Evidence from Ron Dobson, former London Fire Commissioner, covering Lakan al House responses, policies and procedures
00:00:29 good morning everyone welcome to today's hearing
00:00:32 hearing today we're going to continue hearing evidence from mr ron dobson formerly commissioner of the london fire brigade so i'm going to ask mr dobson to come back in
00:00:51 good morning again mr dobson i hope you're well i hope you're ready to continue with your evidence yes sir thank you thank you very much yes mr thanks sir good morning mr dobson good morning uh when we broke yesterday we were about to discuss the lfb uh
00:01:04 were about to discuss the lfb uh commissioned review that was carried out by the bre yes and that report was dated the 9th of september 2015. now there are two particular comments in that somewhat lengthy report that i'd be grateful for
00:01:15 lengthy report that i'd be grateful for your views on okay now if we can go to that report lfb travel zero four six eight one two forward slash twenty two
00:01:30 now we see at the top of the screen the coroner's rule 43 recommendation followed by various excerpts from section 7 of the 2004 act both of which i suspect you're all too familiar with
00:01:43 i suspect you're all too familiar with and then under that italicized text the next two paragraph reads as follows the fire authorities powers to inspect under this act clearly interact with
00:01:54 under this act clearly interact with those under the fso the fire safety order
00:01:57 order currently
00:01:58 currently fire officers carry out inspections of premises under the fire and rescue services act and under the fso usually at different times respondents have suggested that there are opportunities for fire officers who
00:02:10 are opportunities for fire officers who are carrying out inspections under the fire and rescue services act or under the fsa to exchange findings it is not clear to what extent this is or can be done
00:02:21 or can be done since the different legislation is intended for different purposes however coordinated or joint inspections would lead to better information exchange and minimize business interruption for the building owner or
00:02:33 interruption for the building owner or employer
00:02:35 employer now did that report prompt you to think whether there was any merit in having a joint inspection so joint 72d and joint rro inspections
00:02:46 72d and joint rro inspections um it did
00:02:48 um it did it did but i think my conclusion was that whilst it would be a very helpful thing to do um the practicalities about doing that would be very very difficult given that the the number of buildings in london
00:03:00 the the number of buildings in london that need to be inspected by fire stations under 72d uh and the different types of inspection therefore the different time it takes to carry out inspections under the fire safety order so whilst i was keen that there were
00:03:12 so whilst i was keen that there were joint inspections took place when they were particularly necessary on particular types of buildings particularly risks or after fires and things like that i didn't think it was a practical thing to be able to do on all inspections thank you could we go to the
00:03:24 inspections thank you could we go to the second point i'd be grateful for your views on and that can be found at page 31 in this document now page 31 just so you can orientate yourself in the report it was under the
00:03:35 yourself in the report it was under the um general heading inspections right and which starts on page 30. now the first two paragraphs at the top of this page 31 say this in addition bre global is informed that
00:03:47 in addition bre global is informed that the available operational statistics data on inspections needs to be treated with some caution since based on the london experience it does not appear to comprehensively
00:03:58 does not appear to comprehensively reflect a risk-based approach elfipa consider that they do not have data that allows them to properly plan a risk-based approach however it is difficult to see how
00:04:09 however it is difficult to see how better data might be acquired a review of the findings from the irs that's the uk national fire statistics and if people want to look at it the definitions on page 20.
00:04:22 look at it the definitions on page 20. and operational statistics appendix c would appear to indicate that el are currently assigning too much attention to retail premises and license premises which in irs are not appearing
00:04:35 premises which in irs are not appearing as high risk now stopping there for the moment do you accept the finding that elfipa and the lfb were unduly focused on retail and licensed premises at this time
00:04:46 time um
00:04:48 um i would have i would accepted that criticism previously i'm not sure i need to see the data but i'm not sure that i'll fully recognize that as a criticism after lacking a house
00:05:00 after lacking a house now when you read that did you take or did you feel that steps were necessary to recalibrate the focus onto more obviously high-risk premises well yeah we did we have a discussion
00:05:12 well yeah we did we have a discussion about this i believe at the corporate management board in terms of where the way we were assigning our inspection um program
00:05:20 program and the types of risks and obviously the buildings that were shown for the irs that were high risk should obviously be formed part of our uh inspection program so we did discuss it and we did ask for our inspection program to be refocused
00:05:32 our inspection program to be refocused as a result certainly re-examined as a result of this when you saw the bre's observation that that there were inadequacies about the data
00:05:43 data did that cause you to have concerns that the lfb had not got its act together following lachnal in terms of acquiring high quality data
00:05:54 terms of acquiring high quality data regarding high-risk premises in particular no i didn't actually i was very surprised to see this because i think as mrs dexter said in her evidence actually we had in our opinion in our concur mistakes we had a
00:06:05 opinion in our concur mistakes we had a very high quality information management system within the london fire brigade and my my my perception at least comparing london fiberglass data with that of the national database was that london's
00:06:17 national database was that london's database was uh in advance of the national one so i was quite i was surprised to see this observation when you saw that observation did you press the bre on the foundations for that particular conclusion not personally no
00:06:29 particular conclusion not personally no um do you know whether mr mrs dexter did or something well i don't know for definite but i'm quite sure she would have done because she
00:06:36 she concurred with me that our information process was actually better than the national one if we can uh look forward on this page to the third paragraph and it opens with this sentence
00:06:48 and it opens with this sentence with regards to the issue of how the brigade prioritizes its inspections of residential high-rise buildings bre has had has not had sight of any plan or
00:06:59 had has not had sight of any plan or schedule for london now bearing in mind that your letter to the coroner your response to the coroner indicated that the lfb would create an inspection regime do you accept that that report
00:07:10 do you accept that that report demonstrates that as late as 2015 that still had not been done no i believe it had been done i can't account for the comment in the bra report and in this respect um but i'm
00:07:21 report and in this respect um but i'm sure this will be one of the things that mrs dexter would certainly have gone back to bre on to to you know to question him on do you remember whether you yourself push back on this particular conclusion and say listen bre
00:07:32 particular conclusion and say listen bre you haven't considered xyz evidence i didn't personally know but then mrs dexter held the relationship with bra for this report
00:07:40 now the only 72d training package that the inquiry has seen can be found at bab quadruple zero double zero five six
00:07:51 quadruple zero double zero five six and this is the package that we think was released as part of operational news 24. back in march 2013. now we heard evidence during phase one
00:08:03 now we heard evidence during phase one that firefighters undertaking some 2d visits
00:08:07 visits could not recall receiving this training as we established with mr brown the training does not refer to the items listed in appendix one of pn-633 that we looked at yesterday afternoon
00:08:19 looked at yesterday afternoon um
00:08:20 um also
00:08:21 also it does not provide practical guidance to crews on how best to carry out visits and identifying the things they need to identify now at least in relation to high-rise
00:08:33 now at least in relation to high-rise buildings
00:08:35 buildings do you accept that the lfb had not fully discharged his responsibilities under section 72d not least in the fact that crews were not properly trained on what
00:08:46 crews were not properly trained on what they were required to do as part of 72d visits um well i think uh whether this i was confident this this package had been rolled out i can't account for the views of the firefighters that were
00:08:57 of the firefighters that were uh the commented firefighters have seen during phase one so they hadn't seen it um i don't know whether their training records indicate whether they saw it or not i'm sure the training records will obviously tell a true record of that so i don't know the answer to that
00:09:08 i don't know the answer to that um i think we we made good efforts to undertake fulfill our responsibilities under 72d um but i can certainly say there were some deficiencies in what we did and we could have done better
00:09:19 did and we could have done better the
00:09:20 the firefighters who attended grenfell couldn't remember it yeah that at least suggests that the training wasn't effective is that something which you'd accept yes
00:09:31 could i now turn to a completely separate topic and that's the topic of communications now
00:09:37 now would it be fair to say that the lfb had before lachnal experienced communications problems at large incidents and i'm thinking of the king's crossfire in 87 bethel green road in
00:09:48 crossfire in 87 bethel green road in 2004 and in response to the 7-7 bombings in 2005. that's correct
00:09:57 the inquest following the 2004 bethnal green fire identified communications issues as forming part of the relevant circumstances in which two firefighters died have i fairly and correctly
00:10:09 died have i fairly and correctly summarized the conclusion yes yes um i think at that stage you were acting but not yet formally appointed as commissioner is that right no i was as i was the assistant commissioner for service delivery the bethlehem green
00:10:20 service delivery the bethlehem green road fight i believe was in 2004 and i was the assistant commissioner for service delivery at that time when the uh inquest was held in june 2006 what position did
00:10:31 was held in june 2006 what position did you hold by that okay 2006 i would have still been the assistant commissioner for service delivery but i would have been the third officer as well for operational purposes now is it right that the communication
00:10:43 now is it right that the communication issues that are encountered at baton green road related both to the failure to communicate relevant information across teams and officers and also to the committal of two firefighters without radio communications is i call
00:10:56 without radio communications is i call yes
00:10:57 yes do you recall the fact that the coroner expressed surprise that it was standard practice for a team of two ba worries to be committed with only one set of ba communications between them are they
00:11:10 communications between them are they and surprise is the correct word to use in those circumstances is it right for the covenant the government expressed surprise yesterday and as a result of this rule 43 report the coroner endorsed a recommendation
00:11:21 the coroner endorsed a recommendation that had already been made by the lfb's sia process namely that and i quote lfb review and revise allocation of breathing apparatus radio interface equipment barry
00:11:34 radio interface equipment barry and radios on pumping appliances so that every ba crew has radio communication do you remember that particular recommendation now we have a limited number of documents relating to the lfb's action
00:11:46 documents relating to the lfb's action plan arising from the bethnal green fire and if we go to lfb double zero 102 969 and if we could turn to page 60 in
00:11:57 969 and if we could turn to page 60 in this bundle
00:12:02 if it could be rotated
00:12:07 could we look at key objectives 6.1 and 6.2 which were identified in the far left hand side column now in summary those objectives uh required a review of allocation of
00:12:19 required a review of allocation of battery sets and to ensure that the procurement of the next generation of radios took into account the various issues identified by the coroner arising at bethnal green road is that right it is
00:12:31 is now we don't have the documents that show what came of all of this but we heard phase one that ba teams were committed into the tower with one barry set per team
00:12:42 barry set per team and that when teams became mixed this sometimes resulted in neither member of the team having a barry set now that evidence would suggest that the lfb took the decision following bethel
00:12:55 lfb took the decision following bethel green road not to extend provision of barrie sets notwithstanding the coroner's recommendation what's your response to that my recollection is that the we did two things as a result of the
00:13:06 things as a result of the recommendations from definite green road one was to ensure the allocation of a fire ground radio to every firefighter as a personal issue or an individual issue for all incidents so every every firefighter had a radio available to
00:13:17 firefighter had a radio available to them
00:13:18 them and that my recollection at least is that we did um be brought in uh guidance or
00:13:24 or it was more than guidance it was a instruction that all teams committed to the incidents would have barry now moving away from lfb specific instance to the best of your knowledge
00:13:37 instance to the best of your knowledge what was the state of awareness at the lfb about radio communications issues that had been identified as a result of the world trade center bombing in 1993 and the uh the attacks on 2000 in 2001.
00:13:51 and the uh the attacks on 2000 in 2001. well we're certainly aware of the communications issues that arose at the uh attacks on at the world trade center in 2001
00:13:58 in 2001 and we were certainly aware of the the the communication problems occurred and the bombings in seven seven because one because we were part of that came out in our own debris and we're also
00:14:09 out in our own debris and we're also part of the greater london authority uh scrutiny committee that set about the seven seven plummets could we go to a particular document which is cwj
00:14:21 which is cwj quadruple zero double zero nine two
00:14:26 as the logo in the top left indicates this is a document produced by what was then clg
00:14:32 then clg and it's a 2008 report called instant ground communications in broad terms that report identified various communications related issues for fire and rescue services is that
00:14:44 for fire and rescue services is that right i think so yes and there were issues that arose following the 9 11 attack is that right they were including that yeah now at lachnal is it right that the ba
00:14:56 now at lachnal is it right that the ba entry control officer was unable to make contact with ba teams via battery sets seemingly due to signal problems was that a fair summary on occasion yes
00:15:07 that a fair summary on occasion yes and that more generally the crews were overwhelmed with the volume of radio traffic which in turn impacted adversely on the ability to communicate effectively by radio yes is that right yes it is
00:15:19 yes it is now in your evidence to the latino inquests you attributed these problems to the lack of radio discipline as well as the decision not to utilize the spillover
00:15:30 spillover incident command channel which i think is channel 2 is that right that's correct yeah now that being the case why were radio communications not identified as an internal action point by the latino
00:15:41 internal action point by the latino house board
00:15:46 i don't know i can't
00:15:49 i can't i can't account for them i think we the communications issues as you've quite rightly identified with mr caneer
00:15:55 mr caneer at all large incidents there are issues with radio communications in terms of signal and traffic etc so i think we whilst we believed that you know we knew there were problems at lac and was i
00:16:06 there were problems at lac and was i don't think we believe they were extraordinary in terms of what we usually experience and the other thing was that in the investigation into the communications issues which was carried out as part of
00:16:17 issues which was carried out as part of the lack of house review where all of the radio sets that we used were inspected for defective things because actually both nine was only one radio set that was found to actually be
00:16:29 radio set that was found to actually be defective on the day um so i don't think we necessarily believed that the radio communications issues were something that needed to be a formal or a very a very defined action point
00:16:42 a very a very defined action point i hope i put this fairly but
00:16:45 but was the belief that communications problems occur at every or most big instance
00:16:52 instance indicative of a degree of complacency about addressing those problems that were experienced at big incidents such as latino
00:17:01 as latino i i don't think i would use the word complacency i think we were well aware of the radio communications issues we had looked at these communication issues over a long period of time but the
00:17:12 over a long period of time but the advice that we'd received from technical experts the biggest techniques which at that time were there was there wasn't any way to overcome some of the problems in terms of the types of buildings and the types of locations that we use the radios
00:17:23 of locations that we use the radios given the you know the use of fire and rescue services in high-rise buildings with concrete and steel structures so we were aware of it i don't think it was complacent about it but i think we thought that there wasn't a technical
00:17:34 thought that there wasn't a technical solution in which we could apply it at that point now radio communications were the subject of recommendations by the coroner at act nor probably the most useful way to
00:17:45 probably the most useful way to start to look at what was recommended in the lfp's actions thereafter is to look at the pro forma that we looked at yesterday okay and that can be found at lfb 0034062
00:17:59 and if we could start at the very foot of page eight
00:18:09 thank you you see at the very bottom [Music]
00:18:13 [Music] of page 8. you see that it deals with the recommendation and if we turn over the page to page 9
00:18:21 we see it is recommended that brigade consider whether it would be beneficial to use additional ba radio communications channels and personal radio channels of major incidents
00:18:32 radio channels of major incidents now
00:18:33 now if we look at the row below we see a bold and heading policy documents
00:18:40 documents and in broad terms first that sets out the lfb's policy documents relating to radios communications and messages is that right it does secondly it summarizes
00:18:52 secondly it summarizes uh under the second heading the lfb's training on the subject of radios and communications and that text says this use of radio is included within phase one and phase two
00:19:03 included within phase one and phase two of firefighter development ffd there is no current requirement for refresher training all personnel receive training in the use of the digital main scheme radio prior to it going into
00:19:16 scheme radio prior to it going into operational service no continuation or refresher training is provided
00:19:21 provided and then finally there's a summary of the systems which are deployed by the lfb which i think for our present purposes consisted at that time of the uhf instant ground
00:19:32 that time of the uhf instant ground radios
00:19:33 radios airwave digital or main scheme radio is that right yes now the next two rows in this table we're going towards the foot of page 9 now and over the page into page 10
00:19:44 page 10 set out first of all considerations and options which were explored and secondly the proposal for the lfb zone response the rule 43 recommendation
00:19:55 the rule 43 recommendation now at this stage can i just draw out four particular bullet points which we find in the bottom half of page 10 over leaf and you'll see those in the latter half
00:20:06 and you'll see those in the latter half of that page what they say is this raise all operational personnel's awareness of the identification of communications issues or incidents and
00:20:17 communications issues or incidents and the methods of overcoming them these include the use of uhf channel 2 repeater and leaky feeder equipment the completion of training materials and the requirement to carry out training by
00:20:28 the requirement to carry out training by all operational personnel on the use of radio equipment will reinforce and raise awareness of potential radio issues incidents and improve radio discipline
00:20:39 incidents and improve radio discipline exercise the use of fire survival guidance fsg procedure including the use of a dedicated uhf command channel for the passing of fsg information
00:20:52 consider the possibility of using additional legacy police interagency analog radio frequencies these are no longer utilized by the police and are already programmed into
00:21:04 police and are already programmed into all of the brigade's analog handheld radios
00:21:08 radios explore the use of digital airwave radios to provide additional command channels should communications difficulties being counted at a specific incident
00:21:19 incident now
00:21:19 now we know from your response the coroner which can be found at lfb 0042089
00:21:28 that the majority of these proposals were not taken forward now your response to the communication specific recommendation if we can go to
00:21:39 if we can go to your response to the coroner and page eight
00:21:43 eight thank you
00:21:45 now if we start with the second paragraph onwards and we looked at this in detail with mr reason and so i i'm going to just summarize matters for you rather than going over it
00:21:56 you rather than going over it again ultimately the lfb considered that the coroner's recommendation but decided that three principal concerns outweighed the possible benefits of an additional radio channel
00:22:09 benefits of an additional radio channel those three concerns were these first that additional ba radio channels could cause firefighters to miss risk critical information or cause a delay in the transmission of such
00:22:21 delay in the transmission of such information secondly there could be a lack of coordination between teams thirdly the capacity added by an additional channel may be negated by the need to re-transmit information
00:22:34 need to re-transmit information across the additional channel
00:22:36 channel or trying to coordinate teams have i summarized matters fairly and accurately i think you have i'd like to say one more thing to that please do yeah i think that it will entirely
00:22:47 yeah i think that it will entirely correct what mr reason said i think the only thing that i would add to that is it needs to you need to remember the circumstances in which we're asking firefighters to carry out these actions with the radios so actually we're asking grieving apparatus teams in very
00:22:58 grieving apparatus teams in very hazardous environments where it's very hot very humid there's smoke and fire the visibility is sometimes nil and we're asking them to carry out and they will be concerned for their own
00:23:09 they will be concerned for their own safety as well as carrying out their tasks and we need to avoid trying to ask them to make technical alterations to radios or technical alterations to things and we also need to make sure
00:23:20 to make sure that the communications that they're receiving as well as transmitting are as clear and as short as possible um so we just need to be very clear that actually the circumstances in which
00:23:31 actually the circumstances in which we're asking people to use these radios are not as we're sort of experiencing sitting here it's a very different environment that's a very useful piece of context thank you mr dobson can we look at the foot of this page
00:23:43 can we look at the foot of this page under the heading proposed action [Music]
00:23:48 [Music] you told the coroner this the brigade will engage with its training contractor to ensure that issues relating to instant communications are embedded within the current
00:23:59 are embedded within the current operational training as to time scale that's dealt with under the next heading at the very end of this page
00:24:06 page the work has this work has already commenced and is estimated to be completed by december 2013. now we'll look at training in detail
00:24:17 in detail next
00:24:18 next but your response taken as a whole gives the impression that you as the head of the lfb
00:24:24 the lfb felt that the communications issues experienced at latino were primarily a matter of user error or in discipline and could be rectified by refresher training to prompt firefighters to use
00:24:37 training to prompt firefighters to use lfb's radio communications equipment properly
00:24:40 properly again have i put matters fairly inaccurately no
00:24:45 i um believe it was firefighter i believed it was firefighter pressure on firefighters in terms of the circumstances in which they were operating at laconia house they were under immense pressure
00:24:56 under immense pressure um the circumstances were deteriorating most of the time and while communications is extremely important incidents they would be fearing for their own safety as well as everybody else at the same time so it
00:25:08 everybody else at the same time so it certainly wasn't error but the reason we thought the training might be effective must be to embed the procedures and the actions required to communicate effectively more
00:25:19 required to communicate effectively more in firefighters not actually so it wasn't actually error it was just failure of the procedure broke down under the pressure that they were experiencing could we go to your third witness statement on this point lfb double zero double one zero six five
00:25:33 lfb double zero double one zero six five two forward slash three
00:25:37 and if we look at paragraph nine you said this
00:25:40 said this the issue of the difficulties reported in relation to instant ground communications was the subject of investigation instigated by the latin house investigation team involving the brigade's health and safety department
00:25:52 brigade's health and safety department and experts from the brigades instant communications team the aim of the investigation was to look at as a whole at what may have caused the communication issues as reported on
00:26:03 the communication issues as reported on the instant ground as there were a number of factors to consider that may have contributed to the difficulties reported these included the material used in the construction of the building the radio
00:26:15 construction of the building the radio equipment itself the distance of the ba teams from the bridgehead or the amount of instant ground radio traffic taking place and if we could go to paragraph 11 at
00:26:27 and if we could go to paragraph 11 at the foot of the page
00:26:31 there you explained that a team led by dac cut bill investigated the communications difficulties and that a report was prepared addressing the impact of steel
00:26:42 prepared addressing the impact of steel framed buildings on interference with radio signals which ultimately fed into the lfb's lachnal operational review report
00:26:51 report that's a long run run up to a straightforward question which is why did these issues not form part of either the lfb's pre-actions or the response to the rule 43
00:27:03 or the response to the rule 43 recommendations um for the same same reasons as i said earlier um which was that these were issues that we had experienced other incidents um i don't we didn't think
00:27:14 incidents um i don't we didn't think that there was an action that we could include in the action plan as a result of lack of house which would resolve these difficulties because they think they could experience other incidents as well
00:27:22 well um
00:27:23 um we felt that reinforcing the training would be sufficient to actually correct some of the or to embed the the procedures more in our firefighters but
00:27:34 procedures more in our firefighters but as far as the technical issues was concerned we were i mean in that paragraph 11 we mentioned mr tapley there who was a brigade radio expert at the time and his advice was that actually the
00:27:45 and his advice was that actually the equip there wasn't the equipment that we could have apart from leaky feeders and things that would have improved the situation
00:27:51 situation and therefore we didn't feel it necessary to include an action in the action plan you mentioned mr tuckley can we go to some email correspondence passing from mr tuckley if we go to lfb
00:28:02 passing from mr tuckley if we go to lfb double zero double one zero six five seven
00:28:11 uh we find here an email from peter the magic have i pronounced it that's correct yes some hesitation there to roger tuckly on the 13th of april 2010 which shows that uh report being
00:28:23 2010 which shows that uh report being commissioned and if we look at the second paragraph on this page uh mr zamanczyk stated this as part of the inquiry into the lack of house fatal fire a number of statements made by
00:28:35 fire a number of statements made by firefighters suggest their radios failed however having tracked all these statements back i've identified that in reality
00:28:44 reality only one barry set failed a point you made earlier on and was subsequently repaired would you be able to provide me with a report
00:28:53 report slash explanation of why steel framed buildings interfere with radio signals now in response mr tuckley sent an undated report which we can find
00:29:05 undated report which we can find at lfb double zero double one zero six five nine
00:29:12 five nine as you see from the top of the page it's entitled in building radio user difficulties can we look at the second paragraph on that page which is below the the two bullet points
00:29:23 bullet points and the text says this when propagating into buildings radio signals pass through various materials before reaching a receiver's antenna
00:29:34 antenna the interaction of radio signals with building materials usually results in lower signal strength different construction materials have different attenuation characteristics
00:29:46 different attenuation characteristics some construction materials very rapidly attenuate signal strength buildings which have a significant thickness of concrete or amount of metal used in its production
00:29:57 used in its production will attenuate the signal concrete floors are often poured onto a metal pan which completely blocks most radio signals some solid foam insulation and some
00:30:09 some solid foam insulation and some fiberglass insulation used in exterior walls have foil backing which will reduce signals energy efficient windows and metal window screens are also very effective
00:30:22 window screens are also very effective at blocking radio signals to be specific rf energy entering a building
00:30:28 building will be partially absorbed and partially reflected by the building materials encountered now given the buildings with materials such as concrete metal foam insulation
00:30:39 such as concrete metal foam insulation etc
00:30:40 etc might all impact or indeed entirely block
00:30:44 block radio signals but that was likely to be an issue indeed a significant issue at a great many buildings attended by the lfb to fight a fire is that a fair observation it had been it was and it
00:30:56 observation it had been it was and it and i believe it still is and is that a particular problem in relation to high-rise residential buildings yes it is
00:31:05 is and so communications issues and interference was likely to be a significant issue at a number of operational incidents yes were you aware that similar problems had presented themselves at shirley towers
00:31:16 presented themselves at shirley towers in i think april 2010 was yes could we go to the report preferred prepared by hampshire frs into shirley towers on the 6th of april
00:31:27 into shirley towers on the 6th of april 2010. now the report is dated the 8th of april 2013 and can be found at lfb-00107130
00:31:39 and if we could turn to page 53 and paragraph 3.10
00:31:46 this can be found under the heading hand-held radios and the text says this the handheld radios used by hampshire fire and rescue service may not always operate effectively in
00:31:58 may not always operate effectively in high-rise buildings these radios are also used by ba wearers to communicate with the ba entry control officer at this incident communications proved
00:32:09 at this incident communications proved difficult necessitating the need to use other forms of communications notably mobile telephones the problem of poor radio communication in structures such as high-rise
00:32:20 in structures such as high-rise buildings or ships is well known post-incident testing of radios by hc showed that they were operating effectively now
00:32:31 now this
00:32:31 this report is april 2013. that was a week after the lachnal rule 43 recommendations were published and sent to unclg did you see this report or hear about it
00:32:44 did you see this report or hear about it after it was published i heard about it after it was published and i saw it later
00:32:48 later um how much later i can't recall i'm afraid
00:32:52 afraid was it are we talking months are we talking years no no we're talking months i would say weeks or months
00:32:59 now could we go back to the rule 43 pro forma that we were looking at earlier lfb trouble zero three four zero six two forward slash nine
00:33:14 if we could look at the uh the highlighted yellow sections and particularly look at the first paragraph which effectively summarizes the np's decision
00:33:25 summarizes the np's decision not to adopt an additional ba channel would you accept that your response made sense in the context of smaller incidents
00:33:34 incidents but less so in larger instance where that one channel might simply become overwhelmed um
00:33:41 um not really because i think certainly it would well i think i think i think there was no question that smaller incidents as a second va radio channel would not have been of help in fact it would have been an obstacle so i was really only
00:33:53 been an obstacle so i was really only considering the recommendation for use of an additional v8 radio channel in the context of large incidents because that is really where we had the problem so
00:34:03 so i would
00:34:04 i would my conclusion from that is that we consider it in the right context in terms of the size of into the large incidents um but actually at larger incidents where there's a lot of ba traffic
00:34:15 of ba traffic the date the the risks of introducing a second ba radio channel as described by mr reason and i've i've added two um would be would just be would be magnified at large incidents because
00:34:26 magnified at large incidents because there was a lot more radio traffic taking place so it's a really difficult issue in terms of whether or not additional radio channel is helpful or not and the and the decision we took was that it wouldn't be if you were
00:34:38 was that it wouldn't be if you were supposed to put it to contact if you when you start an incident incident start usually start small and get big if you were to start an incident uh expecting it to get big and therefore introduce two ba radio channels
00:34:50 introduce two ba radio channels immediately then there's a way that would help you it could potentially help you in managing the communication of the incident
00:34:57 incident once you've started out an incident which is you know smaller or smallish that then develops it's then very difficult to introduce a second ba channel because you then get all the problems identified mr breeze by
00:35:08 all the problems identified mr breeze by mr reason in terms of making users switch from one radiator's channel to the other messages can get lost etcetera so i think i still i still think that in the in the context of what
00:35:19 think that in the in the context of what we'll be looking at in the comments recommendation the the decision to not accept not not adopt a second bra channel was the right one now
00:35:28 now mr reason wasn't entirely clear on the point
00:35:31 point but did the lfb actively and sincerely consider the possibility of adopting additional channels for handheld uhf instant ground radios i believe
00:35:44 instant ground radios i believe you said i believe we did can you be well i didn't do it personally um but there was there was certainly it was one of the things that we were obviously the current recommended it and therefore we we considered it but i think the conclusion that came to me was put to me
00:35:57 conclusion that came to me was put to me was that we already had the opportunity for use of additional ba channels and sometimes we would use channel 2 for incident command etc so we believe that the procedures we had
00:36:08 so we believe that the procedures we had given the operational experience of the people that was carrying out the review was that our system was probably the most appropriate and you're certain that was actively considered and a recommendation made to you not to
00:36:21 and a recommendation made to you not to proceed
00:36:26 well i can't i'm not absolutely i can't actually remember it happening happening but i'm very confident it did now
00:36:34 now i hope i'm summarizing this correctly but channel warned was the primary instant command channel and channel 2 which required the use of repeaters i think yes was available to instant
00:36:46 think yes was available to instant commanders as a spillover channel yes have i summarized matters correctly i recall yes
00:36:52 does it follow that the concerns raised with the coroner the issue of different personnel reading receiving different information on different channels and the possibility of needing to repeat information
00:37:03 information was already occurring when people were using channels one and two anyway well i think the the the response to the coroner was in some way informed by that yes
00:37:15 way informed by that yes however um when we when you introduce channel two for command the people using the channel are in a very different situation to the ba wearers so ba wearers are in the midst of an incident
00:37:27 wearers are in the midst of an incident with all the dangers that i've explained a few minutes ago the people that are using the command channels are officers not usually in hazardous situations they're working as head of um sectors or they might be on command units so they
00:37:39 they might be on command units so they might be on other commands just doing functions it's about functions rather than really stressful situations so and you've actually got people on the command unit who are managing the radio traffic on their behalf so it's a much
00:37:52 traffic on their behalf so it's a much more straightforward and much more controlled process to introduce channel two for command than it is to split the a channel so ba whereas already in an incident does that control still exist where
00:38:05 does that control still exist where there's a transition between the default ba channel 6 and its backup channel 5. uh i believe so i can't confirm completely you can't no i can't
00:38:16 completely you can't no i can't we also heard evidence during uh earlier in this module that channel 3 was a task specific channel to be used by the water sector for example or as it was used on the 14th of june
00:38:28 or as it was used on the 14th of june 2014 17 for fsg calls and that channel 10 was a command unit specific channel is that right i think so yes
00:38:39 mindful of that surely firefighters using those radio channels were facing again the same risks as those conveyed to the coroner as a reason for rejecting her rule 43 recommendation i.e
00:38:51 recommendation i.e different messages different channels and a potential confusion well they are but nonetheless i go back to my point that we're talking about people that were not working in the highly stressful situation of actually fighting a fire or
00:39:03 situation of actually fighting a fire or carrying out a rescue and actually people working in those functional sectors as i would call them as you described this so water sector or whatever
00:39:11 whatever they are under much less stress and therefore they're able to control and think about their communications and the method of communication much more than the va crews working in incidents are now steve mcgurk you know was retained
00:39:23 now steve mcgurk you know was retained by the inquiry as an expert told us that the transition between channels was not a risky practice provided the transition is well managed do you agree with that no
00:39:35 do you agree with that no why do you disagree my experience my experience has been actually the transition to changing channels at major incidents such as lacking or grenfell is a very dangerous time for the holdings of the incident command because messages
00:39:47 of the incident command because messages can be lost um not everyone changes at the same time it's not possible to to achieve a complete transfer exactly the same moment so my i'm afraid i must
00:39:58 the same moment so my i'm afraid i must have screamed mr mccoy there and my experience has been when i've witnessed this tried to be done or i tried to do it personally incidents it's a very difficult thing to do gary reason explained that an instant
00:40:09 gary reason explained that an instant commander's management of a transition was the primary control mechanism as he did um for a transition between channels five and six what would be your response to that evidence well i would say that the it find it's
00:40:21 well i would say that the it find it's the incident commander's decision whether to do this or not it's not something that officers on the instant ground whether in the command unit or elsewhere would do without the incident commanders approval but once the commander has
00:40:32 approval but once the commander has approved that is then down to the usually the command unit through the crew working on the command unit to actually make that transition happen in terms of notification to people who need to know
00:40:43 notification to people who need to know it's happening confirmation of people have changed onto the correct channel making sure that the whole process is still working effectively in terms of being integrated into incident command
00:40:54 being integrated into incident command now separate to the question of uhf handheld radios and we've heard evidence both in phase one and module five about the communications difficulties and weaker signal strength associated
00:41:06 and weaker signal strength associated with the lfb's one what intrinsically safe barrie radios now we heard professor johnson's evidence that policy 458 on the use of handheld
00:41:18 on the use of handheld raid instant grand radio specified that the lfb's
00:41:22 the lfb's hx480 and the hx481 radios were not intrinsically safe that they and i'm quoting should only be used where barry sets are unavailable close
00:41:33 where barry sets are unavailable close quotes
00:41:35 quotes do you accept that that was an unnecessary restriction on the strength of radios deployed by the lfb keeping this one-watt rule um i think we need to think about the
00:41:46 um i think we need to think about the reason why it was was there and the reason for having these radios which are lower strength which are to use the term intrinsically safe is because we can't always be sure of the nature of the atmosphere in which we've
00:41:58 nature of the atmosphere in which we've committed firefighters to carry out their role and therefore would be transmitting messages so the idea of having intrinsically safe radios at lower wattage is to reduce the possibility of a spark or some sort of ignition source being made
00:42:10 ignition source being made when firefighters are transmitting at incidents
00:42:13 incidents now there is there is a discussion and that one that my personal view is that um intrinsic safety was something that we we followed slavishly in the fire rescue service not just land fighter i know it's changed in
00:42:24 just land fighter i know it's changed in some places recently but that was something that was followed relatively slavishly by the fire and rescue service for the reasons i've just explained
00:42:33 explained but i think there is a it is a reasonable thing to say and i think it might have been mr mcgurk who said this that in incidents such as where there's a large fire it's unlikely that firefighters are going to go into an
00:42:44 firefighters are going to go into an explosive atmosphere because the fire's already ignited the atmosphere and therefore
00:42:48 therefore the the the other point though is that we have one set of radios issued to firefighters and they wear those at every incident they go to and we can't always be sure what is going to go to
00:42:59 always be sure what is going to go to next time they use the radio so things like when we attend terrorist incidents that could have explosive atmospheres gas leaks chemical incidents or major chemical works or what else explosive atmospheres can be caused by
00:43:11 explosive atmospheres can be caused by lots of different things so
00:43:13 so on balance the decision we took within lfb
00:43:16 lfb was to maintain the allocation of intrinsic safety safety radios for breathing operator sets for those reasons i've just explained there is still a debate about that whether or not that's the right decision
00:43:28 that's the right decision i think at the time with the information available to us and with the national guidance from government departments home office as well at that point i think it was a right decision but i'm not sure it's the right decision completely going forward
00:43:40 completely going forward do you think the lfb's experience of poor radio signal coverage that major instance was in part caused by the use of one watt radios
00:43:51 caused by the use of one watt radios i'm sure it was in terms of transmission from battery sets yes could we go to lfb trouble zero three one two six eight [Music]
00:44:03 [Music] this is dclg's operational guidance on breathing apparatus it was published in january 2014 could we go to page 83
00:44:18 we see here a section of guidance concerned with ba ancillary equipment and additional procedures and under the heading key elements
00:44:30 and under the heading key elements the first sentence reads thus the level of intrinsic electrical safety of the ancillary equipment provided should be appropriate to that of the hazard to be encountered and cognizant of the existing standards applicable to
00:44:43 of the existing standards applicable to the ba set and integral equipment would you accept that contrary to the apparent weight of that advice the lfb in fact took a one-size-fits-all
00:44:54 in fact took a one-size-fits-all approach to radios um
00:44:57 um i would but if i could just explain that i think the issue here is i can't disagree with the comments made here that the
00:45:04 that the um the level of safety should be appropriate to has to be encountered but that would potentially imply that we need to keep a range of radios on fire engines and deploy different types of radio depending on what incident we're going to
00:45:15 going to and i think that would be completely impractical because time would not allow for that firefighter when they respond to incidents are trying to respond as quickly as possible and therefore we use a radio set which is generic to the
00:45:26 a radio set which is generic to the risks that we think they would encounter one of the points that professor johnson made apropos what you've just said was that
00:45:34 that to encourage fire and rescue services to adopt what he called an evidence-based approach that determined the intrinsic safety requirements of the various environments in which a fire and rescue service would find itself
00:45:46 service would find itself what are the advantages and disadvantages of that course in your view the advantage would be that obviously we could use higher strength radios in certain circumstances which would probably hopefully lead to greater
00:45:58 would probably hopefully lead to greater signal strength which would mean to greater consistency of the radio communication the practical problem with that is that we don't know what we're going to attend we'll be when we respond to calls as firefighters so once again i say we
00:46:10 firefighters so once again i say we would need to keep a stock of more than one type of radio and deploy the type of radios appropriate to the incident the problem once again with that would be that we don't always know what the risk is when we tend an incident so for example even
00:46:23 we tend an incident so for example even a fire there could be parts of the parts of the building that are on fire where there is flammable gases that haven't yet been ignited so we want to send firefighters into that situation with a non-intrinsically safe radio
00:46:35 non-intrinsically safe radio similarly as we know when we attend gas leaks or chemical leaks or terrorist incidents we don't know the environment which we're going to go into and therefore we need to default to the highest level of safety for our
00:46:46 highest level of safety for our firefighters in terms of intrinsic safe in safety until we know the risk we're actually exposing them to now the lfb has now moved to higher strength battery radios and it's maintained a stock of one watt
00:46:58 maintained a stock of one watt radius for high risk environments why couldn't that step have been made during your tenure um well it could have been but we we did consider whether we needed to maintain
00:47:10 consider whether we needed to maintain intrinsic safety for our radios and as i said as i said earlier decision we we we came upon was to maintain a current situation in terms of treatment safely the reasons i've just explained in terms
00:47:21 the reasons i've just explained in terms of operational difficulties but also because i can't quote what it was now but there was certainly guidance from the home office and others in terms of radio streams and wattages that were
00:47:32 of radio streams and wattages that were available to fire rescue services if you are going to maintain the one watt approach if i can call it that then the lfb has to fully assess and mitigate the
00:47:44 fully assess and mitigate the consequences that flow aren't there for limited radio strength yes
00:47:49 yes and i believe we did that because there were procedures in place where firstly there was procedures for ba crews introduced after i think it's after the bethnal green fire where if
00:48:00 after the bethnal green fire where if radio signal is lost then that crew should consider exiting the incident so they can maintain communications and the other thing that we introduced subsequently was the ba telemetry boards which improved communications for ba
00:48:12 which improved communications for ba teams with the entry control could we turn over the page and
00:48:17 and under the heading additional considerations
00:48:23 this may be the text which you had in mind which you referred to earlier on i don't know but the first paragraph says this
00:48:28 this the provision and use of non-intrinsically safe electrical equipment may be considered appropriate for all normal operational requirements where such provision confers a significant benefit to the safety and
00:48:40 significant benefit to the safety and effectiveness of ba teams such equipment may include for example handheld radios and thermal image cameras
00:48:48 cameras now looking at that the guidance from clg appears to be envisaging that ba crews should be permitted to use non-standard equipment
00:48:59 non-standard equipment if it improves their safety and effectiveness would you agree with that uh yes i would agree with that would you also agree that by sticking slavishly to the one watt limitation for
00:49:10 slavishly to the one watt limitation for ba crews
00:49:12 ba crews the lfb's policies and procedures hampered safety and notably the effectiveness of its crews um
00:49:19 um not entirely no i think i mean this this guidance i think you said mr canel was dated 2014. january 2014. yeah well the the guidance that preceded this my recollection if the guidance
00:49:30 my recollection if the guidance proceeded this had different advice to this
00:49:33 this so i think the advice that came with the previous guidance certainly in terms of the guidance we had previously through the firefight the fire service manuals of firefighting
00:49:44 fire service manuals of firefighting was different to this and advised a more um and more cautious approach than stockholm was providing so i'm pleased that london fire brigade have changed their approach now in response to this but this was came out in 2014 and it
00:49:58 but this was came out in 2014 and it takes time to change all these things but
00:50:02 but bear in mind what you say why didn't this january 14 guidance prompt a review by you to look at the use of non-standard equipment for the reasons it sets out there
00:50:13 the reasons it sets out there well i think i think we would have done that um i think as i eluded to yesterday when this guidance came out in 2014 i'm not trying to excuse inaction but we were going for a very difficult period
00:50:24 were going for a very difficult period of 49 strikes by the fire brigade union the additional pressure that was placed on the whole organisation and this was one of the things that couldn't that wasn't prioritized right at that moment would have been carried out later on just so i can clarify that answer you
00:50:36 just so i can clarify that answer you said it would have been done and then you later on went to say you didn't want to excuse inaction we've got no evidence and have seen no evidence that a review was carried out
00:50:47 evidence that a review was carried out following publication this january 2014 publication so which is it did it happen or didn't it happen it didn't happen then no so when you say it would have happened
00:50:58 so when you say it would have happened that's not right subsequently subsequently well subsequently after the grenfell fire no subsequently after the industrial election had finished and we had more time to actually two things that come out during that period
00:51:10 that come out during that period can we go back to the rule 43 pro formula on communications which we find at lfb trouble zero three four zero six two four slash nine and if we could look at the final paragraph on that page
00:51:27 as its opening words indicate it's considers to some extent transmission strength
00:51:34 strength and the solution that's identified is over the overleaf on page 10 which says this
00:51:43 radio coverage can be enhanced it's in the first three lines on page 10 radio coverage can be enhanced by the use of analog radio repeater equipment which can be further
00:51:54 repeater equipment which can be further improved by attachment of a leaky feeder cable
00:51:57 cable additional repeaters can be deployed to increase the area covered this equipment is carried on command units and by the duty radio officer now gary reason explained to us that the
00:52:08 now gary reason explained to us that the use of repeaters and leaky feeders was the lfb's primary means of overcoming the communication difficulties flowing from the use of one watt radios
00:52:21 is it right that repeaters and leaky feeders were not deployed at latino yes
00:52:28 yes could we go back to the transcript of your evidence to the inquest at lagnal c w j
00:52:35 w j quadruple zero double zero one zero forward slash seven zero if we look at line 22 onward
00:52:55 you were asked there what are your views on how best to overcome radio communications problems which as i understand it can have two causes
00:53:05 causes one is communication blind spots in a high-rise building or a steel frame building and over the page the other is sheer volume of information now in response
00:53:17 now in response at line two going through to line 16 you said the following taking these two aspects really it's not firefighters in london are not uncommon with communications
00:53:29 are not uncommon with communications difficulty related to the building environment in which we work so radio signals from the report that we've commissioned or many reports particularly one that we commissioned following latino house now just stopping there did you have in mind then mr
00:53:41 there did you have in mind then mr tuckley's report once again identified and confirmed the signals work best when they're in clear line of sight of each other's radios in high-rise buildings which are
00:53:53 in high-rise buildings which are constructed from steel construction and steel and concrete there are many factors which will what do something which we call shield the signal from getting to the radio or the one that is intended to get to and
00:54:05 the one that is intended to get to and these things are not uncommon to fire fighters
00:54:08 fighters we can then move ahead a few pages to page 73 and line five
00:54:13 like you said this so in terms of addressing this problem for the future and it is that many instant debriefs that we've attended over the years instant ground communication is very often raised in
00:54:25 communication is very often raised in terms of an issue and that does relate to the shielding of the problem of the buildings and sometimes the traffic if the shielding of the building is a problem then there are other facilities
00:54:37 problem then there are other facilities available to incident commanders to seek to overcome that now mr reason's evidence was that communications did not feature as part of the impd diot or odcb
00:54:50 diot or odcb processes in all the time that he was sitting on odcb that he was not aware of issues with the barrier sets now based on your evidence the latino inquests
00:55:00 inquests um the
00:55:01 um the comms problems were commonplace and often featured at debris do you accept that the absence of discussion at least at odc b level demonstrates a failure both at impd diot
00:55:14 demonstrates a failure both at impd diot and the odcb processes um i can't i can't account for why there's no there was no uh entries on the inp process for communication because it was a common problem
00:55:25 because it was a common problem so yes
00:55:26 so yes and so there's a consequential problem in the sense that not only is the nature of the problem not cascaded down to operational crews the workarounds are equally not communicated to operational
00:55:37 equally not communicated to operational crews would you accept that well no because the operational crews were the ones that would be raising not not for the imp database but the operational crews are well aware of the issues relating to highways buildings and radio communications and they came out of many
00:55:49 communications and they came out of many performance reviews of command that would not be an uncommon thing to come up
00:55:53 up flowing from the commonplace nature of the problems is it fair to say that the use of radio repeaters and leaky feeders themselves would add to congestion at
00:56:05 themselves would add to congestion at instance
00:56:09 can we go back to the passages actually in front of us where you say this as i recall it starts at line 14 onwards i think mr holland referred yesterday to leaky feeders which is basically a cable
00:56:21 leaky feeders which is basically a cable or an aerial that we run out of the drum like an extension lead through a building or through an area and that will pick up the signal and transmit it back to the base station
00:56:32 back to the base station they are predominantly in place for long tunnels and for things like use on london underground where the communication issues between radios is even the communication difficulties between radios is much greater
00:56:44 between radios is much greater than usually is above ground and it would not be the instant commander's first choice to use leaky feeders in a scenario such as lachnal
00:56:54 lachnal because they would firstly they would divert attention from other priority tasks to lay the cable out but more importantly they would institute it would represent a further hazard in the
00:57:06 would represent a further hazard in the stairwell where they have to lay the cable up so it would not be the instant commander's preference but it would be a piece of equipment that would be available to them now in addition to your own observation
00:57:17 now in addition to your own observation to the coroner professor johnson explained that leaky feeders are typically only effective within line of sight of the cable was that particular limitation something about which the lfb
00:57:29 limitation something about which the lfb was aware uh before the 14th of june 2017. yes
00:57:35 given your evidence that leaky feeders would not be an instant commander's preference or first choice um why were they used as the primary fallback mechanism
00:57:46 fallback mechanism um because they were the most practical one that we had i can't think of any other
00:57:52 other method of fallback that we had available to us so they were the best that was recommended to us by our technical experts at the time wasn't there a case given the weight of
00:58:03 wasn't there a case given the weight of evidence regarding communications problems and the repetitive nature of the problems that you're encountering wasn't there a case for going back to the drawing board and identifying
00:58:15 and identifying technology which improved both strength and performance of radio signals at instance rather than on makeshift supplementary kit that had its own limitations and presented its own
00:58:27 own limitations and presented its own risks
00:58:28 risks i absolutely agree but the information or the advice would have been provided by the technical experts at the time was that such equipment didn't exist and therefore that would have been a yeah not not not a fruitful process
00:58:40 not not not a fruitful process when clg
00:58:41 when clg or before clg published its guidance in january 2014 we were looking at a few moments ago do you remember was there any move in the fire sector generally in the country
00:58:52 the fire sector generally in the country to review
00:58:53 to review the quality of radio communications and how they could be enhanced to ensure greater signal strength and more effective communications particularly at larger incidents um i do recall um a discussion about
00:59:05 um i do recall um a discussion about this at one of the cfl committees that i attended
00:59:09 attended and it was passed to the one of the the cfa technical committee to actually deal with i'm not aware of anything that came out after that i think i think probably for the same reasons as we were experiencing
00:59:20 the same reasons as we were experiencing in london fire brigade at that time we were being advised that there was no other there was another technical solution which would improve the situation for us can we say this though that following
00:59:31 can we say this though that following lachnal and review of the communication specific issues there was not a full comprehensive root and branch review of what technology was
00:59:42 and branch review of what technology was needed that could be used both safely and effectively in fighting fires yes and for the reasons you've given yes
00:59:54 can we look at another email chain which apologies mr dobson lfb trouble 0-867-4142 [Music]
01:00:09 here we see an email sent to you and other senior officers by gary reason on the 14th of may 2013 entitled feedback from rule 43 meetings
01:00:20 meetings the opening line of the email says as promised please find below a brief summary of the issues that were discussed and in some cases agreed during the two lac normal meetings held
01:00:31 during the two lac normal meetings held earlier today if we go further down there's a heading outcome from second meeting that
01:00:39 that the email then lists the coroner's five recommendations if we look in relation to recommendation five we can scroll down
01:00:49 thank you instant communications the text says this
01:00:54 this it was agreed that we should state with supporting evidence why we do not agree with the first part of the coroner's recommendation to consider additional ba radio channels
01:01:05 radio channels i will work with jim jim knighton and dave presumably dave brown i think to draft this evidence which will use the benefits v versus risks argument to
01:01:16 the benefits v versus risks argument to support our position however it was accepted that it would be advisable to offset this by committing to undertake additional awareness raising and raising on instant communications
01:01:28 raising on instant communications through some form of training across the various staff groups now the decision to release training packages was not i think i'm right in saying but please disagree
01:01:39 disagree the considered outcome of a comprehensive risk benefit analysis on the contrary it appears to have been a mean supplicating the coroner about the lfb's decision not to pursue the
01:01:50 the lfb's decision not to pursue the first element of her recommendation would you accept that i would agree with the first part of that statement i'm not sure that we ever made comments justificat the coroner in your terms mr can hear and that was not
01:02:02 your terms mr can hear and that was not the way we approached the governor's recommendations we were keen to actually take them on board and actually look at them very carefully and implement whatever whatever improvements we couldn't and this was certainly one
01:02:13 we couldn't and this was certainly one of the improvements that we thought was appropriate one in relation to the information arising from the debriefs of the latino house and also what the coroner said now the lfb had no policy
01:02:25 now the lfb had no policy or training provision to help crews deal with or to establish restore lost communications can you help us as to why there was no such policy or
01:02:37 us as to why there was no such policy or training on that apparently common phenomenon um
01:02:43 um well i refer back to the train you referred to earlier in one of the documents she showed me which was during phase one and phase two firefighters development training about radio procedures and the use of the radio the task fireball radio as
01:02:55 the radio the task fireball radio as well as main screen and airweave radios um
01:02:58 um my i would i would hope or maybe i'm wrong but i would i would expect uh training around that particular element to be in one of those those phase one or phase two training interventions
01:03:10 interventions now
01:03:11 now if we can just deal briefly with communications training we dealt with it with mr groves but i'd be grateful for your views for obvious reasons your response the coroner indicated that the communications related training
01:03:23 the communications related training would be done by december 2013. mr groves accepted that both the station-based and senior officer package did not meet or address the communications issues that were
01:03:35 the communications issues that were experienced at latino and mr reason's evidence on seeing the relevant slides of the packages was that they did not reflect what the package was intended to cover including the role
01:03:46 was intended to cover including the role of construction materials and the potential need to restore lost communications now although tcap double zero three nine was signed off as complete in may 2015 it was never released
01:04:00 2015 it was never released due to the same i.t issues that we've discussed with you yesterday and with other witnesses previously were you aware of the dire state of the implementation
01:04:11 of the dire state of the implementation of the recommendations regarding communications training i was aware there were problems with the rollout of some training packages as a result of the incompatible the brigade's i.t system
01:04:22 system whether or not i was aware of this particular one i can't quite recall but i certainly was aware of the issue and what steps did you take to remedy the situation well um firstly
01:04:33 to remedy the situation well um firstly um when i spoke to officers is there another way the training could be delivered without need to resort to the i.t system that the response to that was it would
01:04:44 that the response to that was it would undermine the effectiveness of the training program and the other side of that was i spoke with the people responsible the officers responsible for the i.t system in general about one what were there
01:04:57 general about one what were there improvements fixes we could put in place to actually facilitate the rollout training packages which to some extent we tried but were limited of limited success
01:05:08 limited of limited success um and following that subsequently and later on um obviously we managed to get elected members to approve the replacement of the it system there was a notwithstanding all of that
01:05:19 there was a notwithstanding all of that there was a basic and obvious solution that the two relevant tcaps double zero three nine and radio equipment and zero two one two on highly insulated buildings
01:05:30 buildings those programs could have been released without the videos thereby overcoming the video related issues that could have been easily done couldn't it could have been done yes but it wasn't it wasn't because i was advised by well the decision mistaken devised by officers
01:05:42 decision mistaken devised by officers that it would undermine significantly undermine the effectiveness of the training package now
01:05:49 now the criticism that might be made of you is that in relation to communications during your tenure as commissioner the lfb failed to improve its equipment policies or training in
01:06:02 its equipment policies or training in response to its experiences at lachnal what would be your response to that criticism i wouldn't accept that criticism for the reasons i've displayed in my evidence for the last half an hour or so
01:06:14 could we turn to the nature of the lfb's response to the latino recommendations and the fire itself now for all three of the recommendations that we've explored in detail instant command
01:06:26 explored in detail instant command training 72d and communications the lfb's response was broadly put that its existing systems were adequate but that it would go away review matters is
01:06:38 that it would go away review matters is that a first summary um well three messages could you take the three matches for me please instant command training 72d yeah and communication yes
01:06:49 mindful of that was there a feeling whether held by you your senior officers or more broadly across the organization that
01:06:59 that in substance the rule 43 recommendations were superfluous and that in effect the lfb had learnt and applied the lessons from latino absolutely not can we go back to your evidence to the
01:07:11 can we go back to your evidence to the inquests cwj quadruple zero double zero one zero forward slash one one six and if we go to line 15
01:07:22 one six and if we go to line 15 you were asked this question all right
01:07:25 all right now with that in mind bearing in mind the future and prevention of fires of this kind and the risk to life in the future do you feel as an authority that full efforts have been made to learn the
01:07:36 full efforts have been made to learn the lessons and to address them in the form of the policies that we've heard about today and your answer is this i do
01:07:44 i do and we're always keen to learn new lessons and approve our performance but i do believe london fire brigade has taken on board the lessons from the fire notwithstanding what may come out from the coroner following the inquest but i
01:07:57 the coroner following the inquest but i do believe london fire brigade has taken full account and learnt as many lessons as we possibly can if that was your view of march 2013
01:08:10 if that was your view of march 2013 were you disappointed to see the extent of the recommendations that the coroner thought fit to direct towards the lfb um
01:08:19 um no i wasn't actually i thought the current i made i mean i think
01:08:23 think firstly the coroner um when the letter commended london fire before the actions we've taken since the fire and the things we'd already changed and i think that that work we we'd completed and the
01:08:34 that work we we'd completed and the commoners comment reflected that there would have been other recommendations to coroner had we not completed that work prior to the part of inquest um but i felt the coroner made some very
01:08:45 um but i felt the coroner made some very relevant um and important recommendations and we took them very seriously just flowing on from that point despite identifying 34 action points the
01:08:56 action points the pre-action points that in the lfp and internally identified the coroner remained sufficiently concerned by the evidence that she'd heard to make the recommendations she had
01:09:07 to make the recommendations she had did that give you cause for concern about the adequacy and the thoroughness of the lfb's own internal consideration of the lessons after latino well i
01:09:18 of the lessons after latino well i certainly um i certainly was disappointed that the coroner
01:09:22 coroner had had found additional things because obviously i thought we'd done we've done quite a good job in terms of being doing a thorough review of our performance at the latino incident and and other things relating to you know the guidance around
01:09:34 relating to you know the guidance around building regulations etc and communication with the government so of course i was disappointed the government found things that we hadn't um but that said that was the point of the coroner's inquest to do that so an external scrutiny was always welcome as
01:09:46 external scrutiny was always welcome as far as i was concerned so the fact that coroner did identify additional findings that was to be welcomed in my view would you accept that there's a failure on the part of the lfb following lachnal
01:09:58 on the part of the lfb following lachnal to take effective action and to really grapple with the problems that have been identified as a result of that fire first of all the risks of rapid external fire spread um taking in general
01:10:12 um taking in general i was
01:10:13 i was i was pleased with the approach the london fire brigade took and the outcomes of the work of the lakinal board and the latino members working group
01:10:21 group subsequently i was disappointed and i still am disappointed with the extent to which some of those actions that we took were implemented and you've highlighted quite a few of those to me over the last few days mr khalil in
01:10:32 over the last few days mr khalil in terms of where the actions weren't followed through appropriately perhaps and i've tried to give you the explanation of reasons as why those were but yes i was disappointed but we hadn't completed them all perfectly because
01:10:43 completed them all perfectly because that would have been my intention because we've taken it very seriously as far as external fire spread is concerned um i think we we did our best to highlight to the relevant people about the risks of fast bread
01:10:55 about the risks of fast bread external fast spread we haven't touched on a pool at all during my evidence the work we did with local councils and others to actually communicate the risks of fire in high-rise buildings to residents which i
01:11:06 high-rise buildings to residents which i was very proud of that as well but i think we did our best to communicate the risk of external fire spread as it related to lack of house and i think i said before that the the difference between the lack
01:11:18 that the the difference between the lack of house fire and the grenfell tower fire was that we had panels below windows that were not of the right fire resistance that failed early and allowed normal natural
01:11:30 early and allowed normal natural naturally occurring and frequently occurring
01:11:32 occurring um fast bread effects to take place from one window to another going upwards the greenville tower fire was very different to that in that the building was effectively wrapped in flammable material and which wasn't the case at la
01:11:44 material and which wasn't the case at la canal house i do believe we did all that's appropriate following the circumstance of the lack of house fire can i ask you just some brief questions on some discrete issues um before we break for the morning really it's going
01:11:56 break for the morning really it's going back to that cultural divide between fire safety on one part and ops on the other in terms of addressing that divide did you
01:12:05 did you set up a formal initiative at any stage or consider setting one up which identified the extent of the divide and appropriate remedial measures we did discuss it a lot in the early
01:12:17 we did discuss it a lot in the early stages of my when i was commissioner and subsequently a couple steps to explain to on day one of my evidence to actually try to address that we didn't set up a formal project or a formal intervention to identify the
01:12:30 formal intervention to identify the problem to more staff and to deal with it i wish we had yesterday we touched upon the complexities of evacuation would you accept now
01:12:41 would you accept now with the benefit of hindsight that instead of the informal discussions the debate you referred to yesterday afternoon
01:12:48 afternoon it would have been better and indeed needed to be done for the lfb to study the question including by calling evidence from stations etc to methodically establish what the best approaches to evacuation
01:13:01 what the best approaches to evacuation of a high-rise residential building might be um i wish we i wish we'd taken a number of actions in relation to the evacuation of high-rise buildings um
01:13:12 um as i explained to yesterday um
01:13:15 um whilst it whilst it was a risk and we knew evacuation did take place in fact and it was being dealt with um
01:13:22 um we didn't we it was difficult to identify what the steps would be that you would give fi tell firefighters to take to actually manage a full evacuation in a residential highways building where there was no central fire alarm no record of who was in the
01:13:34 alarm no record of who was in the building or not yes i wish we'd consult with wider on that i wish we'd involved evidence from fire stations on that um we didn't and i regret that we didn't and also
01:13:45 and also there was a need to ensure that operational firefighters indeed officers will rank uh were better aware of the limitations of stay put and it considered the prospect of evacuation high-rise residential building should
01:13:56 high-rise residential building should the need arise yes could i turn briefly to section 72d again
01:14:02 again we can go to it if you want but you remember appendix i'll remember it clearly
01:14:06 clearly um
01:14:09 you express very clearly your assessment of the limitations of the the 20 or so bullet points would have set out and how some particularly the 10th and 12th bullet points may well be
01:14:20 and 12th bullet points may well be beyond the technical knowledge of the crews attending on those visits could those crews not have been required to
01:14:28 to identify that the building had a cladding system first of all that was within their expertise and knowledge wasn't it um to an extent if you look at walking just walking
01:14:40 if you look at walking just walking around london any day of the week and you look at buildings some of the cladding systems that exist on these buildings are not entirely evident to me but sure they do exist there are some buildings where the cladding has been
01:14:51 buildings where the cladding has been added
01:14:53 added as a subsequent range screen or insulation method on these buildings and probably it would be within the competence of most firefighters to identify that but
01:15:04 most firefighters to identify that but i'm not sure it's a fair statement to make generically that all firefighters will be able to identify cladding existing on high-rise buildings um crews would have been able to ask the
01:15:15 um crews would have been able to ask the responsible person to specify details of a cladding system if they suspected or thought or speculating as to whether one was in place couldn't they
01:15:24 they they could but it wouldn't be normal practice for operational crews to require or to ask for the um presence of the responsible person at all seven two d visits that just as i've said earlier
01:15:35 d visits that just as i've said earlier in my evidence about the difficulties of identifying the responsible person let alone getting them to actually come along and talk to fire safety officers so it's not reasonable in my opinion to
01:15:46 so it's not reasonable in my opinion to expect fire crews to actually expect the responsible piece and to be there present on every 7-2 d visit and that would
01:15:52 would slow the process down very significantly mr dobson over the past three years we've covered a lot of evidence we've gone through a lot of matters and you've you've made concessions that you've set
01:16:04 you've made concessions that you've set out
01:16:05 out with the benefit of hindsight and knowing what you now know what if anything would you done differently
01:16:15 [Music] well that's a question that i've asked myself
01:16:18 myself many many times since um june 2017. um it really it concerns me greatly that i could have taken other actions that would have in some way mitigated i don't think i could
01:16:29 some way mitigated i don't think i could have prevented the disaster at grenfell tower because we didn't know about the cladding and i think the difficulties around the building regulations have also been very clearly identified by dame judith hackett in her review of building regulations etc
01:16:41 building regulations etc in this country um i think there are some things that perhaps are what i do wish i'd done differently i think you've very uh eloquently highlighted to me the failings around
01:16:53 highlighted to me the failings around the cultural issues between the the gap between fire safety and operations in london fire brigade i knew about that gap it's something i've experienced all of my career
01:17:04 of my career i did try to change it i was unsuccessful certainly into the extent that i would like to have done and i wish i'd taken more action to deal with that it's quite a controversial thing to say
01:17:16 it's quite a controversial thing to say in some ways with some people it will be but where we've i've seen the evidence in relation to the problems in the control room around training records etc at one point prior to 2012
01:17:28 at one point prior to 2012 the fire authority took a decision to outsource the control um both the system and and start this training of the staff um that was subsequently changed due to a changing political nature of the
01:17:39 a changing political nature of the authority in 2012 at least the control of the authority i wish i'd fought harder to actually maintain the decision to outsource the control and the control training the reason for that is that had the training
01:17:50 reason for that is that had the training been outsourced in the same way as it was for operational firefighters i think the issues with the training records and training hadn't taken place would have been highlighted much more clearly and much more earlier than it was through the managers that sat in the control
01:18:01 the managers that sat in the control room i think there would have been an external body notifying us and letting us know when training wasn't taking place so i wish i'd pushed harder in relation to to actually outsource that because i think it will resolve that problem
01:18:13 problem and i think the other thing is i regret not pushing the government department harder in relation to all the issues we raised in the letters to second night and to the minister
01:18:24 to second night and to the minister during the time around the dangers that we proceed through um
01:18:29 um lack of clarity in terms of the building regulations around things like regulation b4 and also around things like the testing of materials that were in place on buildings and i think dame judith
01:18:41 buildings and i think dame judith hackett
01:18:42 hackett highlighted quite appropriately that the building control regime in terms of the way materials were approved to be on buildings using desktop reviews and those sorts of things was inappropriate
01:18:54 those sorts of things was inappropriate and i think i wish i and i would stand the fire brigade had pushed the government harder on that to actually to deal with those problems the final thing i think i would like to you know and i've given this lots of
01:19:06 you know and i've given this lots of thought thing i would i think i wished i'd done differently was i wish we'd learnt more from international fires and we'd raise the issues of fast spread externally more clearly with firefighters and i do wish we'd done
01:19:18 firefighters and i do wish we'd done that i don't once again i don't think that would have prevented the fire grenfell tower taking place um i don't think many respects would have probably changed the outcome too much but i think it would be a relevant thing to actually um to make
01:19:30 thing to actually um to make firefighters aware of mr dobson thank you um sir i've come to the end of my prehead question yes thank you um it chimes conveniently with the usual morning it does yes
01:19:41 usual morning it does yes and so might i ask for a quarter of an hour yes well uh of course and mr dobson you probably know that uh when council gets to the end of his questions we have a break
01:19:51 a break so that he can just review the position and indeed we can receive suggestions from other people about further questions that perhaps ought to be asked so we'll have a break now um is quarter now going to be longer yes
01:20:05 obviously that takes precedent would it be an opportunity for me to make a couple of comments after that i really think i would really like not to like to leave the inquiry without making a couple of comments i think might help yes well i'm sure you can do that um
01:20:17 yes well i'm sure you can do that um perhaps we'll see if there are any further questions first and then we'll do it then thank you so we'll break now we'll come back at 25 to 12 please and as before please don't discuss your revenue with anyone while you're away
01:20:28 revenue with anyone while you're away from the room thank you very much
01:20:37 thank you 25 to 12 if you find you need more time just ask the usher to let us know thank you thank you very much
01:36:56 yes would you ask mr dobson to come back in please okay
01:37:09 all right mr dobson well we'll see if there's any more questions mr dobson i have no further questions for you um the only thing that is for me to say now so thank you very much for attending to give evidence over the past
01:37:20 attending to give evidence over the past three days we greatly appreciate it thank you thank you now mr dobson you indicated earlier that you'd like to say something brief about if i may say yeah it's very it's very brief and i know the
01:37:31 it's very it's very brief and i know the query's got a very long agenda in front of it and a difficult task um first of all i'd just like to thank the inquiry very much for listening to my evidence over the last few days uh i'd like to say it's been a privilege to come along and help with the deliberations of the inquiry um
01:37:44 the deliberations of the inquiry um there are some very serious and important matters that need to be identified as a result of gravity and i've full confidence in the plan of getting to the bottom of those and i hope i've been able to help in some way um there uh next thing i'd like to say
01:37:55 um there uh next thing i'd like to say is not on behalf of myself it's on behalf of the officers and firefighters london fibre dead actually and that is that i can say absolutely truly and clearly
01:38:06 i can say absolutely truly and clearly everyone in the london fight became 100 committed to learning and learning the results the the lessons to be learned from the lack of house fire i'd like to think of the things we put in place in terms of to establish the
01:38:18 in place in terms of to establish the facts
01:38:19 facts a demonstration of that um i'm disappointed as my officers would have been as well that we didn't actually complete all those tasks in a way that we set out to um and i don't make this this i make this statement particularly not for me
01:38:30 this statement particularly not for me but for the offices that work for me and to say that my second statement lays out a range of circumstances that london fire again was operated in during that period
01:38:39 period in particular um that period during uh i think it was september 2013 and february 2015
01:38:46 2015 where my offices were under significant pressure because of the period of industrial action i think it was a testament to my office as they came through that london came through that without any significant loss of life
01:38:58 significant loss of life um and i think uh but i shouldn't i don't think we should in any way underestimate the debilitating effect ahead of my officers and the brigaders overall because it was a very difficult period for us
01:39:09 very difficult period for us and the final thing i'd like to say for may which is just very briefly um we've spoken a lot about the training contract or i know the inquiry's heard a lot of evidence about training contract and that's entirely appropriate um the
01:39:21 and that's entirely appropriate um the decision to outsource the training contract was in my view taken after a thorough investigation by the fire authority and that is contained within the future absence of training reports that i think of the inquiry has already
01:39:32 that i think of the inquiry has already had access to but the reasons for doing that are very clearly laid out and then the benefits and what we're trying to achieve
01:39:38 achieve um and just one comment that i i i regret having to raise this but i think i do the one comment was made by miss danny cotton last week when she said that before the training contract you could have whatever training you liked
01:39:50 training you liked and that comment is so far from being accurate
01:39:53 accurate i just felt i need to make the comment that it's just not accurate because even before the training contract there were checks and balances in contr in place um the budget was not limitless
01:40:04 the budget was not limitless um and the truth was you could you could probably ask for what's raining ever you wanted but you'd wait a very long time for it to be delivered and there were long lists of training that people had asked for
01:40:13 asked for that were never delivered because there was no real controls over it and with all its faults and things that i know there are faults with the training the contract it's administered but actually there is a business
01:40:25 but actually there is a business regimen and a process about it that enables things to be properly um prioritized if the system is working properly and i just want to make that comment i apologize for making that but i feel i just needed to
01:40:36 i feel i just needed to thank you very much yes well thank you very much well mr dobson
01:40:40 mr dobson all three of us on the panel find it really
01:40:43 really useful and helpful to hear your evidence i think it's particularly valuable for us to hear from someone who's at the pinnacle of the organization and who has such a clear sighted view of
01:40:55 and who has such a clear sighted view of what went right and what perhaps didn't go quite as well as it might have done and you've been very candid in giving us your account and we are extremely grateful
01:41:03 grateful and i'd like you to get away in the knowledge that we have found it very useful to hear from you great thank you so thank you very much again and now you are free to go thank you very much thank you
01:41:22 yes mr canoe um so that concludes excuse me the evidence for this morning mr millett will be examining the present london fire commissioner starting at two o'clock this afternoon right thank you very much well in that case we'll uh
01:41:35 very much well in that case we'll uh we'll stop at that point we'll resume at two o'clock with our next witness thank you thank you very much two o'clock please
01:41:51 you