incident doesn't mean that it's automatically covered in other words it doesn't mean that it automatically meets the rule 43 recommendations but it covered
01:01:44 recommendations but it covered as it says there all the issues are covered but we accepted and i hope it's conveyed obviously not as explicit as you may would have liked but yeah that we were working to improve in the
01:01:56 that we were working to improve in the areas and take every opportunity to embed the learning that came from the lack of house incident yes i mean what you've just said doesn't quite reflected by the language of that sentence is it no i said that the the the the update
01:02:08 no i said that the the the the update could be more explicit in respect to uh the position as it was currently in the date this was written yes and in fact um the way this is presented in this document significantly dilutes what
01:02:19 document significantly dilutes what babcock had actually said um
01:02:22 um i don't think it was ever an intention to dilute it or mislead members or the members of odcb i think the people that are involved in this would have been uh very much uh
01:02:36 you know on top of the issues and what was the intended outcome um and there's certainly no lack of intent or ambition to improve the training across all of the issues that are highlighted in this
01:02:47 the issues that are highlighted in this particular tcap no but there may have been an uh an intent or ambition not perhaps to expose the commissioning department or the lfb more generally
01:02:58 more generally to the lhwg in the sense of revealing to them that the existing training wasn't quite as good as it should have been um i don't think there was any deliberate intent to mislead or
01:03:09 deliberate intent to mislead or misinform the latino house working group that's not the relationship we had with members um they they were very uh robust in their scrutiny of officers as i think you've heard from other
01:03:20 i think you've heard from other witnesses
01:03:21 witnesses and certainly uh we had a very good dialogue at the lack of house working group i had a very good working relationship with the chair and there was certainly never an intent to
01:03:30 to mislead the the group there would be no point i mean we are we are the officers that are going to have to turn up and take charge of these incidents so it's in our interest as well that we have robust training in place to prepare us
01:03:42 robust training in place to prepare us for that challenge can you explain why you didn't make clear to the lack of house working group that in fact babcock's conclusions as you agreed with me
01:03:53 conclusions as you agreed with me earlier whether the 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 their training depending on their rank well i
01:04:04 training depending on their rank well i was very much dependent on the updates i got through odcb obviously if i i felt they weren't robust enough or i needed more information then i i think you've probably seen emails from me that
01:04:16 probably seen emails from me that uh have pushed back on some of the updates that we got through during the life of this particular committee uh because i was the one that had to face members and ask answer the question so
01:04:27 answer the question so um
01:04:28 um again i i hadn't seen that tcat response i would have been taking my cue from the information i was given yes i mean had you seen that tcap response can we take it that you would not have
01:04:39 can we take it that you would not have allowed the text such as this to appear in this action update i would have probably been a little bit more careful about expressing it slightly differently yes yes can we take it that you never yourself took steps to verify the
01:04:50 yourself took steps to verify the findings of babcock's rule 43 review or ask anybody in your own directorate to do so as against what commissioner cotton was giving you were an assistant commissioner yeah assistant actually was there an assistant commissioner cotton
01:05:01 there an assistant commissioner cotton that that was the job of that commissioning department i wasn't going to check on every piece of work i mean i had a big job and i was like all the top managers were very busy and you know we relied on our heads of service and their
01:05:12 relied on our heads of service and their teams that worked for them to do this this work and i 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
01:05:23 at my level that this was being progressed appropriately you say you had no reason to doubt but standing back did you know did it not ever strike you as unusual or odd that the latino house coroner had heard evidence which caused
01:05:35 coroner had heard evidence which caused her to recommend improvements to lfb's incident command training in these seven specific areas and yet babcock's summary having examined them was that the existing training was to paraphrase
01:05:47 existing training was to paraphrase largely fine subject to certain enhancements which had been identified did that not strike you as peculiar um not peculiar as i said earlier i don't think there
01:05:58 as i said earlier i don't think there was any complacency in the approach we took
01:06:01 took we certainly took the recommendations extremely seriously the commissioner by virtue he'd set up you know his own working group prior to the inquest i think shows
01:06:13 the inquest i think shows the ambition and the intent of the organisation and that was driven through all heads of service there was no doubt that we'd experienced a significant and tragic event that was beyond what we'd
01:06:24 tragic event that was beyond what we'd probably
02:58:09 you