London Fire Brigade Evidence - Tuesday 28th September 2021 (2/2)

Full transcript

00:00:28 would you ask mr reason to come back in please thank you

00:00:41 all right mr reason who ready to carry on yes sir good thank you yes just a minute um yes there's a reason um i just wanted to just explore briefly a couple

00:00:52 wanted to just explore briefly a couple of things that we covered before the break

00:00:54 break and first in the answer that you gave before the lunch break you referred to policy 120 policy note 120 yes uh and you did say uh in that that there's no

00:01:07 you did say uh in that that there's no specific guidance in that policy or anywhere else that gives an incident commander a specific criteria against which they would make a decision to consider partial or full evacuation

00:01:18 to consider partial or full evacuation of a tower block a residential block that's right isn't it i did say that yes yes just to be absolutely clear can we look at policy note 120

00:01:29 i want to be clear with you what i'm going to put to you which is that it does not cover evacuation of occupants of a high-rise residential block it's at lfb 50701

00:01:47 and the title lfb

00:01:51 lfb 50701 and the title of this policy note is phased evacuation of office buildings and it was issued in february 1991 and reviewed as current in november

00:02:03 and reviewed as current in november 2015.

00:02:06 2015. as you can see it is about office buildings and if you go down to um page six

00:02:11 six of this document you can see that there's paragraph 6.7 implement actions as per policy number 633 high-rise firefighting am i right in

00:02:22 633 high-rise firefighting am i right in thinking that that is the the only reference in this in the text of this policy

00:02:27 policy uh to high-rise firefighting more generally than in the context of an office building uh

00:02:35 uh yes i would accept that there is a mention of high-rise somewhere in this document um but i i i accept it's more akin to uh not a non-residential high-rise building

00:02:46 not a non-residential high-rise building yes and indeed this this policy actually covers low-rise and high-rise office buildings yes it does yeah um secondly can i just show you something uh in

00:02:57 can i just show you something uh in in

00:02:58 in lfc rose uh second witness statement of the inquiry lfb three zeros eight three eight three four lfb three zeros eight three eight three four

00:03:11 i'll just show you the first page of that it's his witness statement uh to the inquiry of december 2019 and if you go please to page seven

00:03:24 uh you

00:03:26 you can see that at the foot of the page he deals with the lfb's understanding of stay put and on page eight uh

00:03:34 uh we go to uh

00:03:38 if i'd like to look at the question at the foot of page seven forgive me if we go to the question of the foot of page seven he's asked this in paragraph 21 you state and that's back to his first witness statement the lfb openly recognizes that there are no

00:03:50 lfb openly recognizes that there are no clear parameters in its policies and training for when and how a stay put strategy should be disapplied and what alternative strategies should be put in place for the avoidance of doubt this is

00:04:01 place for the avoidance of doubt this is the question to him please confirm it if it is your evidence that there is no explicit guidance or direction at all in the lfb's policies training or other any other source of information as to when

00:04:13 other source of information as to when and how staple should be withdrawn and what alternative strategies should be implemented in that event so that was the question he was posed let's look at the answer he gives over on page eight

00:04:24 on page eight he says this i can i confirm that at the time of the grenfell tower fire that was the position

00:04:31 position whilst our policies explicitly recognized that the statement strategy and advice may need to be withdrawn paragraph 745 to 747 of policy note 633 that's high-rise firefighting and

00:04:43 that's high-rise firefighting and paragraph

00:04:44 paragraph 8.7 of policy note 790 i think that's incident command we recognize that we had not provided explicit guidance as to when and how it should be withdrawn and the alternative

00:04:56 should be withdrawn and the alternative strategies which should be implemented save for the explicit reference to partial or full evacuation i also explained the difficulties associated with evacuation in quotation marks and that the lfb has reflected upon this as

00:05:08 that the lfb has reflected upon this as an organization we recognize that we did not have contingency planning in place for situations where a state put strategy is no longer attainable for an entire building my question mr reason is is that correct

00:05:21 my question mr reason is is that correct um

00:05:22 um i would agree with the majority of that answer yes what would you disagree with um it's more

00:05:29 more sort of nuanced that uh just remind the inquiry of my answer just before the break lunch break about the difference between evacuation and

00:05:40 the difference between evacuation and rescue

00:05:43 so we're talking about stay put here specifically in the context of evacuation and as you recall my

00:05:50 my interpretation of evacuation and that's my understanding when i was working as well

00:05:55 well it's a sort of a managed process that is used uh as a precautionary measure to reduce the risk to members of the public mostly

00:06:07 mostly wednesday put needs to be revoked obviously you're requiring

00:06:11 requiring the individual members of the public who are making the fire survival call to make their own way out of the premises

00:06:20 premises that's why you'd make that assessment and they may be assisted but they may not be assisted by fire office personnel so it's really just a nuanced thing is that the point you probably would

00:06:31 that the point you probably would change the stay put guidance is you're probably into either what i would describe as a mass rescue or a rescue a search and rescue operation rather than a sort of pre-planned evacuation strategy it's it's becoming a

00:06:44 evacuation strategy it's it's becoming a rescue operation at that point but equally isn't it correct as uh

00:06:51 uh the commissioner says here that as at the time of the grenfell tower fire there was no guidance at least no explicit guidance as to how and when staples should be withdrawn and the alternative strategies

00:07:03 withdrawn and the alternative strategies that should be implemented not specifically for a residential high-rise building no no right can we then go back please to the training guide we were looking at for holdcroft house before the break

00:07:14 holdcroft house before the break and that is at bab 6011 and i'd like to go back to page 69 which is where we left off

00:07:23 and we left off at the very point where we were considering together the consideration of partial or full evacuation of the block and i think you accepted that there's

00:07:34 and i think you accepted that there's nothing in the training on what it was that a candidate should consider or should note which would prompt consideration of a partial or full evacuation of the block

00:07:45 partial or full evacuation of the block yeah from what i've seen in this document i can't see where that no that's been introduced no no um in general and i again i i detect that you're not familiar with the document so you may not know the answer to this but

00:07:57 you may not know the answer to this but um

00:07:58 um did the training proceed on the basis that holcroft house

00:08:03 house was a block with a stay put policy in place

00:08:07 in place um

00:08:10 um i could guess but i don't know specifically because i say i wasn't involved right um more generally so far as you were involved in the development and detail of the um command decision exercises or

00:08:23 um command decision exercises or incident command training more generally for high-rise firefighting was it generally the working assumption that all residential high-rise buildings should be approached on the basis that they had a state put policy in place

00:08:35 they had a state put policy in place yeah i think that's a fair assessment that at the time of my period in as director and before as an operational commander

00:08:44 commander that yeah i think it was well understood that stay put policy for residential high-rise probably was the default position unless there was specific evacuation procedures developed by the responsible person

00:08:55 responsible person now um can we please turn onto page 76

00:09:00 here we can see the 10th inject page 76 of this document uh yes thank you here we can see um

00:09:10 um inject number crew manager watch manager 10

00:09:14 10 yes

00:09:15 yes and then there are some performance criteria and then in the box you can see inject 10

00:09:20 inject 10 as incident commander you receive information from the bridgehead that the fire is actually on the fourth floor and has spread from building debris in the communal hallway to at least one flat on the fourth floor

00:09:31 to at least one flat on the fourth floor in addition to a large quantity of debris left in the hallway apparently by the renovation contractor the flat is now 50 to light take it from me if you would there's nothing else in this document either before or after

00:09:43 this document either before or after this inject that refers to fire spread uh now against the backdrop of the latino house fire particularly its rapid external fire spread affecting a number of flaws in that building do you accept

00:09:55 of flaws in that building do you accept that that was a failure here to train firefighters on the extent of the risk posed by

00:10:02 posed by external fire spread and poor compartmentation if this indeed was the final um command decision making exercise uh that was mentioned in the

00:10:13 exercise uh that was mentioned in the response to the rule 43 then that didn't convey

00:10:17 convey what we'd intended in terms of fire spread i mean it does talk about fire spread but it looks like more internal compartment and fire loading within the hallway is the focus in this inject

00:10:28 hallway is the focus in this inject and in order to address the risks posed by external paneling it doesn't appear to from what i've seen in so far no it doesn't nor rapid external fire spread no no and to that

00:10:39 external fire spread no no and to that extent would you agree that this training exercise did not in substance meet the coroner's seven incident command recommendations if this is indeed the the one that was produced and not a different version uh

00:10:50 produced and not a different version uh blackwell tower springs to mind um yes i accept that this doesn't convey uh a response to the rule 47 rule 43 sorry thank you now let's turn to a

00:11:01 sorry thank you now let's turn to a slightly different uh topic one which i think you've referred to before which is the babcock incident command course review process now we've looked at a number of documents so far in your evidence mr reason which would suggest that the

00:11:12 reason which would suggest that the coroner's seven incident command recommendations would also be fed into babcock's incident uh course review of incident command training yes yes yes i mean we've looked at that um the update in the tcap

00:11:25 at that um the update in the tcap one two four form uh which said that the following the tcap the recommendations would be made for further enhancements that would be fed into the incident course review yeah i accept that incident course review yes now um we

00:11:38 incident course review yes now um we also i think confirm that you were the chair of the course review board weren't you i was yes now if we go then against that background to this document lfb three zeros four three five five two

00:11:52 uh we can see that this is babcock's initial

00:11:56 initial uh program course review report yes i recognize that yes july 2013 and it's its full title is initial program course review ipcr stage 2

00:12:08 program course review ipcr stage 2 report incident management training and

00:12:12 and the reports date on the front cover as you can see is july 2013 but if we go to lfb 3073973

00:12:22 in fact we can we see that the the email which was

00:12:30 was which covered the production of this email sorry but covered the production of this report was actually dated 27th of october 2014. this is an email from doug massey of babcock to phil butler

00:12:42 doug massey of babcock to phil butler enclosing the document pdf glossy with photos etc and it appears that there were different drafts and discussions of this report between july 2013 and october 2014 when it was finalized i can take you to some

00:12:55 it was finalized i can take you to some detail of that if you want to but does that accord with your recollection generally

00:12:59 generally yes my recollection is the previous document the 2013 version although it doesn't say draft i was given a

00:13:07 given a an early copy uh just to sort of get a feel for

00:13:11 feel for the approach i think this was the first document i'd seen that was a the outcome of a course review and it was just i think for babcock's purposes to get a feel

00:13:22 purposes to get a feel uh whether they were going in the right direction and the sort of scope and intention and the style of document was was what we were expecting right so although the document bears the date july 2013 it wasn't finalized is this

00:13:34 july 2013 it wasn't finalized is this right until october 2014. from memory uh and i have checked the course review bill minutes i don't think we formally took the incident command review report at that ball i may be wrong but i don't

00:13:46 at that ball i may be wrong but i don't remember it i remember seeing it but i don't remember taking it at the board right now let's get back to the report can we go first please to page 12. i want to pick up the references in it to lachen house

00:13:58 to lachen house and on page 12 the first reference to national house we see is in the left-hand column under 6.1 historical context

00:14:09 under 6.1 historical context if you cast your eye down your screen and we now need to scroll down to the bottom half of the page

00:14:17 uh you can see that there is uh a paragraph that starts since 1991. can you see that yes and it says this since 1991 there have been other notable events which have been further

00:14:28 events which have been further influenced which have further influenced incident management training including bethel green july 2004 two london firefighter fatalities harrow court february 2005 two hertfordshire

00:14:40 court february 2005 two hertfordshire firefighter and one resident fatalities atherstone on stir in november 2007 four warwickshire firefighter fatalities lagnal house camberwell in july 2009 six

00:14:52 lagnal house camberwell in july 2009 six resident fatalities shirley towers in april 2010 to hampshire firefighter fatalities now as i've shown you lachlan house is the fourth in that list there

00:15:03 the fourth in that list there um

00:15:04 um noting that and we'll come back to atherstone in a moment um the second reference to lachenal house is on page 30. if we look at page 30 we see an appendix to this document

00:15:16 to this document which is entitled stage 1 incident management review output document you see

00:15:22 see and if you go to the bottom of page 32 two pages into appendix one we can see that there's a row-headed political considerations can you see at the bottom right-hand left-hand corner of your screen yes i can say that and in the

00:15:33 screen yes i can say that and in the middle it says this corporate responsibility for managing the health and safety of employees whilst at work is a statutory requirement failure to meet and maintain these statutory obligations exposes the fire authority

00:15:45 obligations exposes the fire authority to the risk of legal action you see that yes i'll say that and then over the page if you go uh over to page 33

00:15:55 33 towards the bottom of that row it includes a list of current issues for consideration the first bullet point of which says this the outcome of the latin house inquest and rule 43 letter

00:16:06 latin house inquest and rule 43 letter to the

00:16:07 to the now those are the only two references in this document that we've seen the latin house fire and the um subsequent inquest and the rule 43 recommendations from it

00:16:18 recommendations from it um

00:16:20 um you're familiar with this document i assume would i be right about that i read it at the time yes do you agree there's nothing in the report certainly as of october 2014 to indicate that the coroner's seven

00:16:31 to indicate that the coroner's seven incident command recommendations have been substantially incorporated into or considered by the incident command course review i don't recall seeing the later version of this i may well have seen it but i

00:16:43 of this i may well have seen it but i don't recall seeing it so i can only base it on the what i would call the early draft in 2013 right i accept that there was no specific uh detail about the rule 43

00:16:54 specific uh detail about the rule 43 recommendation just to pass in reference to it

00:16:57 to it no no you referred to the early draft in 2013

00:17:00 2013 that's about a year or so before the final review report was issued take take it from me i think this is the final version

00:17:07 version um

00:17:08 um looking at the october version that is at lfb 3071968

00:17:16 and this is a string of emails in october 2013. if we go to the second email done in the chain it's from you on the 8th of october 2013 to james van glich and peter groves

00:17:28 glich and peter groves and the subject initial program course review ipcr stage 2 report incident management training at 7th october 13. so this is the year before the document we've just seen james and peter please

00:17:40 we've just seen james and peter please find attached my ops and revisions relating to incident the incident command course review document in summary i don't have any major issues with the direction of travel being proposed by babcock but i but i'm still

00:17:53 proposed by babcock but i but i'm still struggling to see how we move forward in terms of designing and delivering some of the new courses the idea of a joint working group appears to be the most pragmatic and sensible way to progress these course reviews and it's clear we

00:18:05 these course reviews and it's clear we now need a discussion on how to make this work both for the brigade and babcock

00:18:10 babcock and why did you not take the opportunity in october 2013 2013 to highlight the fact that the rule 43 recommendations needed to be woven into this review

00:18:21 into this review um

00:18:23 um i can't specifically uh

00:18:26 uh making an active decision to not put it in maybe i just didn't consider it given it was at a draft and i knew that there was other work going on um and this wasn't the final iteration but i it just didn't from

00:18:39 iteration but i it just didn't from memory it didn't cross my mind but it certainly wasn't an active decision on my part to not put it in so would it follow that you took no steps at all as director with responsibility for the

00:18:51 as director with responsibility for the training and the course review board and also for implementation of the coroner's uh incident command recommendations to ensure that those recommendations lay at the heart of babcock's review of incident command

00:19:02 babcock's review of incident command training well it was it would be one of absolutely i agree it would be one of the considerations but it it was much broader this review was across the whole of the incident command curriculum not just those issues uh relating to the

00:19:15 not just those issues uh relating to the lack of house fire well quite but i'm not suggesting um that the review was only related to the issues coming out of the latin house fire what i'm suggesting to you uh is that you failed uh to weave

00:19:27 to you uh is that you failed uh to weave into this course review the

00:19:31 the specific

00:19:32 specific rule 43 recommendations about incident command that the coroner had made yes in that context i didn't put them in yes i just want to know why that is if you can tell us i i can't say i can't recall

00:19:44 tell us i i can't say i can't recall actively making a decision to put it in or leave it out i just probably didn't come to my attention when i was reviewing the document which i say was an early draft and i was reading it in the context this

00:19:55 and i was reading it in the context this was the first course review report i'd seen from babcock and i think the reason i got an early copy was to give some feedback

00:20:03 feedback more about style and approach rather than specific content i mean i did read it obviously and i think this email uh supports that assertion but uh i don't think i was crawling over it line by

00:20:15 think i was crawling over it line by line and checking that every single bit of incident command training was covered by this document well even if you weren't crawling it over over it line by line why didn't you get somebody in your

00:20:26 line why didn't you get somebody in your organization to do that given that that was ultimately something for which you were ultimately responsible well i think if and you may be able to help me with this in a minute if this did come to the course review board then a much wider

00:20:39 course review board then a much wider group of officers and you know the constituent members of the course review board other than james and peter groves would have seen this document and i would have then taken um you know we've

00:20:50 would have then taken um you know we've had a discussion about the document itself and what it contained and and then we would have fed back formally to babcock uh whether that was going to be accepted as their final iteration but i don't recall it formally

00:21:01 iteration but i don't recall it formally being taken at the course review board in 2014

00:21:04 in 2014 whether it subsequently came to that board assuming that board continued after i retired i i don't know the answer to that i'm afraid sorry well no and you you of course retired in january 2015 and it's right to think that the

00:21:15 2015 and it's right to think that the incident command course review remained incomplete as at that time didn't it yes it did yes are you aware of any changes to the lfb's incident command training being implemented whether in response to

00:21:27 implemented whether in response to the latin recommendations or otherwise before your retirement in respect there was a lot of training delivered uh in that period well there were tweaks to existing training you've described before but other than those i

00:21:39 described before but other than those i think there was more than tweaks we published

00:21:42 published and this isn't all involved babcock's some of it predates babcock in 2011 we published

00:21:48 published a new high-rise procedure which took account of the issues that had been identified through the lack of house investigation i'm pretty certain that had a training support package and it

00:22:00 had a training support package and it was published through the operational news

00:22:02 news uh there was other aspects of those seven eye

00:22:05 seven eye criteria in the rule 43 recommendation like search and rescue we published a brand new policy around search and rescue and that subsequently had a training support pack

00:22:16 training support pack developed and was published through ops news

00:22:19 news and there was new equipment and numerous operational policy updates to reflect what we'd learned from nakano so i don't accept there was no training but obviously the tcap we're referring

00:22:32 but obviously the tcap we're referring to and this course review was not concluded before i retired you referred to new high-rise procedure in 2011 is that the new 633 uh 363. yes

00:22:44 uh 363. yes i believe the after the lack of house fire

00:22:47 fire before the generic risk assessment was updated which didn't get published until 2014

00:22:53 2014 the brigade uh operational policy department and that was before i was director but i i know this happened so it's a fact that a new 633 policy as soon as we knew

00:23:04 that a new 633 policy as soon as we knew enough about la canal that we were confident that we could put that into an updated high-rise policy we published and that became a station support training pack now after your retirement do you know

00:23:15 now after your retirement do you know who adopted or took over the position of director of operations resilience and training yes i do that was james douglas on an inter-invasion basis right did you have any form of handover as between you

00:23:26 have any form of handover as between you and james delgalesh yes i had an extensive handover for james he was working in my director anyway was obviously aware of the babcock issues and training issues because that was his reference and i

00:23:37 because that was his reference and i gave him a you know a very comprehensive handover in the months leading up to my retirement right in the months leading up to it how did this handover take place did you have meetings with

00:23:48 take place did you have meetings with him or did he sit with you and take gradually take over your your role how did it work um a bit of all of that uh james uh was a standing member of corporate management

00:23:59 standing member of corporate management board so he was cited on a lot of the organizational issues that were beyond my directorate at that time we had regular one-to-one meetings and there was a succession of meetings in

00:24:10 there was a succession of meetings in the lead-up to me leaving the organisation where i went through all of the

00:24:16 the work streams projects uh in my directorate and all the other work that he would be aware needed to be aware of that didn't already sit within his own department uh and i'd like to think it was a a very

00:24:28 uh and i'd like to think it was a a very comprehensive handover did you have any did your handover specifically focus on the incident command course review which he took over from you uh

00:24:38 uh no because the as i said i don't believe the document had formally come he would have been aware that obviously because i've sent him emails about it and he would have been aware because of his relationship with babcock and his role

00:24:49 relationship with babcock and his role within the organization that there were a whole raft of course reviews scheduled

00:24:54 scheduled we did have a program of when those course reviews were going to be published and when they would come to the course review board and he he sat on the course review board so we were doing aware of all of that

00:25:07 now i just want to ask you some final questions on incident command and training

00:25:12 training uh

00:25:13 uh you told us i think that the elfipa strategy committee received two updates on the work of the latino house working group one in november 2013 and one in july 2014. that's correct yes and now

00:25:26 july 2014. that's correct yes and now you've exhibited your july 2014 report your witness statement uh which i think we saw yesterday let's go back to it it's at nfb 306 7819

00:25:42 fb67819

00:25:51 yes and we looked yesterday i think at the front page and saw that it was drafted by the deputy commissioner rita dexter and by you

00:26:03 by you yes that's correct now if we go to paragraph

00:26:06 paragraph three on page two under the heading lhwg work program you can see that it says this at the inaugural meeting of the lhwg 24th july

00:26:18 inaugural meeting of the lhwg 24th july 2013

00:26:20 2013 the following work program was agreed and there are six bullet points the first of which is ongoing updates on the rule 43 action plan and the fourth is incident command

00:26:33 yes

00:26:38 that's i think the only mention of incident command in this document um

00:26:44 um is it correct that this report was intended to bring the strategy committee up to speed with the work of the latino house working group uh i think it was uh we were asked to produce this report by the lacrimal

00:26:56 produce this report by the lacrimal house working group or and or the strategy committee i can't which remember which way around it was um when the members of the lack of house working group felt they'd exhausted

00:27:07 working group felt they'd exhausted the issues and obviously the work program that we put forward to them and worked with them on so it was it was purely a kind of a

00:27:17 kind of a i think it was a governance process to it was formally open this this black house working group by the fire authority

00:27:24 authority which said they would obviously create the lack of house working group and it would report to the strategy committee and then when the members of the latino house working group felt they'd concluded their work then we'd have obviously take a report to close down

00:27:35 obviously take a report to close down the lacrimal house working group just for for completeness and for governance purposes

00:27:40 purposes i don't think it was ever intended to go sort of rehearse all of the information that had been at the lakinwa house working group just to give a flavour of the overview of the themes that have been

00:27:50 been researched and developed through that right but let's go and see what we can see if we go back to page one please we can see the summary

00:28:01 and in summary is it says it's the final update to the strategy committee detailing the work that's been initiated and progressed by the lachlan house working group and you can see the two recommendations underneath that

00:28:12 underneath that the work be noted and secondly that this group be agreed as the formal conclusion of the work of the latin house working group

00:28:20 group so that that was the that was the intention behind this report wasn't it that's correct yes now we've also i think established an agreed together that the latin house working group was intended to report its

00:28:31 working group was intended to report its findings and recommendations to the el fipa strategy committee given that context can you explain to us why you didn't explain to the strategy committee

00:28:43 didn't explain to the strategy committee that

00:28:44 that the work was still continuing in relation to the nfb's incident command actions

00:28:49 actions for rule 43 purposes and had not been completed at that date um

00:28:54 um again similar answer to one i gave earlier after lunch is again it wasn't an intention not to include

00:29:03 any information deliberately to mislead members

00:29:06 members i'd certainly refute that i think

00:29:11 i think elected members on all the committees are a different constituency of audience when you're writing these types of report they generally other than a few exceptions were less interested in the

00:29:24 exceptions were less interested in the granular level of kind of operational procedures policy and training they wanted to get a sense of the overview of the direction of travel of the brigade so certainly reports written to members

00:29:36 so certainly reports written to members were

00:29:37 were looked and felt and contained different information than reports that were written for operational and internal colleagues i know that probably doesn't quite answer your question but that that may explain in part why these these reports to

00:29:50 in part why these these reports to elected committees and the full fire authority contain less granular detail than the internal reports well granular or not granular

00:30:03 you were giving the impression weren't you through this report to the strategy committee that the work of the latter house working group was done when it wasn't

00:30:10 wasn't well that was our that's what the words say i mean the lack of house working group would have made that assessment themselves at the point they felt they'd exhausted the

00:30:21 they felt they'd exhausted the programmer work which we set out at the beginning at the inaugural meeting a few items were added during the lifetime of the lacrimal house working group we certainly wouldn't have been allowed to close down the lack of house working

00:30:32 to close down the lack of house working group it's a member working group so officers attended it in their capacity as advisers to the to that particular committee it was the committee itself the latino house working group the chair

00:30:43 the latino house working group the chair and the two the two other members that worked on it that you know chose to decide based on information we've given them and the information they'd seen that they felt that they had concluded the work as

00:30:54 that they had concluded the work as originally intended by this particular working group it wasn't officers recommending to close down the working group it was the elected members were satisfied with themselves

00:31:06 were satisfied with themselves that they had concluded what the working group had originally set out to achieve yes well you put your finger on it if i may say so um you they made the decision based on the information you had given them and

00:31:18 the information you had given them and the information they'd seen that's right isn't it that is correct yes but the working group's decision was entirely based on what you told them through your monitoring reports and your incident command development report

00:31:29 incident command development report and and they obviously other presentations and and people that attended the meetings over the life of that group yes so their decision was only going to be as good as the information they had yes i accept that and if it was

00:31:40 yes i accept that and if it was incomplete then the decision was made on on an

00:31:43 on an incomplete basis from memory i don't think the they were obviously clearly interested in the rule 43 that was one of the catalysts for this working group but the

00:31:54 catalysts for this working group but the work of the group was much wider than than just the coroner's ruling um and i think at some point i mean you know for a fact that some of these

00:32:05 know for a fact that some of these actions uh went on until 2016 before they were finally closed off and and the tcap was signed as complete i can't believe that the lachen house

00:32:16 i can't believe that the lachen house working group would have stayed operational over that whole period they would have satisfied themselves that the brigade had the appropriate level of governance and assurance in

00:32:28 level of governance and assurance in place which would have been through the odcb as you know because the same ver or a different slightly different version of the same update went to odcb so i i can't remember specifically and i

00:32:39 i can't remember specifically and i don't think we had this conversation but my sense is that they would have been satisfied that if if they closed down the latino health working group the the rule 43 wouldn't just disappear into a black hole and

00:32:50 just disappear into a black hole and there was no governance to check that it was being progressed uh and assured and they would have satisfied themselves that the odcb was the appropriate level uh to manage that work going forward and

00:33:01 uh to manage that work going forward and that they'd satisfy themselves they concluded the work of the working group did the conclusion of the latino house working group at this time mid july 2014 and this report to the strategy

00:33:12 and this report to the strategy committee mean that the el fifa no longer exercised had any scrutiny over the lfb's progress as against the coroner's

00:33:20 coroner's seven incident command recommendations at that level of detail yes i believe that was true that didn't stop members obviously asking for information if they wanted it but we didn't provide a proactive report

00:33:32 but we didn't provide a proactive report to members or wasn't required to at that time so the formal structure of reporting to uh up up to the strategy committee was essentially terminated before the

00:33:43 was essentially terminated before the rule 43 recommendations in relation to incident command had been fully carried into effect that is correct

00:33:52 you or or anybody else ever seek to update the coroner to explain that as of december 2013 and onwards the deadline hadn't been met and the changes to training had not yet been

00:34:04 changes to training had not yet been carried into effect no i didn't where's that

00:34:08 that it never occurred to me to update the coroner we'd responded obviously with the original response uh and to be honest i didn't know if there was even a process to update coroners

00:34:19 was even a process to update coroners at some future day now we heard from peter groves that the new the new incident command courses started to be delivered in 2016

00:34:31 courses started to be delivered in 2016 and that was when the holcroft house exercise was was used that's when it became live when you retired in january 15 was it a concern to you that the incident command courses

00:34:42 courses which addressed the latino rule 43 recommendations had not yet been rolled out to personnel in relation to the uh command decision making exercises uh

00:34:54 uh command decision making exercises uh yes but i refer to my earlier answer i did believe that some of the existing high-rise

00:35:00 high-rise command decision-making exercises had been updated because they weren't new training uh from scratch they were sort of amendments to existing training i was aware that the this particular whole

00:35:12 aware that the this particular whole cross house or i believed it was back blackwell tower actually but um that there was another significant brand new package that that was on its way but hadn't been delivered before i retired

00:35:23 retired did he not um concern you were you not concerned that the urgency with which this was supposed to be addressed uh was not being observed

00:35:35 addressed uh was not being observed yes so there was always a concern about the speed in which uh not just this training but other training in certain curriculars was taking uh i think peter groves covered this in some

00:35:46 think peter groves covered this in some of his evidence and i was doing my best with babcock at a strategic director level to try and resolve some of these issues and i've given you one example which was

00:35:57 and i've given you one example which was the offer of group manager phil butler to assist babcock in this particular field of expertise did you yourself in your position as dort take any action

00:36:08 in your position as dort take any action to expedite these training packages uh not specifically because i think the the blockage to use a clumsy term was around that expertise and it was

00:36:20 was around that expertise and it was about three months before i retired i think that uh group manager phil butler returned to the brigade and that's when we seconded him into operational assurance with the view that he would also straddle the babcock design team

00:36:31 also straddle the babcock design team for incident command did anybody think of going to el fifa and telling them six months nine months after the latino house working group was terminated

00:36:42 house working group was terminated that there was a blockage with expediting the command decision exercises

00:36:48 exercises because you couldn't get the expertise no i didn't consider doing that um as i've said before the the tdes the cdes are a component of

00:37:00 the the tdes the cdes are a component of a suite of training that we made available to staff in the aftermath of the lacrimal house fire so yes i accept it it's not media as it was described in the tcap or urgent

00:37:12 the tcap or urgent um

00:37:13 um but there were if there had been a complete absence of training that yes of course we'd have escalated that i would have been directly involved in that because of the health and safety risks to that

00:37:23 to that but i was satisfied that there was a body of training going on that was addressing some if not most of the rule 43s and these

00:37:34 the rule 43s and these cdes and tdes packages were were just another tool in the toolbox so to speak that would come online to support that that already quite rich body of training

00:37:45 that already quite rich body of training that we were doing the rich body of training that you were doing was really just existing exercises which had had enhancements tweaks to them yeah a refocus of existing training materials

00:37:57 refocus of existing training materials to cover those seven items in the rule 43 yes yeah now i'd like to turn to a different topic which is training on external fire spread and something called the highly

00:38:08 spread and something called the highly insulated buildings package see see what you can help us with on that

00:38:13 that um

00:38:14 um can we start with lfb double zero one two one one two five please

00:38:21 this is an email from you

00:38:24 from you to danny cotton graham ellis and dr adrian bevin on the 12th of november 2014

00:38:36 yes i've read that uh and uh you've read it and i'm going to assume you're familiar with it this may not be quite so quick um please if you say danny and graham please find attach the final report detailing the lessons learnt from the atherstone on

00:38:47 lessons learnt from the atherstone on ster incident warwickshire frs is keen that other brigades are made aware of the content of the report so i've attached the learning points detailed in the main report that runs to over 80 pages nb the

00:38:58 report that runs to over 80 pages nb the full report can be accessed on the wfrs

00:39:02 wfrs website

00:39:04 website uh not surprisingly you will see that many you will see many parallels with the issues that have emerged from other incidents such as harrow court shirley towers lachenal our own sai outcomes

00:39:16 own sai outcomes from my own review i think that we are already cited and progressing many of the issues detailed in the report however you will see from the extracts from the bre global report pages 75 to 77 refers though there are some themes

00:39:29 77 refers though there are some themes that may be worthy of inclusion in future impd reports to odcb now the um the full report is at

00:39:41 is at three zeros one four seven six five

00:39:46 i'll just just i'll just pull that up and show it to you um there it is it's the report on the fire in athenston on stir second in november 2007.

00:39:57 and um just to be clear for everybody atherstone on stir is in warwickshire and wifrs is it right is warwick shafarian rescue services that is correct right so there it is um the extracts that you

00:40:10 so there it is um the extracts that you attach to the email are at wfb00121126

00:40:24 and here are the learning points if you see that now uh

00:40:30 now uh first of all do you recall the email yes i recall the email and you recall the extract yes right now just as a bit of uh background it's right to think that the atherstone on stir fire in 2007

00:40:41 the atherstone on stir fire in 2007 involved a fire in a vegetable packing warehouse yes you did where the fire spread beyond the compartment of origin yes you did is it that that made you compare or drew you to compare it to

00:40:52 compare or drew you to compare it to latin house shirley towers and harrow court

00:40:55 court um that amongst other features of the fire

00:40:58 fire significantly obviously the death of four firefighters was uppermost in my mind it was not it was something that i professionally would do anyways when there was other reports on fatal fires

00:41:12 there was other reports on fatal fires um you know of this nature i would always try and familiarize myself with with the reports that were coming out or coroner's recommendations and then asked my ops assurance team to

00:41:24 and then asked my ops assurance team to benchmark ourselves against any of these issues

00:41:27 issues as i said in the covering email you've shown earlier i felt from reading this that we were pretty much covered on most issues because there was nothing that was not anything significantly different

00:41:39 anything significantly different although the type of fire was different obviously to lachenal and other fires we'd had but uh you know almost like a belts and braces i wanted just to go through that process and as you saw in my email uh if there were any concerns

00:41:51 my email uh if there were any concerns from the operational assurance department then bring that through the normal reporting process to odcb now you say in that answer that you felt from reading this that we were pretty

00:42:02 from reading this that we were pretty much covered on most issues when you say we were pretty much covered do you mean from the point of view of health and safety your health and safety obligations to your employees

00:42:13 obligations to your employees um

00:42:13 um i think more in the context i mean ultimately that is that was my job but um i think in terms of these these uh bullet points on this page that's up at the moment uh these are the

00:42:24 that's up at the moment uh these are the things that you know you'll see the similarity to some of the things that you've seen elsewhere in evidence relating to lack of house and probably other fires um so that's probably what i meant more

00:42:35 um so that's probably what i meant more that there was nothing in here that sort of jumped out that we either wasn't sighted on or we weren't in my opinion progressing at that time let's look at page three of this document

00:42:51 and under the heading

00:42:55 uh it's the very top of the page and easy to miss fire safety and building construction knowledge can you see yes i can it says post-incident investigation highlighted that some of the fire safety features of the warehouse were

00:43:06 features of the warehouse were incomplete and some of these features influenced fire development there was also a lack of understanding of modern methods of building construction by many of the operational crews

00:43:15 crews the learning point is that operational crews should be able to recognize the fire safety features and wider construction methods used in modern building to identify potential hazards

00:43:27 building to identify potential hazards and safety features and then it goes on identification of sandwich panels the presence of sandwich panels in the part of the building affected was not widely recognized at the incident the three types of

00:43:39 the incident the three types of construction used in the premises had been clad with the same material of the same color which made recognition in the dark problematic the national guidance available highlighted the need to identify the

00:43:50 highlighted the need to identify the presence of sandwich panels although it did not provide guidance on the method of identification the learning point is that national guidance should clarify a consistent and practical method for identifying the presence and type of

00:44:02 identifying the presence and type of sandwich panels used within buildings see also national ventilation work finished overleaf yeah i read that now you said in your covering email that you considered the lfb to be already cited

00:44:13 considered the lfb to be already cited and progressing many of the issues detailed in the report we saw that email yes was that true of operational personnel being familiar with sandwich panels and other modern construction

00:44:24 panels and other modern construction methods and materials or was that one of the areas that you consider the lfb could learn from well we certainly had uh in around 2007 and i we'd had a a

00:44:35 a a a number of high-profile uh commercial buildings

00:44:40 buildings where sandwich panels really first came to prominence and and the difficulty for firefighters and commanders is they they burn fiercely as we all know and they are

00:44:51 know and they are collapsed very quickly once they're involved in fire so uh in the context of this particular report as you said it was a food packing warehouse ie a commercial premises

00:45:03 warehouse ie a commercial premises and so

00:45:04 and so in terms of this particular conclusion uh i would have felt that for commercial buildings we were fairly well cited there was certainly publications in operational news and i think there is

00:45:15 in operational news and i think there is a station training support pack which specifically covers sandwich panels in use in commercial premises yes now you focus on the part on the screen which which relates to sandwich panels um i'm interested in

00:45:26 to sandwich panels um i'm interested in the more general passage immediately above it

00:45:30 above it where the learning point is that there is a quote lack of understanding of modern methods of building construction by many of the operational crews learning point is that operational crews

00:45:41 learning point is that operational crews should be able to recognize the fire safety features and wider construction methods used in modern building to identify potential hazards and safety features i've read that again because i want to refocus you on it was that

00:45:52 want to refocus you on it was that one of the issues on which you considered the lfb already to be cited and progressing no i don't believe it was i didn't think of it in that context no and therefore was that something that you took forward

00:46:04 was that something that you took forward knowing that you weren't covering it um that you then wanted to see in policy and training uh i didn't explicitly express that in the email which you've seen but

00:46:17 the email which you've seen but i had asked the operational assurance department to review this document and i know they did do it and i believe that there were some recommendations that went to the operational

00:46:28 operational um

00:46:30 um yeah the operational improvement board uh around uh i think what you called highly insulated buildings now that post dates my time in in the fire service so i'm aware that

00:46:41 in the fire service so i'm aware that there was

00:46:43 there was uh a report that went uh but i didn't see the outcome of this review from the operational assurance department and or the impd report that uh potentially came out of this review because i had already

00:46:54 out of this review because i had already left the organization right um let's just explore that a little bit then and like that you're covering emails you have seen a particular reference to extracts from the bre global report i've read you

00:47:05 the bre global report i've read you that and you said it may be worthy of inclusion in future impd reports to adcb um

00:47:11 um in fact the extracts from the bre report are or some of them are in in this document the ones you draw attention to in your email and we we need to see those at page 12. go to that

00:47:23 those at page 12. go to that if you go to that page and look halfway down the page you'll see some metallic text

00:47:30 under the heading bre global report you say

00:47:35 you say and i'll read you the part above the italics probably easier the bre global work reviewed in the chapter titled understanding the fire highlighted a number of issues which bre global and wfrs are of the

00:47:47 which bre global and wfrs are of the opinion need further consideration these are taken from the matters arising from this program of work section of the bre global report on applestone onto incident

00:47:56 incident for warwickshire fire and rescue service and then it's a quotation 17.1 highly insulated buildings and this is a quotation from the bre global report and it says this i'll read it to

00:48:07 report and it says this i'll read it to you highly insulated buildings are becoming increasingly popular as a means of reducing the energy consumption of buildings bre global sustainability experts are heavily involved in the development and certification of highly

00:48:20 development and certification of highly insulated buildings of all sizes ranging from domestic properties through to commercial offices industrial buildings and warehouses the popularity of these buildings is driven by the sustainability agenda which currently

00:48:31 sustainability agenda which currently carries far more interest in the construction industry and is currently achieving far more rapid development than the fire safety agenda as the level of insulation afforded to buildings increases two factors

00:48:43 buildings increases two factors pertaining to the fire are affected uh and it goes on uh and if we go uh to the next substantive item on the following page page 13 you can see it says uh rapid fire growth

00:48:58 you can see it says uh rapid fire growth uh partly as a side effect of the increased insulation afforded to buildings but also as a result of changing materials materials present in and around buildings rapid fire growth is becoming increasingly common

00:49:10 is becoming increasingly common during the course of carrying out the reconstructions it was noted that modern fire and rescue service training involves the use of simulator units these units often show firefighters trainees firefighter trainees fires that

00:49:21 trainees firefighter trainees fires that burn at a steady rate for a considerable period of time they do not show a fire growing suddenly from a relatively small well-contained fire to a fire that is engulfing an entire compartment and extending beyond

00:49:33 entire compartment and extending beyond the boundaries of a compartment as a result trainees are not necessarily taught how to identify signs and symptoms of impending sudden fire growth and how to respond to these signs and

00:49:46 and how to respond to these signs and symptoms

00:49:47 symptoms now given the explicit reference in your own email to these extracts which is embedded which are embedded in the the learning points and given your ref and given uh the reference to other

00:50:00 ref and given uh the reference to other compartment breaching fires that we've seen

00:50:03 seen and the defects in training which this brought to your attention in terms would it be fair to say that it was this information here that was worthy you thought of

00:50:14 here that was worthy you thought of inclusion in future impd reports to the odcb

00:50:18 odcb well my email certainly references this section of report explicitly there are obviously other areas in this report that are relevant to the london fire brigade but yeah i i obviously read

00:50:29 fire brigade but yeah i i obviously read that

00:50:30 that and

00:50:31 and and obviously the fact that they've been four fire deaths uh obviously is very much focuses as well as you know when members of the public die and fire that's a real focus for us that's what we exist to do is obviously

00:50:42 that's what we exist to do is obviously save and rescue people and and not injure our firefighters in the process so

00:50:47 so those two sections yeah would definitely would have caught my interest and that's why i asked for this report to be further reviewed and to bring forward any recommendations to the odcb

00:50:58 the odcb yes but that information wasn't simply as you put it worthy of inclusion it was downright essential wasn't it uh yeah in the context of uh commercial premises we already had a

00:51:09 commercial premises we already had a body of uh training material for commercial buildings um so i knew i knew that and i'd undertaken that training myself i've been in charge of

00:51:20 been in charge of highly insulated buildings but predominantly all commercial um so yeah it would have been in the context of a commercial structure in terms of this report but obviously i i know where you're going with this

00:51:31 i i know where you're going with this but um

00:51:33 but um i didn't make an explicit link to residential highly insulated buildings

00:51:41 now let's look at the response to this email comes the same day 12 november 2014 nfb 30 88107

00:51:55 in the second email down on this page uh graham ellis

00:52:00 that's i think it's the same graeme ellis as we've seen referred to before isn't it that is the same person dcl is he

00:52:07 he writes to you in response and also copy to dr bevan and assistant commissioner cotton and he says this sir i think that you

00:52:18 and he says this sir i think that you are right in saying that many of the identified lessons have been considered and actioned by the lfb the need for improved and more frequent operational and command training is something that we will hopefully address further through the ongoing review of ic

00:52:31 further through the ongoing review of ic training

00:52:33 training just pausing there is that a reference to the um

00:52:35 to the um continued review by babcock of the incident command review process yes i think by this time group manager phil butler had joined or returned to from his second and was

00:52:47 returned to from his second and was starting to work with graham's team graham ellis's team and babcock to assist with the incident command review and the work falling out all right sorry i got the impression of your evidence

00:52:58 i got the impression of your evidence earlier that in fact

00:53:01 he that is group manager butler had returned after you had left no no he returned

00:53:07 returned it was an opportunity i think maybe even graeme ellis brought it to my attention that that phil was due to return and that's when i can't remember who i discussed it with probably ac cotton and graham that he

00:53:18 probably ac cotton and graham that he would be a real asset to both the you know incident operational assurance team but also could straddle the gaps that have been identified at that point with babcock uh

00:53:30 identified at that point with babcock uh which were which were acknowledged by babcock to be fair to them and and and group manager butler would be a real asset for both parties to take this piece of work this important piece of work forward so he i think he

00:53:41 of work forward so he i think he returned

00:53:42 returned around october 2014 and probably took up that role

00:53:46 that role immediately on his return now um continuing with the email

00:53:54 he says does tac ellis they have clearly identified the need for more frequent and enhanced training as operational exposure of staff decreases a few initial observations are that we should

00:54:05 initial observations are that we should consider an ops news article of highly insulated buildings crates on quotes we are already seeing examples of compartment fires in modern well insulated properties the challenges associated with firefighting in such

00:54:16 associated with firefighting in such premises will no doubt continue to test us given the unprecedented increase in the development of modern high-rise premises across london i will have a more detailed look over these findings

00:54:27 more detailed look over these findings with the im team now we know that a cbt package entitled highly insulated buildings was subsequently developed and discussed at the odcb

00:54:38 the odcb although never released was that package a result of your conversation with graham graham ellis at around this time or was that package already in motion at the time of your highlighting these

00:54:49 the time of your highlighting these materials in november 2014 do you remember

00:54:52 remember yeah i think i remember this correctly uh i believe my email and and this response to it was the catalyst i believe from other information that

00:55:03 i believe from other information that i've seen in preparation for today that the ops news or the odcb that considered graham's impd report apologies for all the abbreviations there um included this

00:55:15 abbreviations there um included this topic and

00:55:17 topic and i don't know who was sharing that odcb because i wasn't there i'd retired by that stage but it was agreed that an ops news article on highly insulated buildings and the associated new training

00:55:29 associated new training was agreed at that odcb so i i think i could take some credit for you know prompting that piece of work to be done which ultimately led to odcb considering these issues as part of

00:55:40 considering these issues as part of their normal business as usual right and indeed if we turn to the top of this email run

00:55:45 email run page one we can see that dac ellis responds

00:55:49 responds to uh adrian bevin and danny cotton on the 27th of november as follows we've shortlisted fires in highly insulated buildings on the wish list for the next main ops news

00:56:00 the wish list for the next main ops news and better and more frequent and solid command training is being addressed via the review of ict was that that was the position was it when you left in january 2015. yeah that was my i hadn't seen this email obviously but that was my understanding

00:56:12 obviously but that was my understanding that there would be a piece of work based on the analysis of the atherton onstar incident and other you know emerging issues that agree menace's team would have picked up in normal business and that would be brought forward to the

00:56:24 and that would be brought forward to the meeting of the odcb in 2015. yes now following this email exchange in november 2014 did you take any additional steps to ensure that the lessons to be learned from the aphiston

00:56:35 lessons to be learned from the aphiston on stir incident were embedded within the lfb's operational training uh it was right at the you know you see the dates of the email there november it was literally weeks before i retired so

00:56:46 was literally weeks before i retired so i obviously didn't want to leave the organization having read this report without me at least starting the process where it would be formally reviewed so that was my intention

00:56:57 intention and i believe that subsequently happened so obviously my intention did result in some consideration of these issues now

00:57:06 now i want to turn to a completely different topic please communications and i want to start within that topic with the latino rule 43 response and

00:57:16 and in that

00:57:17 in that the the sub-topic of additional radio channels now in general is it right that the responsibility for incident communications fell under your directorate yes he did in operational policy it did

00:57:29 yes he did in operational policy it did yes

00:57:30 yes and who was it within the director that held that responsibility uh the head of operational policy when i took over as uh director was assistant commissioner jim knighton

00:57:42 commissioner jim knighton he left the organization in around july 2013 and uh deputy assistant commissioner peter cowep who was already the deputy assistant commissioner in

00:57:53 the deputy assistant commissioner in that department at that time acted up as head of service for an interim period until such time there was a promotion round uh

00:58:01 uh peter carrick was successful in that promotion round and was appointed assistant commissioner head of operational policies and procedures uh i can't remember what date he was promoted but i think it was around the

00:58:12 promoted but i think it was around the end of 2000 and sometime in 2015 i think or maybe earlier i can't remember the exact date but he he had a he took over from ac night and then became the assistant commissioner

00:58:23 assistant commissioner uh in an unbroken sequence so we had continuity in that department and what about um group manager jim acord or accord yeah jim uh a court was

00:58:34 acord or accord yeah jim uh a court was as far as i recall uh he worked in one of the sort of functional teams within operational policy i had and he had responsibility for incident communications right

00:58:45 right um

00:58:46 um now we have a statement from dr bevan who is the lfb's head of health and safety as you've told us on the question of communications which you've given to the metropolitan police and that is at met3080505

00:59:01 can we please go to that

00:59:15 met 308050

00:59:27 thank you now

00:59:29 now that's the first

00:59:35 that's not not it there it is thank you that's it uh and you can see that it's dated the 5th of august 2021 that's a recent statement and can we go to page 12 in that please

00:59:49 he says in the second page on that on that page page 12 this he says it's my understanding that the incident communications team should lead on specifications

01:00:00 should lead on specifications procurement operational policy and training relating to radios between 2013 and 2014 i believe the department was managed by group manager jim acorte who

01:00:11 managed by group manager jim acorte who is now retired when he retired the incident communications team was depleted and it is my understanding that there wasn't a direct replacement for him

01:00:21 him just pausing there did mr acor's retirement occur while you were still working for the lfb do you remember we're looking at that day it would suggest he did but i don't remember him

01:00:32 suggest he did but i don't remember him retiring when i was director right now let's go next to lfb three zeros four two zero eight nine

01:00:44 this is commissioner dobson's uh letter in response to the lack of house coroner's rule 43 letter of the 28th of march this letter stated the 23rd of may 2013 and we go to page

01:00:57 the 23rd of may 2013 and we go to page eight in it we can see at the top of the page that the coroner made recommendation five

01:01:07 and i want to read that to you in in terms it says this it is recommended that the brigade consider whether it would be beneficial to use additional breathing apparatus radio communications channels

01:01:17 channels and

01:01:18 and personal radio channels and major incidents to reduce the amount of traffic on each channel

01:01:26 and under the heading response the lfb said this

01:01:29 said this in the second paragraph if you look at it it says the use of a single ba radio channel allows for the safe monitoring and overview of risk critical safety critical and general information to and

01:01:40 critical and general information to and from ba teams the use of separate channels would make it more difficult to maintain this complete overview and may result in a delay in exchanging critical information for example by using a single channel

01:01:51 for example by using a single channel the transmission of risk critical information relating to a phase or emergency evacuation of a ba crew can be heard and appropriate action taken by all concerned multiple channel use could also lead to

01:02:03 multiple channel use could also lead to a lack of coordination between teams and increase the risk that the firefighting actions of a team on one channel might adversely affect teams on another the need to pass information across multiple channels may negate any perceived

01:02:15 channels may negate any perceived benefit

01:02:16 benefit because of the requirement to re-transmit all relevant information across the channels in use the result would be to reduce the amount of radio capacity and create further possibilities for duplication and

01:02:27 possibilities for duplication and confusion

01:02:29 confusion and the next paragraph summarizes the introduction of ba telemetry and the last paragraph says this having carefully considered in summary having carefully considered the recommendation

01:02:41 carefully considered the recommendation the brigade is firmly of the view that the risks associated with using more than one ba channel during an incident but outweigh the benefits that this operational practice would afford

01:02:53 operational practice would afford now um

01:02:54 now um i think earlier in your evidence you told us that you and the other members of the commissioners group met to discuss how the brigade should respond to the rule 43 recommendations and i think we saw a meeting

01:03:06 and i think we saw a meeting uh invitation for the 14th of may 2013. that's correct yes which followed on from the 11th may 2013 emails that we saw

01:03:14 saw can you are you able to summarize for the panel the discussions that were had in relation to this recommendation at that meeting i can't recall them verbatim but it would have been along the lines of what

01:03:26 would have been along the lines of what you've just read out to me um i believe when the rule 43 recommendation came in around incident communications there was a risk assessment process undertaken to look at

01:03:37 assessment process undertaken to look at the

01:03:38 the risks versus benefits of introducing additional breathing operators channels into service and this is the conclusion of that risk assessment um and i think the board will comfortable

01:03:49 the board will comfortable uh you know a number of the border senior operational officers who've got a lot of operational experience and i think from memory we all felt that this was a a sensible approach

01:04:01 was a a sensible approach in terms of ba particularly the fact that we were also introducing ba telemetry which would further reduce the voice traffic on the radio system that's used specifically for breathing apparatus crews was there any discussion about

01:04:13 crews was there any discussion about personal radio channels at all or was the discussion all about ba channels breathing apparatus channels the

01:04:20 the recommendations primarily focused uh because of uh what had happened at la canal uh there were some issues with ba comms at la canal from memory uh so that the

01:04:31 canal from memory uh so that the substantive element of the rule 43 was focused on uh ba but not exclusively it does touch on incident ground communication so this was the one we focused on and as part of the response

01:04:43 focused on and as part of the response to this particular rule 43 we also undertook to introduce additional training for fire ground radios

01:04:54 yes my question was really whether there was any discussion you can recall about the topic of personal radio channels at major incidents as well as discussion about the use of

01:05:05 as well as discussion about the use of additional breathing apparatus i can't honestly recall you know meetings you know eight or nine years ago now um the detail of the discussion but it would have been along the lines of this

01:05:16 would have been along the lines of this and i can't confirm 100 sure that we talked about in fire ground radio but i'm sure it was part of the the rounded discussion in terms of instant communications

01:05:27 communications the response that i've read to you uh i haven't read it all to you but but um

01:05:33 um the response i've read to you focuses on the use of additional ba radio channels breathing apparatus radio channels but doesn't address the use of additional personal radio channels which

01:05:44 additional personal radio channels which we saw was mentioned in the coroner's recommendation why was that i think we did undertake well i know we undertook to

01:05:54 develop some two training packages as i recall but i don't believe we discussed the introduction of additional radio channels

01:06:05 channels i think you may be aware already that the

01:06:09 the spectrum of radio frequency isn't set by the fire service it's set by a government department and within that spectrum for fire ground radios there are a number of uhf ultra high frequency

01:06:22 are a number of uhf ultra high frequency radio channels that we can deploy and i think from memory i think we had eight or nine potential channels we could use and so

01:06:32 and so we already used two channels for incident command um and i can i won't go into the detail of that i i will if you want me to uh we had two channels for ba already one to be used in normal fire ground use and

01:06:45 be used in normal fire ground use and one when there's a base station repeater and again i can explain what that is if that has assisted the inquiry and then there were some other channels which the command unit crews used and

01:06:56 which the command unit crews used and there were some spare channels which were used for teamwork you know teams five partnering teams could use channel three for example so we didn't have a lot of scope in terms of spare channels and and the

01:07:08 in terms of spare channels and and the reason

01:07:09 reason that is a problem is when you use certain channels concurrently they actually block each other out because they're so close this is a long answer too i think yeah sorry i was trying to help with the

01:07:21 sorry i was trying to help with the context well yeah we'll come to the the allocation question shortly that it's really a

01:07:25 really a a simple question here we have the recommendation which not only relates to additional breathing apparatus radio comms but also personal radio comms but your response doesn't address personal

01:07:36 your response doesn't address personal radio comps at all it's completely silent about it the question is why is that um i can't answer that but i think there's another part to this isn't there in terms that we did commit in the

01:07:47 in terms that we did commit in the response to the rule 43 action that we would

01:07:50 would uh do some further work and publish some further information in terms of training materials on fire ground radios so we'll come to what did happen yeah shortly but i'm just interested in in this letter

01:08:02 i'm just interested in in this letter yeah i accept that the words are you know i won't contest that continue anymore it doesn't cover incident communications like this service ba so that leads to the next question why did you not give the coroner an explanation

01:08:13 you not give the coroner an explanation in this letter for why you have decided not to discuss personal radios i i can't remember the discussion we had around that i'm afraid sorry now we looked at the pro formas the rule 43 pro formas this morning and indeed yesterday

01:08:27 formas this morning and indeed yesterday which were created by your department uh now i want to go back to that at lfb 3034062

01:08:46 this is the first document that you got in i think august 20

01:08:51 august 20 uh

01:08:53 uh i think it's before that maybe before that because uh the response was the 23rd of may to the coroner so this would have been you were putting it together i think this was the working document we discussed yesterday

01:09:04 discussed yesterday that ultimately fed into the commissioners that um ron dobson and the commissioner at the time response to the coroner yes now um can we go to page nine

01:09:18 yes page nine please and uh there you can see

01:09:21 can see um

01:09:23 um uh the recommendation at the top of the page top of your screen yeah where it's in the text that we've seen in fact reproduced faithfully in the robin dobson letter

01:09:35 dobson letter then you identify the policy documents currently in place within the lfb and then you could see you say the following considerations and options were explored to meet the recommendation and

01:09:45 and in the

01:09:47 in the larger block of text first paragraph in the yellow there you say this the current use of lfb radio channels was assessed and opportunities for additional channel programming for different applications was identified

01:09:58 different applications was identified for the current radio system the use of different ba uhf radio channels at the same incident as possible unused channels are also potentially available for use however the hazards and risks

01:10:09 for use however the hazards and risks associated with this practice would be significant ba teams on separate channels would be unable to communicate with each other and the passing of risk critical information would be complicated by the need to transmit over different channels simultaneously the

01:10:22 different channels simultaneously the level of control and supervision would need to be significantly increased now just pausing there i just want to examine that a little bit with you before coming back to the rest of this this text

01:10:34 this text shortly the opening line to this paragraph reads and i've just read it i'll show it to you again the current use of lfb radio channels was assessed and opportunities for additional channel

01:10:45 and opportunities for additional channel programming for different applications was identified with the current radio system

01:10:51 system now there's nothing there to suggest that that analysis was restricted to breathing apparatus radio channels is there no that's correct did that assessment that's referred to there

01:11:02 assessment that's referred to there consider additional radio channels for crews who were not using breathing apparatus

01:11:08 apparatus i.e for the handheld radios i believe it did it did do you know what was considered um

01:11:16 um beyond what i just said with the availability of channel and the potential for blocking if you use two channels concurrently um as i i can only repeat

01:11:27 concurrently um as i i can only repeat what i said we've got two command channels that was the kind of default position

01:11:31 position channel three of the nine that it mentions here uh was available for uh

01:11:39 uh firefighting teams to use as a sort of self-contained team uh a common if we use channel four channel five and six were ba channel and i think channel eight was used by

01:11:51 i think channel eight was used by command unit crews leaving channel nine which was previously a i think from memory it was a multi-agency channel used by the police and they gifted it to the fire service when they moved over to but you're talking you're talking about

01:12:03 but you're talking you're talking about how the channels are used my question is different

01:12:05 different which was what what well let me try it differently what was the outcome of the assessment of the current use of lfb radio channels so far as personal radios are concerned that the provision uh as

01:12:17 are concerned that the provision uh as the default position as i've just described the channel one and two for command was sufficient for incident command with the addition of uh because we also had airwave radios which isn't mentioned here but we did have airwave

01:12:28 mentioned here but we did have airwave radios as well

01:12:32 now um mr chairman i'm going to turn to a

01:12:37 a document which looks in detail at these channel allocations uh you're going to say be sensible to stuff at this point yeah we'd probably benefit from from a break before we do it

01:12:48 it right well it's a little earlier than usual but i think that would be a sensible point of which to take a break so we'll stop there and come back please half past three yeah and again please don't discuss your

01:12:59 yeah and again please don't discuss your evidence with anyone when you're out of the room thank you thank you very much

01:13:12 thank you half of three then please

01:32:04 yes would you ask mr reason to come back in please think

01:32:14 all right mr reason yes good thank you very much yes yes mr chairman mr reason uh

01:32:20 uh uh i want now to show you um uh what ac ellis uh has said dominic ellis this is not graham relating to the lfb's incident

01:32:32 graham relating to the lfb's incident communications can we go please to um his statement at lfb3089131 [Music]

01:32:45 now this is his statement of the 6th of february 2020 and if we go to paragraph 26 on page 7 at the foot of that page we see

01:32:57 of that page we see he says this there were 10 separate channels loaded onto uhf radios on 14th june 2017 the channels were channel one

01:33:09 the channels were channel one used primarily for incident ground communications and the primary incident command and control channel channel two an ins an additional incident command channel which is used if there is too

01:33:20 channel which is used if there is too much traffic on channel one it's commonly referred to as a duplex channel you've turned the page please note the explanation of this term above and can only be used with a repeater

01:33:32 can only be used with a repeater channel three used by a team for a specific task for example water sector or line operations this channel can only be used on the instruction of the ic or sector commander this is to ensure that the ic

01:33:43 commander this is to ensure that the ic retains control of the channel plan at an incident and can arrange monitoring if necessary now just pausing there is it right that channel three would be used at the same time as channel one

01:33:54 time as channel one yes i believe it could be yeah does that mean that the lfb had uh prior experience of using specific radio channels for specific tasks alongside the general fairground channel channel

01:34:05 the general fairground channel channel one yes

01:34:07 one yes continuing with mr ellis's explanation at d

01:34:10 at d he says channel four not generally in use at the time of the fire due to potential interference with channel six this channel was used if more than more capacity was required because of excess traffic on other

01:34:22 because of excess traffic on other channels and was only to be used after consultation with the duty radio officer and why in the wake of the coroner's rule 43 recommendation did your directorate not give consideration to

01:34:34 directorate not give consideration to increasing the use of channel 4 to combat excess traffic um i suspect because of the potential for interference with channel 6 which is the ba radio channel

01:34:45 6 which is the ba radio channel you suspect that but did you do you know it i i can't remember the specific detail and apologies i went into quite a lot of this detail in my answer i didn't know you was going to come to this um so the reason that we had the working draft

01:34:56 the reason that we had the working draft of the

01:34:58 of the draft rule 43 response was to stimulate this type of discussion so not all of the members who were at that meeting that discussed the rule 43 were operational officers

01:35:10 the rule 43 were operational officers and that's why we added a lot of that detail so that when we started to discuss it everyone had the same understanding of these types of issues and what work if any did your directorate do to address the issue of

01:35:22 directorate do to address the issue of interference across the channels i think that's a facet of the radio spectrum i'm not a technical expert in radio spectrums but that's my understanding of what that

01:35:33 understanding of what that point d is referring to it's they're very close in terms of the radio spectrum so when you're transmitting or receiving

01:35:39 receiving on channel 4 and channel 6 there is the potential for interference um we then see at paragraphs e and f um channel 5 and channel 6. he says at e

01:35:50 um channel 5 and channel 6. he says at e channel 5 used for communications using a repeater or a leaky feeder commonly referred to as a duplex channel please note the explanation of this term above and can only be used with a repeater

01:36:01 and can only be used with a repeater channel 5 was the default channel for ba communications using a repeater f channel 6 the ba communications channel this is the channel used to communicate with is equipment channel 6

01:36:13 communicate with is equipment channel 6 transmits at 1 watt whereas channel 1 for example transmits at 4 watts the lower wattage reduces the risk of creating a spark which could ignite an explosive atmosphere

01:36:24 explosive atmosphere now just to summarize that the channel six was the default radio channel for ba wearers

01:36:29 wearers is this right but they could move to channel five if radio repeaters and leaky feeders were deployed yeah on the instruction the instant commander if available they could move to channel

01:36:40 available they could move to channel five but six is the default channel right

01:36:43 right now how are risks of multiple channels and transitions between channels such as the risks of teams communicating on different channels and missing critical information how are those risks managed or mitigated in a case from

01:36:55 or mitigated in a case from of a move from channel six to channel five

01:36:59 five um i say it would be on the uh express instruction of an incident commander if a base station is available all london underground stations have got base

01:37:10 underground stations have got base stations so that we can communicate uh subsurface and it would be a decision for the incident commander to manage the transition and normally the way that would work is you would change it before you committed

01:37:21 you would change it before you committed crew so you didn't have crews on multiple channels if possible and that wasn't always possible but that's how it would be managed right now then we've got channels seven to eleven now they're set out

01:37:32 now they're set out channel seven not used by lfb at the time of the grenfell tower fire this was a police interagency channel owned and managed by the police and used for interoperability between the metropolitan police service mps in

01:37:43 metropolitan police service mps in london and the nfb and you go on he goes on to say the police now use airwave radio and gifted channel 7 along with channel 8 to all fire and rescue services etc

01:37:55 he says channel 7 is now used by the lfb if more capacity is required because there's excess traffic on other channels and is only only to be used after consultation with the duty a radio officer

01:38:06 officer channel a not generally in use by the nfb at the time of the grenfell tower fire although it's sometimes used for communications using a repeater or leaky feeder for example the fixed leaky feeder system in the shard building like

01:38:17 feeder system in the shard building like channel seven this was the police interagency channel which was subsequently gifted to fire and rescue services this is a duplex channel please note the explanation of this term above it can only be used with a repeater

01:38:29 it can only be used with a repeater there's no channel nine um channel 10 used by command unit crews for inter crew communications this is a dedicated channel due to the normally large amount of command unit

01:38:40 normally large amount of command unit specific radio traffic at an incident now and then we've got over the page channel 11 that's heathrow airport yep um

01:38:49 yep um so

01:38:50 so that summary there is that that's correct is it yes i believe that's correct um the two um channels that were gifted to the lfb uh channel seven and eight those were

01:39:01 uh channel seven and eight those were gifted after the grenfell tower fire were they uh i don't know when they were gifted i suspect it was before if it was uh as i understand it after the police started using uh digital radio and

01:39:12 started using uh digital radio and airwave radio systems if it was before can you tell us why they weren't used before the grenfell tower fire as they weren't

01:39:19 weren't uh because i suspect that we had a discussion at that meeting and we drew the conclusion that channel one and channel two for instant command with the other channels that are used as

01:39:31 with the other channels that are used as described in mr ellis's statement was sufficient for incident communications right how did you judge sufficiency what was your yardstick against which you were making that decision

01:39:43 were making that decision well incident communications from my own perspective can only answer it in my own perspective uh i don't think it featured um predominantly in any of the impd reports brought forward to odcb

01:39:56 impd reports brought forward to odcb uh when i was director comms uh obviously is a key component of incident command

01:40:03 command but i don't remember seeing any trends that we had an issue with communications and indeed i chaired the performance review of command for lacking all and i

01:40:14 review of command for lacking all and i don't recall any of the officers mentioning any significant comms issue in terms of command and control at the lack of house fire um

01:40:25 um no but the rep the coroner did hence recommendation five i accept that but um and we would have taken all of that into consideration i suspect in terms of

01:40:37 consideration i suspect in terms of reaching the decision that the existing radio allocation and usage uh was sufficient at the time that we took the decision right well let's then go back to the communications pro forma

01:40:48 go back to the communications pro forma we looked at a moment ago at

01:40:52 at lfb3034062 page 10.

01:41:03 and at the bottom half of this page we can see row d with your proposal we propose to address the rule 43 recommendation by the following actions and then you see in the main box

01:41:15 and then you see in the main box uh um four bullet points you see that yes um and the third bullet point reads as follows consider the possibility of using

01:41:23 using additional legacy police interagency analog radio frequencies these are no longer utilized by the police and are already programmed into all of the brigades analog handheld radios

01:41:34 brigades analog handheld radios did your directorate do anything to progress that proposal uh no because that when this this is a working draft as you recall and i think the final draft

01:41:45 recall and i think the final draft response to the coroner didn't include that recommendation or that response really

01:41:52 yes so why not i can't remember the specifics or they meet that meeting but we would have obviously discussed it given the volume of information there and the fact it was a

01:42:03 and the fact it was a a proposal uh or an option to take forward and obviously the decision of that group was not to take that particular issue forward i can't remember the detail of that meeting discussion though i'm sorry

01:42:16 discussion though i'm sorry we may be across purposes was the possibility of using additional legacy police interagency analog radio frequencies actually considered well it's here so it would if this was

01:42:27 well it's here so it would if this was the report that went to that meeting so everyone would have read the report we would have discussed all the components of this report so probably the answer is yes to that well um you say it was it

01:42:40 well um you say it was it and the fact that it's in this document doesn't tell us that that as a response to this document consideration was in fact given to that possibility was it in fact given to that possibility this whole document was

01:42:52 possibility this whole document was designed to give that commissioners group plus the heads of service that were responsible for most of these actions uh the opportunity to discuss and consider whether they were going to put

01:43:03 consider whether they were going to put forward those four bullet points and i don't believe all four well i know all four didn't go forward it didn't go forward were they considered yes right

01:43:13 why did this work or why did the reason for this not being taken forward not a feature in the lfe's response to the coroner's rule 43 letter do you know i i can't remember the

01:43:24 do you know i i can't remember the detail of that discussion i'm sorry mr miller all right um now let's go back to lfb3091880

01:43:33 this is an email we looked at yesterday together that's the 11th of the email of the 11th of may 2013 um to ron dobson rita dexter and sue budden

01:43:48 and other senior officers i'm sorry we're looking at page one this is my fault we want page three can we go to that

01:43:56 to that it's your email of that date to those individuals and it attached the latino rule 43 pro formas ahead of discussions to finalize the reply to the latin house coroner

01:44:07 the reply to the latin house coroner which we saw yesterday so this is the 11th of may we had the meeting on the 14th of may and the letter goes out on the 23rd of may um and if we go to the bottom of page two and start

01:44:17 and start and and start there and you can see that sue budden uh forwards the email to julian martin and at the top of page three

01:44:29 and at the top of page three she says you may already be aware of this julian but one of the recommendations from the latino inquest related to radio use the recommendation and the proposed response is set out in the attached i

01:44:42 response is set out in the attached i think it starts on page eight let me know if you have any comments or concerns

01:44:48 concerns first what was julian martin's role at that time he was the head of uh information manager sorry information technology so computers and the brigade's infrastructure rit infrastructure

01:45:01 infrastructure rit infrastructure right and he describes i think he describes himself i think as the chief information officer or cio is that yeah yeah that was he probably became that

01:45:11 yes um

01:45:13 um can you shed any light on why sue bud button might have been contacting him in particular for his comments or concerns on this topic um i think with regards to incident communications there was a a bit of a straddle of

01:45:25 there was a a bit of a straddle of responsibility so julian in the role you've just described in terms of his job description also had responsibility for

01:45:34 for the brigade's i.t infrastructure and i think he also looked after the physical procurement of radios and associated radio equipment so i think sue button would have been informing him

01:45:47 sue button would have been informing him that the policy part of the organization was recommending something that potentially had an impact on his part and his responsibilities i suspect that's why she shared my email with him i see um the next email

01:46:00 email with him i see um the next email up in the chain at the bottom of page one

01:46:03 one which is where it starts

01:46:06 uh is from julian martin back to sue budden on the 21st of may 2013. and that's only two days or so before the 23rd of may letter goes out to um

01:46:19 goes out to um goes out to the coroner from ron dobson and he says this sue i have collated comments received as follows consider the possibility of using additional legacy police interagency analog radio frequencies these are no

01:46:30 analog radio frequencies these are no longer utilized by the police and are already programmed into all of the brigade analog handheld radios and over the page he says we've made contact with ofcom in relation to this

01:46:42 relation to this initial thoughts are that it wouldn't be a problem but we're waiting we are awaiting confirmation from the appropriate office at ofcom i would advise further as soon as this is received

01:46:52 received do you know whether ofcom sent a response i i don't sorry it would look from reading julian martin's comments that this idea was an easy one to implement is that fair um

01:47:04 um in terms of radio capacity and the channels are available yes now we looked at dominic ellis's statement at length a moment ago when he described channels seven and eight as being legacy police

01:47:16 seven and eight as being legacy police channels not generally used by the lfb uh at the time of the grenfell tower of fire but now used in the event that extra capacity is is required do you agree in general terms that it would have been possible for those channels to have been adopted

01:47:28 for those channels to have been adopted and used in that way during your time at the lfb yes i'd grab that do you know why your director didn't take steps to acquire and use those frequencies at that time now miner having shown you this email yeah

01:47:39 this email yeah i hadn't seen this email to be fair um i think i was aware of most of those issues that it was technically possible to use them i can only conclude that the discussions at

01:47:50 only conclude that the discussions at the meeting where we we looked at the working draft of the rule 43 responses that the decision was taken that we wouldn't pursue using the two channels that have been gifted to us or to the fire service by the metropolitan police

01:48:02 fire service by the metropolitan police right did sue blood and raise this at the meeting i i can't remember the specific discussion uh meeting that happened sort of eight years ago i'm sorry did she say to you at the meeting that she contacted julian

01:48:13 at the meeting that she contacted julian martin who was waiting for a response from him

01:48:17 from him she probably would have done if she's if she'd entered into these correspondence with julian she would have raised these issues i'm pretty certain but you don't know whether during the two days between his email back to her on the 21st of may and the 23rd of may

01:48:30 on the 21st of may and the 23rd of may uh sue budden uh basically said stop press i've got something in from julian martin about channel seven and eight no i don't recall any discussion or emails about that um let's

01:48:42 discussion or emails about that um let's then go back to the pro forma again please lfb three zero three four zero six two page ten and get back down to the low the row of bullets under d

01:48:55 bullets under d this time i want to look at the second bullet point we looked at the third one and i want to look at the second bullet point exercise the use of fire survival guidance fsg procedure including the use

01:49:06 guidance fsg procedure including the use of a dedicated uhf command channel for the passing of fsg information what became of that suggestion do you know that was actually progressed it was progressed through dave brown's

01:49:17 it was progressed through dave brown's directorate so it didn't involve babcock and there was a program of exercises at the fire service control center which at that time was based in merton

01:49:28 that time was based in merton and the program of exercises involved a command unit which obviously undertake the fire survival guidance function at incidents station manager

01:49:40 station manager and obviously the control staff and there was an exercise to one familiarise the command units and senior officers with the work of control which was another one of the pieces of work we did post lacanal but

01:49:53 pieces of work we did post lacanal but also to practice passing far survival guidance information between control and the command unit and obviously the senior officer was there because one of the changes we made after lacking was to

01:50:04 the changes we made after lacking was to mobilize a dedicated station manager specifically to manage fire survival information at the incident and make sure it was passed back to control

01:50:15 sure it was passed back to control right

01:50:16 right now we've been provided with a copy of a powerpoint presentation at lfb3084606

01:50:25 which i just want to ask you about

01:50:32 um it's a presentation for an operational procedures briefing day on the 4th of december 2014 um

01:50:43 first of all can you help us were these briefing days regular occurrences

01:50:48 um [Music]

01:50:51 [Music] i'd need a bit more information i've not seen this presentation i don't think right is it is it sorry

01:50:59 sorry let me try and help you let's go to the timetable at page five see if this triggers a recollection um if we can expand that please

01:51:10 um if we can expand that please uh you can see from the timetable that uh you are the first person to speak from 9 30 to 10 15. yes i know what this is now right now

01:51:21 yes i know what this is now right now um

01:51:22 um then coming back to my question were these briefing days regular occurrences i think they were generally undertaken uh

01:51:29 uh annually i don't think they were like formal uh formerly diarised annually but it was really for the head of the department uh to call it it was almost like an end of year wash up look

01:51:41 almost like an end of year wash up look look forward to what's happening what's the challenges coming up in the next year

01:51:45 year uh to share information between the different teams within in this case operational procedures and i think i was there to open the the day and talk about probably some

01:51:57 the day and talk about probably some corporate issues around probably at this time was lsp five implementation and things like that to give a more sort of strategic overview of what was going on in the brigade and the direction of travel

01:52:08 brigade and the direction of travel right

01:52:10 right um

01:52:11 um you don't remember what the the precise topic of your address was do you it would have been i'd have been invited by the head of service to open their their sort of their team building day if you want to call it

01:52:22 team building day if you want to call it that and i would have had uh probably a powerpoint presentation to just touch on issues that i was aware of uh at strategic level which maybe that the the

01:52:33 strategic level which maybe that the the lower rank officers wouldn't have been aware of and you know do a bit of team building and a bit of visibility leadership and to give them a feel for what what the you know the next year is looking like in terms of challenges and

01:52:44 like in terms of challenges and opportunities now if you look uh at the next item down you have operational procedures ac cap and dac to kevin hughes and then after that at 10 45 to 1105

01:52:56 and then after that at 10 45 to 1105 on the timetable jim acort speaks about incident communications and we can go to slide 24 sorry slide 19 we go to slide 19

01:53:07 we go to slide 19 please um

01:53:09 please um page 19. um that's where um jim acorts incident comms talk starts the world of incident comms this is the second page page 20

01:53:21 this is the second page page 20 and there's lots of stuff there yep to enjoy

01:53:24 enjoy and then at page 24

01:53:29 you go to page 24 the world of incident comes and r d exclamation mark what's next

01:53:36 next um and if you look at the fourth bullet point down it says new channel for radio and high rise uh what were those plans to introduce a new radio channel specifically for use in high-rise buildings

01:53:48 in high-rise buildings i wasn't in attendance for the whole of this day i only opened the session and then i would have left the meeting and this is the first time i've seen it so i don't know what the context of that new channel for radio in highrise is but did

01:54:01 channel for radio in highrise is but did nobody tell you i mean never mind about whether you were still at the presentation but did nobody actually tell you that a new channel 5 radio and high rise was being proposed i i don't know if that is the context in

01:54:12 i i don't know if that is the context in what that i mean that's what it says but whether there's a context to that i don't know true it is a slide but

01:54:20 but um the question is a simple one based on a simple and pretty unambiguous statement new channel for radio and high rise what what other context could it be or what else could

01:54:31 context could it be or what else could it mean other than that there was a a new channel which was being explored for radio use in high-rise buildings i i don't know the context of it i'm sorry

01:54:41 sorry i'm right

01:54:43 i'm right um

01:54:44 um was

01:54:47 there any discussion during your work on the rule 43 um

01:54:53 um responses at this stage to having a new channel for radio in high-rise buildings i don't

01:55:01 i don't remember there was some talk about a dedicated channel for passing fire survival guidance which was included in policy note 790 when that was updated which is the fire survival guidance policy note

01:55:13 survival guidance policy note but i i'm not aware of any discussions and certainly not in

01:55:20 not in in consultation with the head of service for this department that there was any work being done to as that indicates to look at a potential additional channel or new channel for radio communications

01:55:31 or new channel for radio communications in high rise right we know that there was a trial run of policy 790 and

01:55:40 and there was a pilot i think wasn't there and there was feedback from that do you was this linked to that i i wouldn't have thought so i think 790 is specifically about passing um

01:55:53 is specifically about passing um well it could be actually thinking about it

01:55:55 it it was passing information from control to the fire survival guidance command unit and obviously back to control and then the information about uh casualties uh that are trapped in terms of a

01:56:07 uh that are trapped in terms of a designated fire survival goal would need to go to the bridgehead yes do you know what happened to the uh the proposal to have a specific fsg channel no i'm sorry i don't

01:56:19 no i'm sorry i don't we know that it was never implemented i it certainly wasn't implemented when i was working no no do you know why it wasn't implemented i don't remember seeing anything brought forward uh formally to either my directorate

01:56:31 formally to either my directorate manager build odcb or any other boards that would have taken this sort of proposal if we were going to do something like that there would have been a a definitive report that explained

01:56:42 definitive report that explained what we were proposing what the implications are etcetera what the training dependencies would be we wouldn't just implement it without some sort of formal sign off

01:56:53 now i want to turn next to a different topic within the bigger top broader topic of rule 43 response on comms and that's radio transmit transmission strength

01:57:05 transmit transmission strength we saw that the coroner's rule 43 recommendations were that the lfb should consider additional radio channels can we go back to the incident communications rule 43 pro forma at lfb

01:57:18 communications rule 43 pro forma at lfb 3034062 and this time start at page nine and let's look at the last paragraph on that page

01:57:25 that page on the left hand side it says the following considerations and options were explored to meet the recommendation and then it says uh in the second paragraph

01:57:33 paragraph uh in in yellow there the transmission strength of an analog radio increases the stability to transmit over distance and through some obstructions there are currently two types of analog radio

01:57:44 currently two types of analog radio intrinsically safe is and non-is the transmission strengths for non-is equipment range between 1 and 4 watts all is analog radio radios attached to

01:57:56 all is analog radio radios attached to ba sets are programmed to 1 watt in order to meet intrinsic safety certification current guidance from the chief fire officers association stipulates that all

01:58:07 officers association stipulates that all radio equipment attached to a ba set should be is certified radio courage can be enhanced by the use of an analog radio repeater

01:58:17 which can be further improved by the attachment of a leaky feeder cable additional repeaters can be deployed to increase the area covered this equipment is carried on command units cus and by

01:58:29 is carried on command units cus and by the duty radio officer now is it right that in summary an intrinsically safe or is uh radio is a radio that will not provide an ignition source in an explosive environment that is correct

01:58:42 explosive environment that is correct um what kind of explosive environments might fire fighters have to operate in

01:58:48 any flammable atmospheres so that could be gas leak it could be the products of a fire if if the fire hasn't reached its auto ignition temperature you could introduce

01:58:59 ignition temperature you could introduce a spark which would be within the flammable range of the smoke gases which could then create a flashover or fully developed fire and some

01:59:09 and some chemical hazmat incidents where when the chemicals are gassing off they can be flammable other kind of main main there's probably a whole load more but they're the kind of main flavor of right

01:59:20 they're the kind of main flavor of right what the risks are right uh is it the case then that ba radios are specifically designed to be weaker so that they are appropriate for use in potentially explosive environments that

01:59:32 potentially explosive environments that is correct yes now there's no proposal in this pro forma here um

01:59:37 um at all what was being considered in relation to the transmission strength of radios

01:59:42 radios um i don't believe we were discussing uh the technical specification of radios in this meeting in the meeting that's the meeting yeah and in indeed this is i think this is

01:59:53 and in indeed this is i think this is for information for for the audience who may not have that knowledge when we were discussing this topic

02:00:02 topic now turning to um or returning to dominic ellis's statement of the inquiry can we get back to that this is at one three lfb3089131

02:00:12 and we can go to page nine in that if we look at paragraph twenty eight on that page he says uh these radios share the limitations uh common to all uhf radios radio signal

02:00:25 uh common to all uhf radios radio signal penetration can be hampered by metal framed buildings thick concrete layers and thick smoke the higher the wattage the better the signal penetration the home office regulates the power output

02:00:36 home office regulates the power output allowed within british fire service radios in line with the home office regulations the lfb's channel 1 transmits at 4 watts and channels 2 3 4 5 7 8 and 10

02:00:48 5 7 8 and 10 transmitted 2 watts there is considerably lower power on channel 6 the ba channel is set out above channel 6 transmits at 1 watt while the lower wattage on channel 6 limits the energy

02:01:00 limits the energy available for ignition in an explosive atmosphere the trade-off is a decrease in the potential range please note that the hx 480 and hx481

02:01:11 the hx 480 and hx481 are not is now just just reading that is it right that not only were the lfbs ba radios breathing apparatus radios limited in

02:01:22 breathing apparatus radios limited in power so as to be is intrinsically safe but also the radio channels themselves were programmed so as to transmit at a different power uh yeah that is accurate yeah so i

02:01:34 uh yeah that is accurate yeah so i understand it and as as mr ellis says here is it right channel one the incident command channel has the highest power at four watts channel six the ba channel has the lowest power at one watt

02:01:46 channel has the lowest power at one watt and everybody everything else transmits uh to two watts that's correct right now dominick ellis has also provided the statement to the uh police um in october last year and that is at

02:02:00 met3077839 if we can just go to that

02:02:10 there we go at the first page 22nd of october 2020 is the date of the statement could we please go to page nine

02:02:20 and in the second paragraph on that page mr ellis says this the reasons why the channels other than one and six are too what somewhat difficult to explain this was the transmitting power of the channels of the maxon radio hx 480

02:02:33 channels of the maxon radio hx 480 stroke one's predecessor and it is assumed that this was due to battery power as the higher the wattage the greater the draw on the battery the reasons that the hx-480 and

02:02:44 battery the reasons that the hx-480 and 81 used the same power outputs even though the batteries had improved was probably because it was not considered at the time that greater output was required however nfe personnel who worked in this area have since retired

02:02:55 worked in this area have since retired as this was 12 years ago now do you remember do you remember when the lfb max on radios were phased out and replaced by the hx 480 and hx 481

02:03:09 and replaced by the hx 480 and hx 481 i i

02:03:10 i i it happened while i was still working but i can't give you a date for that i'm sorry was it before or after the bethnal green fire which was in july 2004

02:03:22 i would imagine that the newer radios that replaced the maximum radios happened after bethnal green but i can't be 100 certain than that that's just what i recall

02:03:33 that's just what i recall trying to remember when i got issued are you able to shed any further light on on why the wattage of a number of the radio channels so two three four seven eight and ten remained limited to two

02:03:44 eight and ten remained limited to two watts following the replacement of the maxon radio that's the first time i've seen that i don't i didn't know that was a potential reason why they were set at two watts

02:03:55 two watts right

02:03:57 right you don't know why no i that's the first time i've that's new news to me right i mean is it right i mean do you accept that that limitation would have negatively affected any crews who are

02:04:08 negatively affected any crews who are not communicating on either the incident command channel or the ba channel uh yeah because it's a lower wattage it's a lower wattage yes now we've got an earlier draft of the

02:04:19 now we've got an earlier draft of the communications rule 43 pro forma let's just look at it lfb30

02:04:28 now this is a a draft sent i should just tell you

02:04:32 tell you from james james jim a court to assistant commissioner jim knighton

02:04:42 uh and we have a covering email for it i don't think i need to take you to it but it's at lfb3098635

02:04:51 this is an earlier draft of what we've been looking at uh as you told us earlier um assistant commissioner james knighton was i think then head of operational procedures that's

02:05:02 head of operational procedures that's correct um and this document was sent on the 30th of april 2013. so that would be consistent with what you've told us about the timing of when this pro forma or draft document was was

02:05:13 this pro forma or draft document was was created by those downstream of you yes that's correct now this pro forma says this if you go to page bottom of page one and over to page two

02:05:25 bottom of page one and over to page two at the very bottom of page one you can see

02:05:28 see some metallics which say this transmission strength of analog radios for non-intrinsically safe radios this has already been raised to improve the transmission distance of the radios

02:05:40 transmission distance of the radios see that yep and then it goes on over the page

02:05:43 the page intrinsically safe radios are limited to a maximum power output of one watt so this cannot be increased however the need for is radios could be re-examined as when entering premises with a

02:05:54 as when entering premises with a non-explosive risk or where a fire is already present the requirement for is equipment is not necessary the requirement is still present when entering potentially explosive atmospheres now i mean translating that

02:06:07 atmospheres now i mean translating that um into something perhaps a little clearer what's being said here and please disagree with me if you do is that the risk of a radiate providing a source of ignition is irrelevant in a

02:06:18 a source of ignition is irrelevant in a residential high-rise fire because a fire is already underway and thus the risk of ignition uh does not reply i i don't accept that you don't i i'm not doing

02:06:30 i'm not doing um

02:06:31 um so i accept that if you're in or near a fire compartment that is involved in fire the most significant risk of you know fire is the fire itself in terms of ignition source but of

02:06:43 in terms of ignition source but of course crews are not exclusively working in the fire compartment they're working in other parts of the building which may be smoke logged there may be gas leaks

02:06:53 gas leaks caused by

02:06:54 caused by the fire or the incident itself and certainly we do have equipment to test flammable range but not on front line fire engine so in the immediate response

02:07:06 in the immediate response we wouldn't be able to confirm that the

02:07:10 that the environment in which the ba crews are being committed is not a flammable atmosphere or an explosive atmosphere to use the term in this document so absolutely accept it if you're in the

02:07:22 so absolutely accept it if you're in the fire compartment the fire itself is obviously the ignition source but of course

02:07:27 course as we know from other fires compartments fail smoke products of combustion uh leach into other parts of the building sometimes you have gas leaks caused by the fire itself that then permeate the building and their

02:07:39 permeate the building and their firefighters will be working in other parts of that structure which then could be exposed to an explosive atmosphere um let me show you what dr bevin says about that can we go please to

02:07:52 five zero met3080505

02:07:57 this is um dr bevin's uh statement to the metropolitan police which i think we've looked at before

02:08:30 uh and it's dated the 5th of august 2021 can we go to page four please in that document

02:08:42 uh and uh he says in the first paragraph he's dealing with this question and he says in the uh third line up from the bottom we also knew

02:08:53 line up from the bottom we also knew from previous experience that an ignition source would usually already be present when firefighters were attending a building which was already on fire i.e the fire itself and or any smoldering embers which would be a better ignition

02:09:06 embers which would be a better ignition source than a functioning radio set do you agree with that or disagree with that

02:09:12 that uh

02:09:14 uh that is true and it's it's similar in response well no not as extensive in response uh to my previous answer but yeah in in principle yes cool sapphire and the smoldering numbers would be the

02:09:25 and the smoldering numbers would be the a bigger risk of ignition source than a functioning radio in the fire compartment yes and therefore it's possible that isn't it that where there is already a fire in

02:09:37 it that where there is already a fire in progress

02:09:38 progress uh the risk of ignition caused by a spark from a radio is uh very much less without trying to quantify it less than the risk which already exists from the

02:09:49 the risk which already exists from the fire itself and embers less in the fire compartment and area surrounding the fire compartment yes but not necessarily in other parts of the structure so i see okay can we give them can we then go back to

02:10:01 back to uh

02:10:02 uh the uh pro forma please lfb3098636 on page two

02:10:18 in fact i think we want the very bottom of page one

02:10:24 where um the first line of the update says

02:10:30 says for non-intrinsically safe radios this has already been raised to improve the transmission distance of the radios do you remember or do you know when that was raised

02:10:41 know when that was raised no sorry i can't help you with that do it by whom it was raised uh

02:10:47 uh i assume it will be a technical issue so it'd probably be julian martin but he wouldn't have done that without someone telling him to do that

02:10:56 did that apply only to channel one which performed at the higher wattage of four watts

02:11:02 watts uh i i don't know the context of this i think the inference is that the other channels that are not non-is channels could also have their transmission strength raised yes and that leads to

02:11:14 strength raised yes and that leads to the question what consideration was actually given at the time to increasing the wattage of the other channels up to four watts i don't believe there was any consideration was that i didn't know the reason why the other channels were

02:11:27 reason why the other channels were transmitting and receiving on two watts i assume that was something to do with the

02:11:32 the uh

02:11:33 uh either the radio spectrum or the radio itself i i didn't know there was the ability or capacity to increase the signal strength on those channels

02:11:44 signal strength on those channels that's a very technical sort of aspect of the job that i wouldn't have been involved in now the final line to this update says if we just go back to page two

02:11:57 and i've read it already i'll read it again however the need for is radius could be re-examined as an as when entering premises with a non-explosive risk

02:12:05 risk or whether fire is already present the requirement for is equipment is not necessary the requirement is still present when entering potentially explosive

02:12:12 explosive atmospheres um that that

02:12:16 that that sentence there wasn't replicated in the final pro forma was it no no

02:12:21 no no um do you know why that was i

02:12:25 i don't think i i don't believe i saw this version so this i assume would have been a discussion between jim knight and the head of service and jim a court before

02:12:38 jim a court before their final version was put forward had you ever yourself given consideration to the idea i set out here uh

02:12:49 the idea i set out here uh not specifically because i think we would have followed national guidance which was that ba crews need is radios i think i don't think we would have gone away

02:13:00 i don't think we would have gone away from that and being realistic i think if i won't speak on behalf of the fire brigade union but i think the fire began union would have a serious issue with moving away from is radios

02:13:13 do you recall the weak transmitting strength of ba radios being a problem at the latino house fire it

02:13:20 it i reviewed the performance review of command and i i know you've got the notes of of that meeting i don't believe incident comms was an issue

02:13:31 comms was an issue i know there was a report produced following lachnal specifically around

02:13:37 around incident communications which was commissioned by i think health and safety with

02:13:45 with one of the radio officers at the time roger tuckley uh i wasn't in the director post and i wasn't in a position to see the the progression of that work or the outcome of that work but i understand there was

02:13:57 of that work but i understand there was a review done specifically around fire ground radios and ba radios as a discrete piece of work immediately following the lapping house fire yes

02:14:08 following the lapping house fire yes well that is something we're going to investigate in a little bit of detail next

02:14:13 next if i may but um it's not something i can finish this evening and i'm not trying to get to

02:14:19 to get to an intelligible natural break before 4 30. it sounds to me mr millet as it would be more sensible to pick this up again fresh tomorrow uh i yes it

02:14:30 up again fresh tomorrow uh i yes it would it's been a long day for the witness

02:14:32 witness i think for others uh well that's right and we're making good progress we're making excellent progress which is why i'm

02:14:39 i'm not uncomfortable about asking to rise at this point well um mr reason it's earlier than we would usually rise but not very much earlier and sunday we've got a meaty topic coming up so we'll

02:14:50 got a meaty topic coming up so we'll postpone the pleasure of that i look forward to that till tomorrow yes so we'll break at this point um we'll resume please at 10 o'clock tomorrow and uh as before please don't talk to

02:15:01 and uh as before please don't talk to anyone about your evidence or anything relating to it during the break all right thank you good thank you you'd like to give the usher that'll be fine thank you very much um mr chairman i just want to raise one

02:15:12 mr chairman i just want to raise one thing and that's um miss dexter you'll recall yesterday that we had not released her at the end of her evidence yes um having looked at the material further

02:15:21 further we

02:15:22 we are happy to say that she should be released

02:15:24 released at least formally um and therefore i'm going to ask you to do that right well thank you very much and can we arrange for someone to contact her then as soon as possible and tell her that she's

02:15:35 as possible and tell her that she's released yes mr walsh is in the room here and he yeah he can do that straight away well thank you very much right well then um she can consider herself formally released any bar on discussing

02:15:47 any bar on discussing things with people is lifted good thank you very much um 10 o'clock tomorrow then please thank you