LFB Commissioner Andy Roe's evidence on organizational failures, firefighter training, operational discretion, and systemic issues within the Brigade that contributed to the Grenfell tragedy.
00:00:29 yes mr millet no then mr chairman good afternoon members of the panel i now call commissioner andrew rowe please thank you
00:00:44 good afternoon mr rowe i gather you're going to take the oath i am thank you there should be a testament there is there there is take it in your right hand please and read the words on the screen
00:00:54 screen i swear by almighty god that the evidence i shall give shall be the truth the whole truth and nothing but the truth thank you very much please sit down make yourself come
00:01:10 yes mr millet yes mr chairman thank you commissioner good afternoon good afternoon thank you very much for attending once again to assist the inquiry at this phase two of our investigations we are extremely grateful
00:01:22 investigations we are extremely grateful to you
00:01:23 to you uh my questions are intended to be short and simple sometimes they aren't and so if you would like me to repeat the question
00:01:30 question or put it in a different way i can do that
00:01:33 that we will take breaks in the normal scheduled way halfway through the afternoon and during tomorrow during the morning and if we get to the afternoon during the afternoon as well can i ask you to keep your voice up so
00:01:44 can i ask you to keep your voice up so that the person who sits to your right can get down onto the transcript everything you're saying clearly it also helps please if you don't nod or shake your head yes or no is necessary
00:01:55 shake your head yes or no is necessary as the case may be now you've provided two uh rule nine witness statements to the inquiry for the purposes of our phase two investigations uh and you've also made a number of statements for our phase one
00:02:06 statements for our phase one investigations which i will not be looking at with you can i show you the first of your phase 2 rule 9 statements that is at lfb 3060655
00:02:20 it's dated the 14th of june 2019 and that's the first page if we look at the last page page 29 you'll see a signature
00:02:30 uh is that your signature i can't see it yet on my screen i'm afraid apologies coming up is that yourself yes thank you that is my signature is that your thank you and your second rule nine
00:02:42 thank you and your second rule nine statement uh is at lfb triple zero eight three eight three four that's the first page of it you'll see it's dated the 6th of december 2019. if we go to page 15
00:02:56 do you see a signature there above the date of december 2019. is that your signature yes that is my signature now both those statements exhibit a number of documents don't they they do indeed have you read both of these witness
00:03:08 have you read both of these witness statements recently i have and have you read the exhibits recently i have are you happy for the content of those statements to stand as your evidence to the inquiry i do
00:03:19 the inquiry i do and have you discussed your evidence with anybody before coming here today only my legal team yes now i'm going to ask you first about the various roles and positions that you occupied both
00:03:30 and positions that you occupied both inside and outside the lfb before you became the lfb's commissioner in january 2020. is it right that you served in the british army between 1996 and 2000.
00:03:42 british army between 1996 and 2000. yes it is and that was in the royal regiment of artillery i think yes it was and by the time you left the army you held the rank of captain didn't you i did and i think you tell us that you were second in command of a battery of
00:03:53 were second in command of a battery of about 120 personnel that's correct and you also had active uh experience of operational tours in northern ireland in 1998 1998 where you were part of the
00:04:04 1998 1998 where you were part of the response among other things to the omar bombings that's correct yes and then you joined the london fire brigade in 2002 yes that's correct and that was as an operational firefighter as an
00:04:15 operational firefighter as an operational firefighter yes and after that i think you became group manager in operational policy rising up through the ranks in 2012. that's correct and overlapping with the same period you were a member of the operational review
00:04:27 were a member of the operational review team or the ort from 2010 to 2015. that is also correct and then to correct me if this is wrong but you became deputy assistant commissioner dac in february 2016
00:04:38 2016 yes that's correct and in that capacity i think you acted as incident commander at the croydon tram crash that is also correct yes and that was the same year i think yes it was yes and
00:04:49 the same year i think yes it was yes and you were then made assistant commissioner in april 2017. yes yes that is correct and it was as assistant commissioner that you attended and indeed acted as incident commander at the grenfell tower fire on the 14th of
00:05:02 the grenfell tower fire on the 14th of june
00:05:02 june 2017. that is correct yes and after that fire you were you were made deputy commissioner and director of operations from november 2019 that is correct and finally then
00:05:13 that is correct and finally then appointed commissioner in january 2020. that is also correct thank you now we've called you um to give evidence at this point in the inquiry commissioner
00:05:24 this point in the inquiry commissioner at the end of module five and at the end of the first part of module six because you are the present london fire commissioner and as such you are the individual carrying the responsibility for assuring londoners that they are
00:05:35 for assuring londoners that they are being kept safe by the brigade do you understand that i do understand that i hold that responsibility fully and we would like to hear from you because as commissioner you have certain
00:05:46 because as commissioner you have certain insights and certain perspectives some of which you have shared publicly in the press i think haven't you indeed yes now
00:05:54 now at heart i have really two questions for you and possibly a third i don't want you to answer them straight away i pose them now so that you can address them as we go through your evidence and
00:06:05 them as we go through your evidence and perhaps revisit them at the end and those questions are these the first one is are you able to explain why the lfb failed to learn all the lessons from the latino house fire in
00:06:17 lessons from the latino house fire in july 2009
00:06:19 july 2009 despite the effort and the resources invested in doing so between that year and 2017.
00:06:26 and 2017. that's the first question the second question we have for you is has the lfb asked itself the question i've just asked you in other words as well as trying to
00:06:37 in other words as well as trying to learn the lessons of grenfell and carrying out the recommendations in the chairman's phase one report has the lfb asked itself why its response to the lachenal fire was defective
00:06:48 lachenal fire was defective in so many respects and the third question arises perhaps from the second which is what has the lfb learned about itself as an organization from its failure to learn from the
00:06:59 from its failure to learn from the latino house fire now those questions have embedded in them some factual assumptions which we will explore together during the course of your evidence but that those are essentially the questions that i have
00:07:10 essentially the questions that i have for you
00:07:12 for you do you understand what i'm asking you i do understand what you're asking us a minute thank you and you accept i think and tell me if this is wrong that it is your task as commissioner from 2020 to answer those
00:07:23 commissioner from 2020 to answer those questions i think that lies at the heart of what i am responsible for thank you can i start then by asking you about an interview you gave to the guardian newspaper
00:07:34 newspaper in september 2020 the 1st of september 2020
00:07:38 2020 this we will find at inq3015028
00:07:46 there it is on your screen in front of you
00:07:49 you and you can see first that the title is we let grenfell tower residence down says london fire chief and the date is tuesday first of september 2020.
00:08:02 september 2020. now to put it into context this was about nine months into your term as commissioner and at that stage you may recall that the inquiry phased two hearings uh were underway we were hearing module
00:08:14 uh were underway we were hearing module one evidence at that stage yes yes now at that point just to be more specific um we were um approaching the end of the module one hearings which focused on the refurbishment and we're about to start
00:08:26 refurbishment and we're about to start module two uh which uh concern the testing and the certification of the relevant cladding materials now if you go um a little bit lower down um you one of the points you make in the
00:08:39 um you one of the points you make in the guardian interview is that and if you go please to
00:08:43 please to page
00:08:44 page two
00:08:47 you can see in the second paragraph third paragraph there
00:08:54 take your responsibility seriously he said if you have cladding on your building work within the framework that is there to get it off as soon as possible this is bigger than money this is about people's lives their mental and
00:09:07 is about people's lives their mental and physical well-being you will get my absolute support as london fire commissioner to do that now you were addressing i think the corporate entities uh uh who had participated in the inquiries phase two
00:09:19 participated in the inquiries phase two hearings to date uh there and also if you look at page three of this article in the fourth paragraph down you say this they should be ashamed he said
00:09:30 they should be ashamed he said understand that 72 people lost their lives now is not the time to seek corporate defense but actually give these families what they deserve which is the truth and an undertaking not to let history repeat itself
00:09:43 let history repeat itself first
00:09:44 first did you say the words there that are attributed to you by the article i think it's a paraphrase of what i said but i think the essence of what is written is my opinion yes thank you
00:09:56 my opinion yes thank you and
00:09:57 and as i say i think you were addressing the corporate entities who had participated in the inquiry thus far weren't you i was yes
00:10:05 i was yes do you agree that your words there apply with the same force to the lfb itself yes i do
00:10:11 yes i do now there are four points that you make in this interview and i would like to ask you about each of those in turn if i can and the first is on page two if we scroll back to it
00:10:22 scroll back to it fourth paragraph from the bottom and the article says this row told the guardian that the lfb had been quotes sorry had been in quotes denial about
00:10:33 sorry had been in quotes denial about systemic issues on quotes and said he had now embarked on a two and a half year retraining program for commanders including new training on cladding fires which had not been delivered before grenfell
00:10:45 delivered before grenfell it did you say as the article attributes to you that the lfb was quotes in denial about systemic issues i can't remember the exact words i use but because it was
00:10:56 the exact words i use but because it was a long interview but i know we discussed in depth both myself and the journalist because he asked me many questions
00:11:03 questions where i thought the roots of some of the improvements we needed to make lay and so would do you sitting here today associate yourself with what this
00:11:14 associate yourself with what this newspaper has attributed to you i i think that the general thrust of the article is accurate i think it reflects my opinion at the time and the opinion i hold now right are you able to tell us
00:11:25 hold now right are you able to tell us what systemic issues you were referring to as attributed to you there yes
00:11:31 yes so i spoke about what i thought had been an erosion not only in the london fire brigade but in the national service of professional standards over a period
00:11:42 of professional standards over a period of probably two decades that had started i suppose its genesis had started with the 2003
00:11:50 the 2003 industrial action around pay and had led to the dismantling of national structures that supported consistent national guidance consistent assurance and inspection of
00:12:02 consistent assurance and inspection of fire and rescue services had led to the removal of all sorts of things such as statutory
00:12:07 statutory exams
00:12:09 exams had moved to a sort of mvq based education system which i don't think validated people's competency and then
00:12:17 and then you know in part to the industrial relations climate you know where we had seen repeated industrial disputes in london that i i thought had taken the focus of decision makers away from some of the
00:12:30 of decision makers away from some of the risks that had slowly built over time so it was a long answer it was more than just
00:12:36 just a sort of a snapshot of one sentence we talked about what i perceived to be an erosion of standards across the national service and the london fire brigade was not immune to that right
00:12:48 brigade was not immune to that right can you help us with what you meant by denial there how did the lfb come to be in denial about the systemic issues that you have mentioned
00:12:59 mentioned um
00:13:00 um i can't speak as to what people had or hadn't seen in the past because i wasn't at a level of seniority that would necessarily have been privy to decision making at the level or now sitter but i think what i
00:13:13 level or now sitter but i think what i meant by that was probably and i think it's been exposed through this phase of the inquiry particularly that we were aware of risks
00:13:21 of risks in particular that existed in the operational environment and indeed at times
00:13:26 times trained people to those risks but hadn't joined all the information up together so if we think of grenfell specifically you know we knew that there was a potential risk of wholesale failure of
00:13:38 potential risk of wholesale failure of compartmentation we knew
00:13:41 we knew for example the the dangers of poor maintenance and and management of buildings the possible large-scale involvement of utilities in the fire the
00:13:52 the fire the the very real possibility of a very large fire in london involving loss of life but i'm not sure that we had joined all of those things together in a way that
00:14:04 in a way that really articulated those risks to officers in totality and have you since you became commissioner sought to get to the bottom of the causes of the denial
00:14:16 causes of the denial let me give you an example have you asked for outside professional help to understand why it was that the lfb denied what it should have accepted and acted on long before i mean i think
00:14:27 acted on long before i mean i think again i can't remember the specifics of the interview i'm not sure denial is necessarily the right word but it certainly not being cited on issues would be the right way to to
00:14:39 would be the right way to to characterize this and the answer is yes because i think one of the most serious issues not just for the london fire brigade but again for the service nationally was that we were simply not scrutinized effectively over a period of
00:14:52 scrutinized effectively over a period of decades it wasn't until the return of her majesty's inspectorate that i think we began to get back to a place where good robust external assurance was brought to bear so it's something about
00:15:03 brought to bear so it's something about bringing people in from the outside to see what you perhaps can't because you're so focused on one area of business that the answer mr miller is yes we have so for example we have set up an independent
00:15:15 up an independent audit committee that is chaired independently i have an independent operational assurance advisor who acts totally independently of me examines different pieces of the organization the former chief fire
00:15:26 organization the former chief fire officer of scotland we have built a completely different business assurance framework based on treasury best practice three lines of defense because i think
00:15:37 because i think one of the things that has struck me from
00:15:41 from the the evidence presented in this phase of the inquiry is that you cannot rely on a single line of assurance you cannot rely simply on a line manager who's probably working very hard to the best
00:15:52 probably working very hard to the best of their ability to always see where the fault lines are and therefore escalate matters there needs to be a second line of attack as it were and that's something we've brought in
00:16:03 something we've brought in in layers now because as commissioner i no longer feel in a position where i would want to rely simply on the assurance of my leaders inside the lfb to tell me that
00:16:15 leaders inside the lfb to tell me that something had happened and assure me that we had delivered the right outcome now you
00:16:20 now you perhaps don't associate yourself with the word denial about systemic issues you say
00:16:26 you say instead not being cited what
00:16:30 what do you say is the cause historically of the lfb in your words not being cited on the systemic issues that have that have emerged i i think it's complex i
00:16:42 have emerged i i think it's complex i don't think there's one single cause i'll i would go back to my first answer which i think there was a gradual incremental erosion of professional standards and governance over a period
00:16:53 standards and governance over a period of decades that was manifest because of a number of factors whether that was the industrial relations climate whether it was the lack of overarching national guidance
00:17:05 guidance whether it was the lack of either effective
00:17:07 effective national scrutiny or local assurance a focus on other areas of risk sometimes so for example post 9 911 there was a great focus on
00:17:18 9 911 there was a great focus on counter-terrorism quite rightly so there was something about how the brigade managed its resources and the focus it bought to bear on whatever risk was presented at that
00:17:30 on whatever risk was presented at that point so i think i think it's multi-layered but from my point of view having joined the service in 2002 as a firefighter i was certainly witnessed at each level i was at to a
00:17:42 witnessed at each level i was at to a gradual erosion of what i perceive to be professional standards and communication of risk and the training to support it would you agree that the capacity to
00:17:54 would you agree that the capacity to recognize shortcomings not just recognizing them but the ability to do so would be and will be crucial to the brigade's ability to learn from the grenfell tower fire yes yes indisputably just going back to
00:18:07 yes yes indisputably just going back to the article if i'm a commissioner you
00:18:10 you are
00:18:11 are recorded as saying after the quotation denial about systemic issues that you had now embarked on a two and a half year retraining program for commanders including new training on clouding fires
00:18:23 including new training on clouding fires which had not been delivered before grenfell
00:18:26 grenfell uh is is is it fair to say that that suggests that the systemic issues
00:18:33 issues which are attributed to you were related to training at least in part i think part of the issues were around the nature of the training we we gave people it wasn't that we hadn't trained people i want to give the impression
00:18:45 people i want to give the impression that the london fire brigade hadn't trained generations of firefighters i've received a lot of training in the london fire brigade i think this was about how we dealt with a a specific risk that
00:18:56 how we dealt with a a specific risk that was known to one part of the organization that hadn't necessarily been effectively communicated to another part of the organization
00:19:06 yes i see now you go on to say if you go on in page
00:19:12 page two to the penultimate paragraph uh
00:19:16 uh that and i'm quoting from the article that the disaster quotes was foreseeable but it wasn't in the culture to anticipate it admitting quotes the fire brigade let
00:19:27 admitting quotes the fire brigade let those families down now again commissioner did you say the words that are attributed attributed to you in quotation marks there on the point of foreseeability i don't believe that that that encapsulates the
00:19:39 believe that that that encapsulates the totality of what i said no i think i gave a much more nuanced answer in terms of the second part i think every single major institution that should have kept those
00:19:51 that should have kept those you know survivors that the bereaved the people who lived in the tower safe let the families down it was the most appalling example of institutional failure i think in recent british
00:20:02 failure i think in recent british history and we were part of that as well and that was how that answer was um delivered to the journalists in terms of the nuance of the first piece i i think that the london fire brigade knew
00:20:13 think that the london fire brigade knew of every single element that that made up the the totality of the
00:20:18 the grenfell tower fire you know as i've said already we knew about the possibility of exterior cladding fires but we hadn't communicated effectively internally i've been trained on the dangers of modern
00:20:30 been trained on the dangers of modern methods of construction you know as a senior officer i had attended some very very high risk large fires the royal marsden hospital fire would be a good example very high risk very difficult
00:20:41 example very high risk very difficult fire to resolve so it was not beyond our imagination that something on a scale could happen involving fire in london what what i would hold to to this day is that the totality the scale and the
00:20:52 is that the totality the scale and the extremity
00:20:54 extremity of that failure of every single part of regulation and human behavior that should underpin it would have been difficult to predict yeah so just focusing in on perhaps some of the key
00:21:05 focusing in on perhaps some of the key elements do you accept commissioner that the lfb had
00:21:11 had what i might call corporate knowledge as of june 2017 of the risks posed by non-compliant facade panels in use on high-rise buildings across london
00:21:22 london yes because i think it's clear from the evidence given to this inquiry that that was the case and same question in respect of the risk of sudden impending fire growth that such panels can cause
00:21:35 growth that such panels can cause yes
00:21:37 yes and the risks of smoke spread beyond the compartment of origin yes probably in a different context but yes i mean la canal itself had shown us that that was a very real possibility
00:21:48 that that was a very real possibility and officers were aware of that and does it follow from that that you also accept that the possibility of widespread compartmentation failure within a high-rise building to the extent
00:21:59 to the extent that the stay put policy in place in such a building became untenable was a risk that was real and known to the brigade as of june 2017. yes and i think the proof of that is in the
00:22:11 think the proof of that is in the lacanal house case study that i certainly received not so long after the fire it made that possibility real to me as an operational officer at a sort of middle rank at that point it was clear to me i
00:22:22 rank at that point it was clear to me i think it's manifest in our response to the shepherds caught fire where officers correctly identified there'd been a partial failure of compartmentation across a number of levels in the building and successfully
00:22:34 levels in the building and successfully evacuated
00:22:35 evacuated those parts of the building that needed to be that was that's a good example of officers recognizing that stay put was not um relevant in the totality of the building at that point
00:22:46 point so i think i think it was known i think what what
00:22:49 what what caught people by utter surprise and i wouldn't include myself in the first few moments of the grenfell tower fire was the just the totality of it it was it seemed almost unbelievable to me that we
00:23:00 seemed almost unbelievable to me that we would lose an entire residential block in in modern britain i'm not you know that it still shocks me to this day so i think it says something about all the systems and institutions that should have
00:23:11 that should have kept those people safe
00:23:14 safe does it follow from that answer that the risk
00:23:17 risk of such widespread compartmentation failure leading to the untenability of the staple policy in such a building is a scenario would have been a scenario at the time
00:23:29 would have been a scenario at the time that you consider that lfb's officers should have been prepared to respond to at an incident i think it's a note that it would you know that possibility was considered inside for example the national generic
00:23:40 inside for example the national generic risk assessment that it was referred to you know in in you know not in any great detail within our own high-rise and fire survival guidance possible you know
00:23:52 fire survival guidance possible you know policies so i think that possibility was acknowledged i think where we didn't do enough for our officers and crews was actually to prepare them for how they might deal with that situation should it confront them
00:24:03 situation should it confront them because i think the possibility was always there it was written down we knew it lfb officers were involved in it you know in the thinking around it but that didn't translate into training as to how you might address it
00:24:16 training as to how you might address it can i just ask this the uh i suppose the the really important thing is to recognize what's happening in front of you and my recollection of uh
00:24:29 and my recollection of uh mr dowden's evidence was that
00:24:34 was that he was faced with a situation which he never experienced wasn't his fault but that he didn't recognize what was going on until
00:24:44 until it really got away and
00:24:48 and it may be that one one of the things that
00:24:52 that was required and maybe this is something you're now doing is to put your immediate responders the the watch manager level uh
00:25:02 uh in a position to recognize a serious breach of compartmentation if it's facing them yeah i mean we've we've done that now so despite the challenges of the pandemic
00:25:14 despite the challenges of the pandemic we we've trained all 5000 operational staff to recognize the early signs of building failure and consider despite the very real operational challenges of doing so how
00:25:25 operational challenges of doing so how they might begin to undertake an emergency evacuation in fact there's a an exercise today entirely coincidentally in paddington testing
00:25:34 testing exactly that testing our crews as to how they might do that with all the challenges you know apparent within that that operation
00:25:43 operation yeah
00:25:44 yeah thank you
00:25:45 thank you right
00:25:46 right um
00:25:47 um going back to your answer a little bit earlier about knowing all the elements of risk does it follow from that and what you've told us that
00:25:59 told us that the
00:26:00 the accumulative effect of the known risk factors
00:26:03 factors so rapid external fast spread across across a non-compliant facade with rapid internal compartmentation failure was also known to the to the brigade
00:26:14 was also known to the to the brigade yes i i think it was and again although it was a in a different context lacking showed us that
00:26:23 and is it the case that although you knew those individual elements the brigade had simply never put them all together
00:26:29 together i think i think there had been an attempt to put them together to to an extent so if i think about you know where it's been submitted as evidence if you think about the exercise i was a facilitator for you know i'd arrange the
00:26:40 facilitator for you know i'd arrange the parking and the water and the you know the the exercise to test the new high-rise policy post lachen now it did foresee the possibility of
00:26:51 possibility of partial failure of a building um you know a number of fire survival guidance calls beyond the you know the two or three we probably thought had been would have been the maximum in the past so i think it was not that we
00:27:03 past so i think it was not that we hadn't anticipated some of the issues that grenfell most terribly demonstrated but there's something about the possibility of the scale at which it might happen the rapidity the you know
00:27:16 might happen the rapidity the you know enormity of that failure so i i think it's fair to say that post lachanel the brigade actually really did want to learn and really did want to bring into operation policies
00:27:27 want to bring into operation policies that addressed you know the very real risks that fire had
00:27:32 had demonstrated does it follow that the scale of the grenfell tower fire was foreseeable uh because all the elements were fought
00:27:44 uh because all the elements were fought were known and put together um i'm not sure that
00:27:52 that it was predictable in the in the in the totality of how it presented itself you know that's my my genuine position
00:28:00 position but what i would say and this is perhaps a slightly separate point if you wouldn't mind is that the history of the london fire brigade and fire services generally
00:28:08 generally shows us
00:28:09 shows us that there will always be another grenfell but it might be a 7-7 it might be a paddington so actually the question for me as commissioner is how do we prepare our people
00:28:20 prepare our people for what
00:28:21 for what you know in those first few minutes might appear wholly unexpected how do we equip them to take discretionary decision making about things we might not reasonably even have predicted might
00:28:32 not reasonably even have predicted might happen because i think we do have a duty as a fire and rescue service to do that to recognize that in a town on this scale with the levels of complexity and risk within it actually there will be
00:28:43 risk within it actually there will be something we haven't thought of i i think that's a very real possibility there will be something as commissioner i have not thought of in terms of future risk or my teams have not thought of and therefore we have a very real duty
00:28:56 therefore we have a very real duty to firefighters who in my experience inevitably act with courage and real endeavor
00:29:02 endeavor to prepare them for that that unforeseen eventuality i think that's a very real duty i think there are ways of doing it although it is difficult
00:29:11 and i'm not going to ask you about things that you hadn't thought of i'm going to ask you about things that you the brigade had thought of and on this point you've accepted that you had thought of all the different risk
00:29:22 thought of all the different risk elements
00:29:23 elements they were contained within the brigade and had had amalgamated them and so my question really is and would it not follow from that that you had actually at least as an organization
00:29:34 actually at least as an organization considered what the outcome would be if all of those risk elements eventuated in one incident i think we had but we we hadn't looked beyond the scale of
00:29:45 hadn't looked beyond the scale of perhaps what we've experienced at la canal what we'd seen actually through years of operation experience so shepherds showed us that you could get up on me external fire spread that it
00:29:57 up on me external fire spread that it might be a difficult situation to resolve i attended quite a challenging fire at marine corps actually as an ort officer where we lost the floor you know these were challenging incidents in in themselves i
00:30:09 challenging incidents in in themselves i think
00:30:10 think our experience and
00:30:13 and our thinking around all the composite elements
00:30:16 elements was there
00:30:17 was there but we had not conceived the scale of failure that we encountered at grenfell and it's still it i have to say just a minute it still seems almost unimaginable to me obviously it is a potential reality we have witnessed
00:30:30 is a potential reality we have witnessed it and seen it um but i i don't i'm not sure that the point we were planning in response we would have planned for the totality of that failure
00:30:41 planned for the totality of that failure however we should have still prepared our people for what they might do if they did experience something on that scale
00:30:50 did the brigade have any as a regret have any particular way or particular method of approaching the assessment of severity of risk
00:31:00 of risk so that it would understand that there were situations where if you put one risk together with another risk the outcome would not be arithmetical but exponentially worse i think that's something we've had to develop since the grenfell tower fire so
00:31:12 develop since the grenfell tower fire so we've taken a different approach to operational risk and and the gathering of risk information and risk management because i think i think that is a fair challenge i think there's something about how
00:31:24 i think there's something about how different parts of the organization knew about different aspects of the risk and that there wasn't something systemic to then put that all together and then a team dedicated to just thinking about where that might
00:31:35 where that might take us possibly again looking internationally perhaps for evidence so there is almost certainly something in that
00:31:43 that so so the next question is why wasn't that done in the wake of the latino house fire i i couldn't explain that i'm afraid because i wasn't either close enough to the decision making in regard to that
00:31:54 the decision making in regard to that um not nor in the part of the brigade that would have been looking at it all i can tell you is that we have done that now so we have established a research and development team whose job
00:32:06 research and development team whose job really primarily is to join up all the different bits of information that come into the brigade we're beginning to look at international research but that is difficult because actually there's not either a national um system really to
00:32:19 either a national um system really to gather that information nor international um but but we're working with a fire the fire research trust and nfcc to explore how we might gather that better with london taking a lead
00:32:30 that better with london taking a lead role can you confirm then that the question i've asked you just the last question i've asked you is a question that you have asked yourself and the brigade in your time as commissioner yes
00:32:42 brigade in your time as commissioner yes it sits as one of our strategic priorities i mean it's got a corporate strap line which is facing the future but what that really means sitting beneath that is we need to be an organization that
00:32:53 an organization that seeks to continuously improve is looking forward at risk rather than accepting that the current situation trying to end so an example would be we've started to see
00:33:05 would be we've started to see a number of fires involving battery storage quite small fires but on the transport network you know we can see that with development of you know green technology and battery storage this is going to become a larger issue so we are
00:33:17 going to become a larger issue so we are beginning to research and think about what that might mean if you start to see them on a larger industrial scale in for example a residential setting or in an industrial setting which is inevitably where we're going to go
00:33:29 inevitably where we're going to go so i think i think we've changed our approach to this but you know this is cultural change as well and it will take time
00:33:36 time to deliver those improvements can you just if you just look back at the article again and the paragraph i've just read to you which quotes you saying that the
00:33:47 which quotes you saying that the disaster quotes was foreseeable but it wasn't in the culture to anticipate it uh i know that you may not have used those exact words but can we attribute the gist of those words
00:33:58 can we attribute the gist of those words to you do you think i i think it's the answer i've just given which is that there wasn't a systemic approach to joining
00:34:05 joining that you know all the different bits of understanding around risk up inside the brigade and then presenting that back for either challenge and assurance or or to firefighters making them aware
00:34:17 or or to firefighters making them aware of a specific risk necessarily some of them yes but not in totality not joined together
00:34:24 together the next point i want to ask you about commissioner on this article is that page three if we turn the page to page three and look at the first paragraph on that page the article says it attributes this to you in quotation marks people
00:34:36 this to you in quotation marks people were caught in the headlights close quotes rose said open quotes i have the greatest sympathy for those offices because we had simply not prepared them for those circumstances and that is what
00:34:47 for those circumstances and that is what we must do now first of all again did you say the words attributed to you again i think it's paraphrasing because i i spoke to robert booth for probably 40 minutes right it
00:34:59 booth for probably 40 minutes right it was a very long interview piece but i think what he's paraphrased there i would characterize myself as being caught in the headlights that night the the experience of turning up at that incident
00:35:09 incident was
00:35:10 was wholly shocking you know any officer turning up you know coming around the corner and seeing that in front of them would at that point have felt under immense pressure faced with what i've got no doubt you
00:35:23 faced with what i've got no doubt you know because i know the individual's concern would have been the most challenging incident of their of their operational careers they'd have seen that instantly and in terms of preparation i think that whilst i'd been trained
00:35:35 i think that whilst i'd been trained repeatedly for command if i was to think about comparative industries my own experiences in the army i think there is a level of investment for example in you know armed policing
00:35:46 you know armed policing public order policing and the military that is different from that in both the national fire service and the london fire brigade i think there has been a narrative
00:35:56 narrative in the service about how because fires are declining you know in a way fire is solved well fire is not solved we still attend a hundred thousand incidents a year in london i had 128 firefighters
00:36:08 year in london i had 128 firefighters injured over the course of the previous year
00:36:13 year you know so i think there's been a narrative in the national service and indeed in london that actually
00:36:19 actually we were solving the problem and i don't think we had put people under
00:36:24 under the sort of simulated pressure we needed to
00:36:28 to repeatedly to give them that taste of what it might be like to turn up to something that actually was unanticipated was really difficult was a shock
00:36:37 shock and i'd certainly had that done to me in another operational environment i think that was something different coming out of that answer you mentioned um
00:36:45 um declining numbers
00:36:49 do you have any uh thoughts or approach about the validity of using
00:36:57 of using statistical frequency of fires when it comes to preparing the brigade for
00:37:03 for incidents
00:37:05 incidents having in mind that an assessment of risk involves understanding both frequency and severity yeah i think i think there's there's two parts this answer the first i would say is actually the less you
00:37:16 i would say is actually the less you attend fires the more you have to train i think it's that straightforward because you're you're gaining less experiential kind of um learning so actually there's a direct correlation there funnily enough between the less
00:37:28 there funnily enough between the less the less you attend the more you've got to train
00:37:31 to train and i think although we are attending less fires i mean it's not a huge decline but it is slowly declining we are experiencing in the london environment increasingly complex fires
00:37:42 environment increasingly complex fires fires involving modern methods of construction therefore it's important that firefighters are skilled and officers are skilled correctly you know which again places an emphasis back onto training and the
00:37:53 an emphasis back onto training and the quality of training to respond so i wouldn't i wouldn't use um statistics in entirety to define our training approach it's going to tell you part of the story and then
00:38:04 to tell you part of the story and then you've got to look at the specific risks themselves as to the the the kind of syllabus that we would expect a firefighter an officer to work to
00:38:15 to but as a general point the point i'd made in that article was that i think one of the areas that although i had received training it would be wrong to say i hadn't had i'd had command training i'd been tested i think it's something that we've come back to since
00:38:28 something that we've come back to since so for example we validate competency now
00:38:31 now on a yearly basis you know like a driving test for operational command because and i think we could still improve because i think it's important to place
00:38:42 because i think it's important to place officers under that pressure on a repeated cycle just to look at the wording in the article for a moment you say or are said to have said that we had simply not prepared them for
00:38:53 we had simply not prepared them for those circumstances specifically what circumstances were you referring to were you referring to a whole building fire or a cladding fire on a high-rise or it was a much more general
00:39:04 or it was a much more general comment really which is why i've just answered the previous question that way because i think what i was referring to there
00:39:12 there is that the shock of turning up to something that is of a scale and an extremity and i suppose that is really personally important to me because of the nature of my own operational career you know i had been prepared as a
00:39:23 you know i had been prepared as a soldier that i might be shot at and blown up both of those things have happened to me they were entirely shocking despite the very good preparation i've received i've been
00:39:34 preparation i've received i've been told as a firefighter and trained well actually if i think about my initial recruit training 20 weeks about the possibility of failure on the transport system within a year of being a firefighter i was the first firefighter
00:39:45 firefighter i was the first firefighter on the platform at the chancery lane derailment i knew that i might face a derailment but the shock of actually seeing a grossly distorted tube train on the black platform
00:39:56 the black platform stays with me to this day so it for me it was about how we really spelled out to officers and crews there are going to be times in your career where despite what we might have instructed you in despite the fact we
00:40:08 instructed you in despite the fact we may have got the preparation right and told you
00:40:11 told you that um
00:40:12 that um you know there could be a transport disaster or a very large fire or a terrorist attack when you actually get there you must prepare yourself for the shock of the encounter
00:40:21 encounter and the ability to take yourself very quickly to a much calmer place of decision-making and analysis of risk sometimes operating outside of available guidance
00:40:32 guidance and that that shouldn't be something that was an add-on but should sit at the heart of what an emergency service does in training its individuals that mindset that that preparation for kind of experiencing stress
00:40:44 experiencing stress um because i think if i was to point to one piece of training i think we we could have delivered better over the course of my london fire brigade career it would be that and i feel that because
00:40:55 it would be that and i feel that because i had certainly experienced a much more explicit approach to that in the military where people told you you simply will not think of all the factors you think you're going to encounter when this happens you're going to be shocked
00:41:07 this happens you're going to be shocked here are some strategies for calming yourself down and beginning to take effective decisions for example we'll come we'll come to the decision making model and the dcp later in your evidence
00:41:18 model and the dcp later in your evidence just on this though given the experience of lachenal in 2009 as a defining learning moment for the brigade and the vast amount of attention and resources that appear to have been directed at
00:41:30 that appear to have been directed at learning the lessons of lachlan the years after are you able to tell us now in simple terms why those lessons weren't learned and so many mistakes made at lachnil were doomed to be repeated at grenfell
00:41:42 doomed to be repeated at grenfell i think very simply there's a lesson in there about how you sustain learning so i think the brigade did want to learn it felt that responsibility for the
00:41:52 the bereaved from la canal and its own firefighters who had you know been you know it was a terrible incident to have responded to um but there was a lesson in there about how you assure yourself that you've
00:42:03 how you assure yourself that you've delivered the outcome you think you have and then how you sustain that change so the learning is carried forward that would be the point i would focus on we'll come to the specific recommendations of the coroner uh from
00:42:14 recommendations of the coroner uh from the lack of house inquest in more detail shortly but in broad terms commissioner would you agree that proper compliance full compliance with those recommendations would have
00:42:25 with those recommendations would have gone a long way to improve the operational response at grenfell and the command response in particular
00:42:33 [Music] i think that the lessons we learned at lacanal were directly relatable to what we experienced at grenfell and if we had
00:42:44 experienced at grenfell and if we had sustained that learning so for example if we had continued to make the case study available if we had brought forward some of the training packages related to it in good time it may have made a difference but i would go back to
00:42:55 made a difference but i would go back to the fact that at the point people arrived at that incident the speed with which the fire developed the extremity of it and the totality of the failure you know made everything extremely
00:43:08 you know made everything extremely difficult in terms of decision making so i have like i said in the article i have real sympathy for the officers who arrived at that instant in the early stages because it would have i imagine i felt overwhelming in terms of the scale
00:43:19 felt overwhelming in terms of the scale and the rapidity of the fire spread and the unusual nature by which it was spreading
00:43:26 spreading can i
00:43:27 can i finally on this article can i take you to the top of page three second paragraph there where you say this or you are said to have said this quotation marks
00:43:37 marks what i need to bring forward is a more confident card of officers who take decisions with discretion knowing the organization is going to back them not being completely bound by policy and procedure reacting
00:43:49 policy and procedure reacting intelligently to what's in front of them again commissioner did you say the words that the article attributes to you again i think it's paraphrased but i i would hold by that
00:44:00 hold by that intent yes is it your view that there's a problem within the brigade or was before grenfell with senior officers not having sufficient confidence in their own actions in their
00:44:12 confidence in their own actions in their own decisions not at the most senior level so if i look at our ac card for example these are the most experienced operational officers in the uk fire service if we
00:44:23 officers in the uk fire service if we turn to people like andy bell who's known to the inquiry he will have attended multiple 15 pump 20 pump potentially even 30 pump fires it's the busiest operational environment in the uk if i look across
00:44:35 environment in the uk if i look across any of my ac colleagues these are people i've stood shoulder to shoulder at some of the most challenging incidents you know in in recent uk history so i don't think it's necessarily a question of experience there's something
00:44:47 of experience there's something in the culture of how we have trained officers in the past that i think didn't always best empower them to take decisions outside of policy for example we recognized that discretionary decision making might be
00:44:59 discretionary decision making might be necessary you know it's there in our operational risk assessment policy but i'm afraid we did not train people as to how they might employ it so when you refer to the more confident
00:45:10 so when you refer to the more confident carder of officers at what level of officer were you referring i think i think officers at the most junior level which is what we've begun to address so again i've never had any
00:45:21 to address so again i've never had any face-to-face leadership training in my years in the london fire brigade we are now delivering the largest face-to-face leadership training program in the history of the brigade i think that confidence is not just related to your
00:45:33 confidence is not just related to your operational decision-making but you know your understanding of the moral and ethical dimensions of decision-making as well for example so i think i think it starts at the most junior level because i think the most
00:45:44 junior level because i think the most junior level are the most exposed when they turn up to an incident they're dealing with the most chaotic and dynamic
00:45:50 dynamic elements of an incident therefore they deserve our greatest response you know support they're holding the greatest risk so i think it's that carter of offices and as they move up through the middle layers of leadership actually
00:46:01 middle layers of leadership actually as people become more senior they will generally have done years and years and years of operational response and growing experience and confidence but for you know a 22 year old leading
00:46:12 for you know a 22 year old leading firefighter experiencing their first eight pump fire that's a very challenging experience and it's there where we need to ensure that the right lessons around confident decision making
00:46:23 lessons around confident decision making knowing they have the support of the the organization is embedded let's um let's look at smc 6011 please i'll show you the first page commissioner this is the uh hmi cfrs uh
00:46:36 commissioner this is the uh hmi cfrs uh inspection report for the lfb for the years 2018 to 19 as you can see from the first page there and if we go to page 22
00:46:50 under the heading command about three quarters of the way down the page there's a paragraph that says we were told
00:46:56 were told starts we were told can you see that yes we were told that organizational culture inhibits commanders from using operational discretion incident commanders aren't confident that the brigade would support them in
00:47:08 that the brigade would support them in using operational discretion moreover not all staff feel that the tone of the brigade's post-incident brief debrief meetings which review such decisions supports a learning environment
00:47:19 environment when you gave your article uh your your interview which produced the article in the guardian were you referring to that finding
00:47:27 finding in this report yes you were because i think it's accurate yes
00:47:33 it's right i think then i'd invite you to accept this that operational discretion is a specific operational concept that empowers or perhaps enables commanders to divert
00:47:44 perhaps enables commanders to divert from operational policy if and when the need arises yes with a view to come back into you know the safer framework of recognized policy at the earliest opportunity yeah and was the point that
00:47:56 opportunity yeah and was the point that that you were making or the gist of the point that you were making in the article that it's not so much the policies but the character and the training of the people making incident command decisions that matter yes and i
00:48:07 command decisions that matter yes and i i i would like to emphasize i think we've got the highest quality people in the fire brigade but again i think for multiple reasons a culture developed where there is an element of fear about
00:48:18 where there is an element of fear about taking decisions on the instant ground the the fear that they might be somehow punished in in in debriefs although there actually isn't necessarily a mechanism to do so but a culture of permeated where people felt
00:48:29 culture of permeated where people felt they were under scrutiny um
00:48:33 um which is necessary but but not in a way that was supportive i'd certainly experienced that and i'd seen it i'd seen that fear in instant commanders when i was an ort officer responsible for providing advice guided
00:48:44 responsible for providing advice guided support but also gathering learning and debriefing people it's been there a long time and i think again that the roots of it lie
00:48:54 lie you know good 20 years back through the development of how we assured ourselves that instance the approach we took a site the old-fashioned approach you know slightly sort of clipboard and marking people as it were and although i
00:49:07 marking people as it were and although i think we're a very very long way from that now and i think we've been a long way from it for quite a long time the culture of the brigade is that people stay for a very long time and they have memories of what was as much
00:49:18 they have memories of what was as much as what is um so so i would recognize that our own staff have told the inspector that it would be
00:49:25 would be incoherent not to listen to them would you also agree with this that if officers are not equipped with the relevant knowledge to begin with and to use grenfell as an
00:49:36 to begin with and to use grenfell as an example only knowledge about the risks posed by certain construction materials or modern methods of construction the problem is is more than a lack of confidence it's rather a lack of technical information and expertise
00:49:49 technical information and expertise that that will have
00:49:51 have something to bear on their decision-making obviously if you don't if you don't know why something's going wrong or if you don't understand you know why something is happening you you will not necessarily make effective
00:50:02 will not necessarily make effective decisions around it what i would say though in regards to the grenfell tower fire and i think i'm an example having turned up on the night and recognized very quickly what occurred was that a lot of those
00:50:15 occurred was that a lot of those elements had been given to operational officers and crews we just hadn't joined it all together so turning up you know i knew that there was the
00:50:26 you know i knew that there was the possibility of you know modern modern materials causing fire spread you know i was really aware of lack and all because i'd run select fire station not long after the fire and i'd seen
00:50:38 not long after the fire and i'd seen what happened there you know it was in that borough so i was able to piece that information together quite quickly i think we've quite often given people lots and lots
00:50:50 quite often given people lots and lots of the bits of information they need actually in the london fire brigade but it's about creating the mindset where you think laterally and join them up and i think you can't assume people are just going to do that i think i think again that's where you
00:51:02 i think i think again that's where you need to address training you need to say how do you apply learning from a different context in whatever situation you find yourself in
00:51:13 can i ask when you turned up at the grenfell fire had you seen the presentation which the fire safety department had put together on
00:51:24 safety department had put together on tool building facade fires in other countries no
00:51:29 no i hadn't just wondered whether it would have
00:51:32 have helped you to recognize what was going on all that actually it sounds like you did recognize what i think it's not just me i don't think i'm unique i i you know particularly in rt i work with a lot of experienced officers
00:51:43 work with a lot of experienced officers who would recognize that whether it's cladding facade systems scaffold scrim vertical gardens um you know i mean i had a strange fireplace at
00:51:54 i mean i had a strange fireplace at grenfell where plaster had been sprayed onto um mesh and the fire had spread beneath the plaster you know that was very confusing actually it took us quite
00:52:05 very confusing actually it took us quite a while at the fire to work out what had happened there that was not something again we'd necessarily encountered but was then fed into the modern methods of construction piece um
00:52:15 um i genuinely think that night is an example of what happens when people are in shock and have to make decisions i think many of the elements of the fire were known to officers who arrived at
00:52:26 were known to officers who arrived at the fire but it was their ability under pressure to join that information up and make decisions you know employing lateral thought and actually i had the benefit frankly of turning up a point
00:52:37 benefit frankly of turning up a point where much of this was very very obvious in a way that might not have been so obvious at the start of the fire and i had the benefit because of my seniority of having experienced many other operational incidents
00:52:50 other operational incidents and having a bit of time and space to make the decision because things were already
00:52:54 already happening
00:52:55 happening i guess yes taking the carder of offices that you were referring to so give great respect to not you more junior officers would you accept that you can't expect
00:53:06 would you accept that you can't expect such officers to act with confidence when they lack necessary information that would enable them to understand why a fire is behaving in the way that it is or what it is that is burning and
00:53:17 it is or what it is that is burning and why it's burning the way it is no i would accept that but what i would say
00:53:22 say in kind of caveat to that is if you provide people with the right training they they're they're prepared firstly to take a decision quickly but then reappraise that decision if you
00:53:33 but then reappraise that decision if you know and and they're constantly monitoring so much of decision making is around developing situational awareness so if you apply a strategy at a fire and it's not working even if you've never encountered those
00:53:45 even if you've never encountered those circumstances before and i've found myself in this place in in multiple incidents you reappraise the situation you will change your tactics you need to be inquisitive for me that is equally important because
00:53:57 for me that is equally important because i think the nature of fire is whilst that base knowledge you're absolutely correct just a minute is very important actually the ability to adapt and flex with what you're seeing in front of you because of the very nature of
00:54:09 because of the very nature of fire is equally important well that's helpful and we'll come on to look at a little bit more closely at some of the learning on this um
00:54:20 um now you may have heard or may have read the evidence of professor jose torreira at module 5 in this inquiry you'll you may recall that one of the criticisms he makes of the brigade
00:54:31 criticisms he makes of the brigade and i'm summarizing his evidence say forgive me but is that training within the fire and rescue sector favors what he calls plan execution so carrying out of protocol if you like in accordance
00:54:42 of protocol if you like in accordance with standardized procedures over plan formulation in other words the ability to conduct a dynamic risk assessment to come up with a plan that is specific to the particular circumstances of the incident would you
00:54:54 circumstances of the incident would you agree with that criticism in part
00:54:57 in part which part would you not agree with um i think that's not that the that doesn't represent the you know the entirety of the
00:55:05 the well certainly the lfb's approach and the fire and rescue services approach generally i think fire and rescue services recognize by the nature of being an emergency service that while standard operating procedures are important the ability to deviate from
00:55:18 important the ability to deviate from them
00:55:19 them to to to you know use a a plan formulation approach is is recognized it actually sits at the heart of things like the decision-making model the dcp um
00:55:30 um the kind of process by which you might consider whether a standard operation procedure actually fits at that point and whilst i don't think we supported firefighters enough in the past to
00:55:41 firefighters enough in the past to take those decisions it's clear there is that mindset there because it is referenced and has been for a long time in
00:55:48 in our own policies and procedures and that's mirrored across most of the fire and rescue services in the country so i think he's correct in the um
00:55:58 um traditionally there's been an approach to reliance on sops which i still think is important by the way you need to have people you need to give people boundaries framework the knowledge and understanding you refer to
00:56:10 understanding you refer to but it's how you then use that in decision making i think it's important as fire and rescue services i think we recognize you need to be able to adapt and flex but there's something in the culture that hasn't best enabled that at
00:56:21 culture that hasn't best enabled that at times
00:56:23 times so
00:56:24 so is your point of departure from professor torreira that although you agree with him as a matter of principle you say that the brigade did embed that degree of flexibility and discretionary
00:56:35 degree of flexibility and discretionary command decision-making in its in its procedures and training not enough so it it it certainly considered it you know again what what we learned post lecture is an example of
00:56:46 we learned post lecture is an example of that you know much of the discretionary decision making piece arose from that incident and others so i think that the thought was there the intent was there the execution needed to be in
00:56:57 there the execution needed to be in greater debt now you may remember also that professor torreira considered that at the root of what he regarded as a problem was disregard it's his word disregard within
00:57:08 disregard it's his word disregard within the sector for technical knowledge so knowledge and understanding of building behavior do you agree with him that there is or was a tendency to prioritize practical hands-on
00:57:19 practical hands-on knowledge or experience at the expense of technical knowledge um
00:57:24 um again i think it's a it's a nuanced stance so i think the answer is there is certainly a focus at the more junior levels around the practical aspects of um responding to an instant because we
00:57:35 um responding to an instant because we know from the thousands of incidents the london fire brigade successfully resolves that is a very important part of
00:57:42 of training you know the ability to use kind of recognition primes decision making um you know repetitive practical skills training is really important i mean a prime example you know despite that the tragedy had grown
00:57:54 know despite that the tragedy had grown for was the successful pitching of a 135 ladder by a crew onto the side of the building under enormous pressure that that requires a very important focus on repeated practical training i think it's
00:58:07 repeated practical training i think it's clear to me that we did not do enough however
00:58:10 however to
00:58:11 to expand the knowledge and awareness of firefighters in relation to fire safety in particular and how that relates to operational practice and that again is something we've addressed um with some energy since the
00:58:24 addressed um with some energy since the fire how have you been doing that we've trained every single operational firefighter and officer to the first level of fire safety knowledge and they are now conducting
00:58:36 knowledge and they are now conducting um the first level of fire safety audit out in london so visits to provide advice to businesses and
00:58:44 and and um
00:58:46 and um premises
00:58:47 premises uh something that hadn't been done since you know we lost the g visits or 20 years before because in conducting that exercise one we're more likely to identify
00:58:58 identify some of the risks apparent in london and therefore we can escalate them to more specialist officers if we need to and secondly by upskilling firefighters and officers in fire safety
00:59:09 firefighters and officers in fire safety we know that they will take some of that knowledge into their operational response
00:59:14 response as well
00:59:15 as well and we're not again we're not standing still on that that's that's a start um you know we've currently got about 400 people on from stations on uh level three accredited courses to be
00:59:28 uh level three accredited courses to be fire safety you know the first level of fire safety inspector and i personally think that all officers
00:59:36 officers based on a fire station should be qualified to level three and that's something we will work to get to in the context of investment and capacity to train to at some point so where can you just help us
00:59:47 just help us uh with where you've got to at the moment you say you've got 400 people from stations on level three accredited courses yeah um for 400 out of what how many station-based staff well i
00:59:59 how many station-based staff well i think this really pertains to officers who've got to leave those visits so we've got approximately 1300 station-based officers i would like to see all of them trained to that level
01:00:10 to see all of them trained to that level but that's about their capacity as well to receive a volume of training frankly since um the first phase of this inquiry and inspection that we need to deliver to
01:00:21 inspection that we need to deliver to them so we have to bear in mind the capacity of people on that shift system to
01:00:25 to absorb the training we're giving them the availability of it and making sure that they're not overwhelmed by the pace of change as well so i think it's a position we have to move to over time right
01:00:35 right now uh so you've got 1300 you've done 400 what what term uh level commander are they are they what are they crew manager watch manager or as they watch officers so it'll be it's open to
01:00:47 officers so it'll be it's open to leading firefighters um sub officers and station officers and by exception firefighters as well we have some potential so we're trying to build some strength and depth into the organization both for
01:00:58 and depth into the organization both for the purposes of ensuring better movement between fire safety and um
01:01:05 um operational fire station department so it you know a cross-fertilization of knowledge and experience that we hope to build over years recognizing of course the
01:01:14 the the the tragedy of grenfell has presented great pressure into the market around the available skills of assessors and fire safety inspecting officers because of the very obvious need for them now so we need to
01:01:25 obvious need for them now so we need to we know we need to grow that knowledge and understanding and potential future inspecting officers from every part of the business two further questions on on this particular point how is that training
01:01:36 particular point how is that training being delivered is it cbt or is it a trainer-led teacher-led so the it was teacher-led the first round to all 5000 staff was a half-day then followed by a full day of training that was
01:01:47 full day of training that was teacher-led delivered to every watch and fire station in london the professional programme for accreditation at level three is a mix of face-to-face learning um modules and
01:02:00 um modules and cbt and accredited learning and that's externally accredited so it fits the model of the external accreditation and and is each candidate assessed
01:02:10 assessed yes right yes so you would have to pass the appropriate assessment to hold that level of accredited knowledge and is there a plan for perhaps um already an arrangement in place for refresher
01:02:22 arrangement in place for refresher training
01:02:23 training yes so there'll be refresher training will be part of that as there is for the very base level of fire safety training we've given officers and crews because again i think one of the lessons we
01:02:34 again i think one of the lessons we learned from lacanol and then subsequently for grenfell is that you need to repeat this learning you know it's obvious on a cycle so yes
01:02:44 so yes and i've said there were two questions there's a third inevitably is that is the content of that training peer reviewed by anybody external from the lfb
01:02:54 the lfb um i can't tell you who that is but yes because it is externally accredited and then what i would say is that it will be firstly i we would show it to the inspector
01:03:05 inspector and secondly we would expect our own um independent operational assurance advisor to consider the validity of it as well
01:03:14 as well so i think there are multiple lines of assurance i think we would both present it to the inspectorate for their scrutiny
01:03:20 scrutiny and consideration uh
01:03:22 uh and
01:03:23 and again we've developed this in partnership with colleagues from nfcc so the standard we're working to is the standard that again is
01:03:31 again is understood and has recently been laid out in terms of a competency framework by nfcc so what we're trying to do really is ensure as many people as possible of eyes on it because again i think that's where you get the challenge
01:03:43 think that's where you get the challenge and we would you know make improvement if required thank you
01:03:48 thank you excuse me thank you very much i'd like to ask you next about a second interview you did with the guardian this year and we have that at inq 301508 zero
01:04:01 you can see that the title of this article is head of london fire brigade says it must face up to racism and misogyny and the the date of the article is 19th of
01:04:12 the the date of the article is 19th of march 2021 uh and the we know what the context of this article was it's in the article people can read it i don't need to take you through that
01:04:24 it i don't need to take you through that uh the first two paragraphs of the article read as follows just read with me a culture of casual racism and misogyny remains so prevalent within pockets of the london fire brigade that the head of the service said he feared
01:04:36 the head of the service said he feared his mixed-race daughter might not be treated with dignity and respect at some fire stations this workplace culture may explain the poor progression of women and staff from
01:04:47 poor progression of women and staff from bame backgrounds to senior positions within the service according to andy rowe the london fire brigade commissioner who this week launched a review acknowledging that the brigade has unresolved problems on race and
01:05:00 has unresolved problems on race and gender
01:05:01 gender now first did you say the words or give the interview the gist of the words at least attribute to to you here yes you did
01:05:12 yes you did now the article refers to you having initiated a review as a result of your concerns is that correct yes that's correct so we've commissioned an independent review of culture that's being led by nazir asphalt
01:05:23 being led by nazir asphalt right
01:05:25 right and what is its current status um so he was recently appointed to the chair so i think in the last month he is beginning to consider how he will gather evidence
01:05:35 evidence independently he's bringing his own team together
01:05:38 together and i i would suggest for the next four or so months he will be on you know he'll be undertaking that process of gathering evidence before he returns to how
01:05:49 before he returns to how he might then um either amend the terms of reference of the review or expand it further right you mentioned the terms of reference i don't think we've seen those i'm not complaining about it but are you able to
01:06:00 complaining about it but are you able to give us the gist of the terms of reference yeah they're very broad which is basically to look at every aspect of the london fire brigades culture and every single part of it so it's not focused on fire stations it's focused on
01:06:11 focused on fire stations it's focused on the entire organization from my office to i.t
01:06:15 to i.t you know questions of leadership questions of um relationships with staff empowerment of decision making you know issues around protected
01:06:26 you know issues around protected characteristics such as this article referred to so very broad and you mentioned the answer before last the process of gathering evidence what have you empowered
01:06:37 have you empowered the reviewer to do by way of gathering evidence um he he has complete independent independence to go to any part of the organization he sees contact any member of staff he sees fit to gather that
01:06:49 of staff he sees fit to gather that evidence and create a space where he can do so in a way that encourages them to do that so they feel safe and confident that the information they provide will be held in confidence and used appropriately
01:07:00 appropriately and when do you expect him to report um i i think it would take approximately a year for him to conduct a review and then report shortly afterwards now if we turn please to page two of
01:07:13 now if we turn please to page two of this article you can see four paragraphs done it says this
01:07:18 this ray paid tribute to the kindness and bravery of his colleagues who risk their lives regularly and quotes have reached in to rescue people regardless of background close quotes but he added
01:07:29 background close quotes but he added quotes in my experience the same people might then come back to the fire station and express themselves casually in racist terms in misogynist terms use crude language around faith and
01:07:40 crude language around faith and sexuality
01:07:41 sexuality we're awash with really great people who are really kind and will be there for anyone at their point of crisis but we still have elements of our culture that we need to transparently face up to and unpick
01:07:53 face up to and unpick again did you say the words attributed to you there or give the gist of that yes i did
01:08:00 yes i did now you came up through the station ranks as you've explained earlier in your evidence are you able to give us a concrete example of the kinds of behavior you yourself have seen which still persist yes so i'll give you an example when i when i was a firefighter
01:08:13 example when i when i was a firefighter we attended a a small but very challenging fire in king's cross involving the somali community
01:08:21 community and we'd found great difficulty in accessing the flat because it was friday night prayers the men of the community were at prayer and it was just women
01:08:32 it was just women who were there with their children and who initially were very reluctant to let us through the security gates onto an open
01:08:40 an open balcony and and none of us spoke the language
01:08:43 language um so there were some real challenges in this but
01:08:46 this but we absolutely persisted and the fire fighter i was with was part of the crew and i went into a flat and rescued um a young woman actually and he conducted
01:08:57 young woman actually and he conducted himself without a courage you know he's a good
01:09:00 a good ba
01:09:01 ba partner in that and you know there was no sense of any kind of um different behavior because this was someone from the somali community you know we were both white men we then got back on the truck
01:09:14 men we then got back on the truck and as we were driving off he went you know and i won't use all his language he said god those pakistanis use a vernacular term for that which i i probably wouldn't want to repeat in this setting
01:09:26 repeat in this setting said they uh god they breathe like rabbits i said well i hope so makes i just married one and there's a sort of tumbleweed moment but i think that sort of exemplifies um
01:09:38 but i think that sort of exemplifies um kind of the the reality of this which is i don't think race or misogyny pays any part in our response what i saw that night at grenfell he's not lost on me 85 percent of the people who died in
01:09:49 85 percent of the people who died in that fire were you know londoners from the the black or asian or or other ethnic minorities um but what i saw that night was people
01:10:00 um but what i saw that night was people who put themselves at the most extraordinary risk without question you know
01:10:04 know firefighters carried out operating in conditions where they wouldn't even have known the background of the people they were seeking to save because of visibility etc that characterizes to me the day-to-day response of the london
01:10:16 the day-to-day response of the london fire brigade but what does exist in pockets around the brigade like many other large uniformed organizations are are
01:10:24 are are aspects of our culture and behavior that are not acceptable you know that mean that it is not always a safe and dignified workplace and that's what we need to drive out that's what we need to examine they're the difficult questions we need to
01:10:35 the difficult questions we need to answer i genuinely do not believe it is manifest in our response because at the point of crisis i've never seen that i've only ever seen bravery in endeavour so to be clear are you saying that
01:10:48 are you saying that your observations about discrimination use a broad term are not about service outcomes but about employment conditions broadly yes and and i think that's not just again i
01:11:00 and and i think that's not just again i would like to say that that's why the review of culture is broad this is not about watch culture watches are strong teams and they need to be and we don't want to dismantle that what we want is people to bring
01:11:11 that what we want is people to bring their best selves to work and value each other in the creation of those teams and that actually we need to look at every single part of the organization to examine questions of whether parts of that culture do impact on our
01:11:23 parts of that culture do impact on our relationship with communities do impact on our understanding of risk but in terms of the moment of response i do not believe it is manifest there at all so
01:11:33 so you know of no cases where firefighters would not rescue a member of the public on the grounds of their their sex or gender or their race all responded less well or less speedily to an incident in an ethnically diverse area or a building
01:11:46 an ethnically diverse area or a building occupied by an ethnically diverse occupancy population absolutely not now and actually i would stand for every firefighter officer in the london fire brigade to say i do not believe that is what we do
01:11:57 what we do now let me show you something on the subject of watch culture can you please look at lfb triple zero six zero three five zero and i'm showing you this for two reasons
01:12:10 and i'm showing you this for two reasons uh not least because of your last answer about safety now this is a set of training materials relating to fast survival guidance calls the date that we have for this document
01:12:21 the date that we have for this document from the lfb's disclosure is the 5th of january 2017 and that's the creation date given in the document properties for this document now let's look at page one file
01:12:32 document now let's look at page one file survival guidance and we can scroll through the slides go to go to page two please fsg
01:12:41 fsg and you'll see two images one is a command unit and the other is a pump and the definition of fsg is the i think by now familiar definition from paragraph one of appendix 3
01:12:52 paragraph one of appendix 3 of
01:12:53 of policy 539 at least in its 2011 edition now we go to page 3
01:13:01 page 3 and we see this prompt to check if mark and darren are still awake and the there is a photograph under the redaction not necessary to see the
01:13:12 redaction not necessary to see the individuals concerned that's why they've been redacted can you tell me what the purpose of that slide would be in apparently an educational slide about fire survival guidance i can't and i've never seen
01:13:23 guidance i can't and i've never seen this presentation well i was going to ask you that was my next question uh you've never seen this presentation no uh let's just scroll through it uh
01:13:33 uh five fsg
01:13:35 five fsg two headings information transfer to the incident and then resources and mobilization for fsg calls and you can see it's pretty basic it's a pretty basic outline of training about
01:13:46 pretty basic outline of training about fire survival guidance page five
01:13:50 page five uh three headings recording and sharing of information advice to fire survival guidance callers and and the watch is told control officers will always use the four principles of escape assess protect and
01:14:02 principles of escape assess protect and rescue to provide guidance to fsg callers and that's a fairly pithy summary of um 539
01:14:12 539 and then communication with control which is an equally pithy summary of the contents of policy 790. i think you can take that from me so so far so good slide six please
01:14:23 slide six please fsg examples of messages from control and from the incident ground and i needn't
01:14:30 needn't trouble you with the detail of that uh and then let's have flight slide seven up
01:14:35 seven up a39 blue watch standard night shift and you can see the image uh i'm going to assume commissioner that you've never seen that before no because if i had it
01:14:46 if i had it it would have not been delivered as a training
01:14:49 training package it's highly unacceptable well i was going to ask you that does it exemplify the kinds of attitudes you referred to in your march 2021 guardian interview
01:14:59 interview i think it it demonstrates a lack of thought about our responsibilities in in regard of how we portray ourselves how we treat each other about how we understand
01:15:10 other about how we understand um
01:15:12 um you know
01:15:13 you know that how we must make people feel included and valued within an organization because obviously if you're a woman
01:15:20 a woman um
01:15:21 um encountering this training particularly i would imagine you you would not feel comfortable you would not feel included you would not feel that that actually
01:15:32 that that actually this was a a
01:15:35 a kind of a picture that demonstrated any sort of regard to value or dignity in january 2017 did the brigade have an equality diversity and inclusivity or
01:15:46 equality diversity and inclusivity or edi policy do you think um we did have policies in relation to that but again if we speak to the change that's happened i took over as commissioner in january 2020 at that
01:15:57 commissioner in january 2020 at that point we didn't have a fully established cultural change team we do now we didn't have a fully established well we didn't have a community engagement team we're not talking about
01:16:08 engagement team we're not talking about community advice here we're talking about people are going to do the hard miles and answer difficult questions from communities search out those people who are less comfortable with us and seek to promote understanding and partnership you know so there's two
01:16:20 partnership you know so there's two examples of how we just didn't even have the people in place to address some of this so i've got no doubt we had the policies
01:16:26 policies but there had been a decision taken many years earlier to remove the equalities unit that had previously advised the commissioner then ron dobson um that that unit was removed it was
01:16:39 um that that unit was removed it was part of the cost savings that were brought to bear over a number of years i would argue that an organization our size needs a dedicated team focused on organizational development cultural
01:16:50 organizational development cultural change and ensuring that it acts as a conscious uh around our very real legal duties in
01:16:57 duties in in
01:16:58 in relation to the you know the equalities act and other bits of legislation that we are duty-bound and rightfully so as an organization to adhere to can you just tell me when the decision had been taken to remove the equalities
01:17:09 had been taken to remove the equalities unit that had advised ron dobson i'm afraid i couldn't i just remember it was a decision that was made clear to us um following a top managers conference many years ago when i was first a station commander
01:17:20 station commander maybe in 2010 2011. it had not existed for many many years
01:17:27 and what steps are you taking at station level today to eradicate the attitudes that have given rise to the to this picture well both in terms of asking the
01:17:38 picture well both in terms of asking the difficult questions no one wants to that that's what the independent review of culture is this will not be necessarily a comfortable process for the london fire brigade but it's important to do and we've got to face it head on and then answer those
01:17:49 face it head on and then answer those questions and then rather than waiting for the results we are engaged on a program of mass education so you know as we speak cultural awareness workshops are taking place on fire
01:18:00 workshops are taking place on fire stations and not you know what i think has been in the past a kind of tired model of explaining you know religious faith or difference but actually real conversations
01:18:11 conversations the best support what i think are on the whole dedicated public servants to kind of challenge their own behaviors think about where they've come from you know understand the tension between different generations really recognize the
01:18:22 generations really recognize the communities they serve so that's that's happening now and it is aligned directly with the leadership program which must be inextricably linked to it because values and behaviors have to sit at the heart of leadership and that relates
01:18:33 heart of leadership and that relates directly of course to these questions as well
01:18:37 as well there i said there were two aspects to this uh are you able to tell us why this kind of image was prepared for a presentation to firefighters presumably a39 blue watch
01:18:48 a39 blue watch at all
01:18:49 at all let alone as part of an nfb training package
01:18:53 package let alone alone a training package on fsg calls of all things
01:18:59 things no i i think it speaks to an unthinking culture i doubt the person who did this thought they were doing any harm but it's more than i'm thinking isn't it commissioner would you agree with that quite apart from the offensive signifier
01:19:11 quite apart from the offensive signifier of unacceptable attitudes it belittles and trivializes fire survival guidance and the control rooms work and so tends to undermine public safety um i don't know if i can extrapolate as
01:19:23 um i don't know if i can extrapolate as much as that from it all i know is it is a wholly inappropriate image that i would not expect um to be delivered as part of a professional training package what it speaks to in greater part to me is a
01:19:34 speaks to in greater part to me is a lack of
01:19:34 lack of professional um kind of delivery of training that that's of a greater concern to me i think it's a poor attempt at humor i would imagine and it's been done in an
01:19:46 i would imagine and it's been done in an unthinking way and actually that speaks somewhat to the heart of the issues i hope we are addressing which is you know let me speak plainly i'm a south london lad you know i've come up and through boxing clubs the army
01:19:58 boxing clubs the army um you know the fire brigade i i have worked with a lot of really decent people who did not hold politically correct views who were can i put it rough around the edges given the
01:20:09 rough around the edges given the opportunity to have a conversation and receive some good education those people very often shifted their views and their behaviors because they were inherently decent people but we just have not offered them
01:20:22 people but we just have not offered them the benefit of that education for many many many years so as much as you know i recognize this is wholly unacceptable i do not think we have best served and supported firefighters in the past to actually
01:20:34 firefighters in the past to actually help people understand why although you think that's funny and if you're in a group of men together who've served together for 15 years it might feel acceptable actually if you're someone new coming onto that watch or into a
01:20:45 new coming onto that watch or into a team in headquarters it may not feel like that it's about that process of education to make people really understand what inclusion means you know it's all very well diversifying an organization but people have got to feel
01:20:56 organization but people have got to feel included and valued when they arrive my experience of firefighters so that guardian article to be frank is one of the single most contentious things i've done as a commissioner i visit fire stations a lot
01:21:08 commissioner i visit fire stations a lot and it is invariably the first subject that
01:21:11 that arises and we very often have a long and detailed conversation about it with people who feel very uncomfortable about what i've said but by the end of the conversation recognize that there's a truth to it that there needs to be a
01:21:22 truth to it that there needs to be a balance in these things and that they need to come on that journey with us if we want to be a fire service that really serves
01:21:30 serves you know all the many communities of this extraordinary city
01:21:35 and going back to the point about fire survival guidance would you accept that perhaps
01:21:40 perhaps of equal importance is the need to make sure that frontline firefighters understand the importance of far survival guidance as a function um can i just say that i don't think you can extrapolate that meaning from
01:21:52 meaning from this slide because actually my experience again having experienced fire survival guidance calls in an operational setting as a firefighter and then officer is that it's the it's when you get that on the cool slip
01:22:05 it's when you get that on the cool slip you you are racing to get there quicker i think firefighters and officers take fire survival guidance very very seriously because
01:22:14 because they know that people could potentially die if we don't get there quickly enough and make the right intervention so i don't think it's a question of colleagues not taking fire survival guidance seriously what i think it speaks to
01:22:26 speaks to is is a lack of good behavior and appropriate standards when delivering training and and says something about kind of the professional approach to training that i would expect
01:22:37 training that i would expect as a baseline standard which clearly that does not represent yeah convenient moments mr chairman well we said we'd have a break during the afternoon commissioner and we'll have it now uh we'll come back and
01:22:49 have it now uh we'll come back and continue please at 20 to 4 and i have to ask you as i have all the other witnesses please don't discuss your evidence or anything relating to it with anyone while they're out of the room
01:23:00 room all right thank you sir thank you very much would you like to go to the auction thank you
01:23:15 thank you 24 please
01:23:26 so
01:43:08 ah would you ask the commissioner to come back in please thank you
01:43:21 all right commissioner all ready to carry on i am good thank you very much yes thank you mr chairman um commissioner what i'm going to do next is ask you about some of the aspects of the material that has emerged through
01:43:33 the material that has emerged through the inquiry in module 5 and the first part of module 6. and we're very interested in your um take as it were on specific points and how they have come to pass and what the lfb is going to do about it or is doing
01:43:45 lfb is going to do about it or is doing about it now and the first topic is translation of knowledge of risks of cladding into operational practice
01:43:54 now first lachnal can we go to please to lfb double
01:43:59 double zero one two three two six three
01:44:04 and fb double zero one two three two six three
01:44:08 three uh this is the module six written opening statement provided uh by you or at least on your behalf uh
01:44:16 uh to the inquiry a few weeks ago take a moment to look at the first page and we can look at much more of it if you like but um did you read it do you think before it was filed with the inquiry yes
01:44:27 before it was filed with the inquiry yes definitely you did yes good can we go to page two please paragraph four um from the top line on page two
01:44:36 where it says uh
01:44:40 uh the nfc respectfully suggests that caution must be exercised before concluding that all previous incidents presented learning opportunities relevant to grenfell tower which were missed
01:44:51 missed and then you may you give an example of maddingly house and then you go on while it is fully accepted by the lfc that there were multiple lessons from the latino house fire that had to be learned and acted upon the most significant issue and learning point in
01:45:03 significant issue and learning point in terms of fast spread was the internal compartmentation failure of the building the nature and extent of the external flame spread over the exterior surface of the building was not in not itself unusual although spandrel panels caused
01:45:15 unusual although spandrel panels caused secondary fires on level floors by reason of melting material falling into open windows can you explain whether that text means that this is how the learning points arising from the
01:45:26 the learning points arising from the lack of fire were perceived internally yes i think that the greatest focus was on the failure of internal compartmentation how the complex layout of the building had hampered
01:45:38 of the building had hampered operational firefighters um response you know it was what was known as a scissor block um
01:45:45 block um and that the exterior fire spread had been caused really by the failure of upvc units so they were the major learning points with some acceptance the external fire spread
01:45:57 some acceptance the external fire spread had occurred through a number of different methods including some some by the spandrel panels does that tell us that for the lfb at the time the fire had primarily highlighted risks around
01:46:09 highlighted risks around compartmentation failure but not so much or perhaps not at all in relation to combustible facade panels uh i think the emphasis wasn't on combustible facade panels but what the
01:46:20 combustible facade panels but what the the big summary lesson that we took away from lacking was the buildings might behave in a way you didn't expect when you first encountered them and that you couldn't rely um in totality
01:46:32 um in totality that that building would operate safely as it was intended to within within the context of a regulatory regime
01:46:40 regime so
01:46:41 so just i'm picking that answer the big lesson
01:46:44 lesson could one put that a different way namely that the assumption that the building complied with the building regulations was an unsound assumption yes you couldn't you couldn't rely on
01:46:55 yes you couldn't you couldn't rely on totality on that that whilst there's a fire and rescue service you you know the national framework itself says that fire and rescue services should only reasonably plan um their their use of resources and their focus of training on
01:47:07 their focus of training on on matters that sit within the regulatory frameworks because that's a you know an appropriate use of public resource
01:47:14 resource but obviously a separate duty of a fire rescue service is to recognize that their very existence is because parts of those regulatory regimes might fail and lack and all showed us that yes it
01:47:25 lack and all showed us that yes it showed us that in some part you could not rely on totality on either constructors those who manage buildings nor inspectors to do their job entirely competently otherwise we wouldn't have
01:47:36 competently otherwise we wouldn't have taken the kind of level of legal action we then took against southwark council yes
01:47:42 yes um coming
01:47:43 um coming back to the point a slightly different way of looking at it um looking back at lac and the learning uh directed at it was latin regarded as a compartmentation incident
01:47:55 compartmentation incident uh rather than a combustible facade incident
01:47:59 incident i can speak into in in two parts one because as commissioner i think it's my job to look back and try and understand what happened in the past so that perhaps we we we you know we improve in a different way in the future
01:48:10 in the future and then from my own personal experience as a station commander at the time so as a station commander at the time the way i experienced the lacanal house case study actually the learning from local
01:48:21 study actually the learning from local colleagues because i was a station commander in southwark at the time was that this was not just about internal compartmentation that what that case study showed me was that buildings could begin to fail in ways that were
01:48:33 begin to fail in ways that were unexpected and then if you had a complex layout you would have to think very very carefully about how you both got to residents and maintained the safety of firefighters i think it taught us lessons about the volume of fire
01:48:45 lessons about the volume of fire survival guidance that might come in and how we might deal with that and indeed we saw developments in policy procedures and equipment available firefighters that recognized that so i think it was much bigger than just a focus on internal
01:48:57 just a focus on internal compartmentation there was a sense it was a
01:49:01 was a it was a very significant fire from under fire brigade it sent a shock through the brigade you know there would not be an officer or firefighter that wasn't aware of it because of the scale of loss of life and what looked like um
01:49:13 and what looked like um you know uh a really challenging failure of a building so it's more the takeaway was more that the kind of multiple aspects of failure actually
01:49:22 actually in the last sentence i've just read to you
01:49:25 you which starts the nature and extent of the external flame spread was not in itself unusual etcetera is it the case that
01:49:33 that this was the perceived extent of the fire risk posed by the facade panels at lachnal in other words was it the was the learning point that the lfb took from the fire um was that it was external fast bread
01:49:47 um was that it was external fast bread and no more than an awareness of the risk that a facade fat panel may catch light and cause fires on lower floors i think it's a combination of all of those things what i took away from it and having looked back at what was
01:49:59 having looked back at what was presented then to our operational crews and officers it chimes with what i experienced which was this show that you could have elements of a building that might fail for example the window
01:50:11 that might fail for example the window frames and contribute to external fire spread but there were panel materials used in buildings that could contribute to fire spread although not in a way that we subsequently have understood
01:50:23 understood you know post-grim form and that that combined with poor management of a building so very poor renovation work would meant that it was it was riven with voids and that the
01:50:34 it was riven with voids and that the combination of external and internal fire spread would represent a really serious challenge i think that was how i certainly experienced it at the time and understood it that you there could be an
01:50:45 understood it that you there could be an element of external fire spread that there could be an element of really significant failure of internal compartmentation i remember talking about it with colleagues and and thinking about what were the sorts of things that might cause
01:50:57 sorts of things that might cause internal compartmentation failure for example so poorly run replacement utilities um you know the wrong approach to cabling um lack of
01:51:10 wrong approach to cabling um lack of internal fire barriers um so we talked about it in that way but it was also one of the first times i think i'd heard such a direct reference for example to the possibility of upvc frames failing
01:51:22 the possibility of upvc frames failing on a scale and contributing to external fire spread as well so i think it i think it brought a lot of learning into the operational environment can i ask you please to look at
01:51:33 can i ask you please to look at lfb00104291
01:51:39 now this is a letter of the 14th of december 2009 from the lfb to ken knight i should ask you first are you familiar with this letter
01:51:50 with this letter um i'm i'm not familiar with it other than it may well have been in one of my bundles
01:51:55 bundles for this but there's about four thousand pages in there so i can't quite remember whether i've read this one or not okay um let's look at the key parts of it the first paragraph says this dear sir ken i'm writing to
01:52:06 says this dear sir ken i'm writing to inform you that as part of our investigation into the fire at laknell house go garden southwark on 3rd july 2009 we have had tests carried out on the exterior wall panels of the building
01:52:17 the exterior wall panels of the building and that those tests have given rise to concerns which may well be relevant to other high-rise premises although our investigations are continuing and the matter has still to come before the coroner i feel that it
01:52:28 come before the coroner i feel that it is in the public interest to draw the issue to your attention say that the matter can be discussed within the department and any necessary advice can be given to owners and landlords of high-rise buildings
01:52:39 high-rise buildings now if we skip then down to the third and fourth paragraphs uh on page one we can see that mr dobson set out the functional requirements of adb
01:52:50 out the functional requirements of adb uh
01:52:51 uh and
01:52:52 and um the building regulations section b4 of the building regulations and then on page two third and fourth and fifth paragraphs down you'll see he said this
01:53:02 said this based on the tests conducted by the building research establishment it appears that there are external wall panels at latino house that do not have the necessary reaction to fire properties required for the location in
01:53:13 properties required for the location in which they have been used we have also become aware that this type of panel has been supplied by more than one company in the circumstances we believe it may be appropriate for a warning to be given to housing providers that it would be
01:53:25 to housing providers that it would be advisable to check the specification for external wall panels in their high-rise housing stock and check that what has been installed meets the correct specification i.e that fire safety
01:53:36 specification i.e that fire safety requirements of the building regulations we've taken into account and to include this in fire risk assessments for relevant properties now um would you agree with me that this letter shows that in an early stage of
01:53:48 letter shows that in an early stage of the lfb's post latino investigations the lfb was aware that external fire spread had been facilitated at least in part at la canal by non-compliant panels on the
01:53:59 la canal by non-compliant panels on the outside of the building yes absolutely i think the letter is clear in that and that those panels having been supplied by more than one company created a situation unlikely to be
01:54:11 created a situation unlikely to be confined to latino house yes
01:54:14 yes and and so serious was the problem that the then commissioner thought it proper to ask the government to step in and warn housing providers to check the specification for external wall panels in their high-rise stock and make sure
01:54:26 in their high-rise stock and make sure it was compliant with the building regulations and approved document b yes i think it's absolutely clear in that it's now i i put you really an interpretation of that letter the next question is is that warning and the
01:54:37 question is is that warning and the content of that warning something that you but you were aware of at any time up to the lack of up to the grenfell tower fire
01:54:44 fire not in that level of detail no right so certainly that there was a possibility of external fire spreading the way we saw at la canal because that did indeed form part of the case study and the learning that arose from it and that i
01:54:55 learning that arose from it and that i had received but not not in the way that it is articulated in that letter right even the sense of what is articulated in that in this letter was that something that you had a sense of from the time of the latin house fire given what you knew
01:55:07 the latin house fire given what you knew about it
01:55:08 about it not to that level of detail i mean my own professional interests have meant that i was aware that there had been cladding fires in the news for example in dubai and other places and i'd
01:55:19 in dubai and other places and i'd certainly encountered fires where all sorts of different materials had contributed to some form of external fire spread i actually i think it's disingenuous to pretend that that was something that the
01:55:30 pretend that that was something that the london fire brigade hadn't previously encountered in lots of different settings
01:55:34 settings but
01:55:34 but not not
01:55:36 not not obviously on the scale we saw at grenfell
01:55:39 grenfell and not
01:55:40 and not articulated in the way that is laid out in this letter
01:55:46 right can we go back then to the written opening which we looked at a moment ago lfb double zero one two three six one two one one two three two six three paragraph
01:55:58 three paragraph four on page two um where in the last three lines you say uh the extent the nature and extent of the external flame spread over the exterior surface of the building was not
01:56:10 exterior surface of the building was not itself unusual doesn't the fact that the exterior panels were subsequently found not to be compliant with the building regulations make the nature of the flame spread at least unusual
01:56:22 least unusual um
01:56:24 um i don't think it means that it was necessarily unusual because as i said i think it would be disingenuous to say that we hadn't experienced some form of external fire spread in other situations before and actually if you look at the
01:56:35 before and actually if you look at the lack of house fire even the photos post fire you'll see that whilst there is external fire spread it but the greater issue and you know i i
01:56:44 i i'd seen the inside of the block it was the internal failure of compartmentation it was a complete burnout on the levels involved
01:56:54 involved so i'm not sure that it represented something wholly unusual but it is of interest to me that that letter existed in 2009
01:57:03 in 2009 speaking
01:57:04 speaking to the concerns of the then commissioner um
01:57:09 um as to what might have been an industry wide issue that could contribute to you know
01:57:15 you know other fires and significant external fire spread yes
01:57:22 now it i don't think the opening statement refers to the fact that after latin or the lfb had as we can see and i suggest from this letter identified that the spanish panels had caught fire
01:57:33 panels had caught fire but and were not compliant uh
01:57:37 uh all the fact that the brigade was sufficiently concerned about it to write to the then cfra
01:57:42 cfra uh ken knight um is it right do you accept sitting there today that the latino house fire presented a learning opportunity not just in relation to internal
01:57:54 not just in relation to internal compartmentation but critically in relation to the concerns that the lfb clearly had at the time about non-compliant combustible materials on use on the exterior of buildings across
01:58:06 use on the exterior of buildings across london i think in light of that letter i would accept that because it's very clear in the way it is written that that was a risk that had been considered at that
01:58:15 that point
01:58:16 point are you able from what you now know sitting here today why the risk identified in ron dobson's letter of the 14th of december 2009 to sir ken knight
01:58:28 sir ken knight appears tell me if this is wrong appears not to have been fed through to frontline staff after lachenal i think it goes back to a point i made earlier which is we had an effective fire safety department that was actually
01:58:40 fire safety department that was actually quite good at identifying risks recognizing challenges in the built environment but they were not integrated fully enough into the operational delivery of the london fire
01:58:51 operational delivery of the london fire brigade i'm afraid i think they at times acted in a silo and actually much of my effort over the past two years on my officers has been to ensure that we integrate and you know we have an
01:59:03 we integrate and you know we have an integrated understanding of what delivery means because i see our fire safety inspectors our school teams our control officers even our digital officers
01:59:14 officers even our digital officers and our firefighters as being on the front line because they are all interfacing with the public on a daily basis and therefore they all hold pieces of information that help us bring build a composite
01:59:25 that help us bring build a composite understanding of risk in the capital and therefore they all need to have the same knowledge as the other party has and that's really what we've been engaged in trying to put in place those systems is systems and processes
01:59:37 systems is systems and processes that drive that commonality of understanding and sharing of knowledge
01:59:43 knowledge now
01:59:45 now i i posed you a question it might be said well what about the latino case study uh and i will look at that in a moment but before we do um i want to show you what the lfbs
01:59:56 um i want to show you what the lfbs lfb's lachnal assurance report said and you'll remember that that report was produced on the 7th of august 2018 in the middle of phase one of this inquiry can we go to that it's at lfb
02:00:08 can we go to that it's at lfb quadruple zero four eight zero one you could see the front page there on your screen commissioner yeah and if we go to page 29 in the document we can see action 3c
02:00:19 action 3c on the right hand side introduce a case study training package incorporating learning outcomes from inquests
02:00:29 and that arises out of the coroner's third recommendation which is set out on the previous page page 28 if we go back to that
02:00:37 that in the middle of the right-hand column there's the recommendation number three relating to incident commanders and in summary it relates to the training of incident commanders in specific matters that were identified by
02:00:48 specific matters that were identified by the coroner as learning points from the incident and if you look down the list of bullet points you can see the third bullet point there which says to anticipate that a fire might behave in a manner inconsistent with the
02:00:59 manner inconsistent with the compartmentation principle now if we get back to page 29 and action 3c there we can see that the assurance review continues
02:01:10 assurance review continues uh as under the red text in smaller black text a computer-based training cbt solution the latino house case study was developed to cover the learning outcomes from the latin house inquests to
02:01:21 from the latin house inquests to specified learning outcomes for the case study incorporated both the coroner's recommendations above and the relevant training recommendations from the brigades operational review report all watches completed the case study
02:01:33 watches completed the case study training package as station-based training senior officers were identified where i were invited to attend one of a series of lack of house training presentations where the case study was delivered by a senior officer who had
02:01:44 delivered by a senior officer who had been closely involved in the latin house investigation now to be clear i think it's right isn't it that you had no personal involvement in the development or the implementation of the latino house case study no not at
02:01:57 of the latino house case study no not at all
02:01:58 all you were i think an operational officer in 2009
02:02:01 in 2009 um did you undertake the study yourself do you remember yes i remember it i remember receiving it i just couldn't tell you where or who delivered it but i do remember it because i remember it as some learning that
02:02:14 as some learning that i thought was really significant you know
02:02:17 you know again it might have been particularly because i was serving in southwark at the time and i had um close contact um frequently with watch officers who'd attended the fire at a guy called chris payton
02:02:28 payton um who who was a watch officer working to me who had been profoundly affected by the fire you know was was really interested in seeing how the brigade was going to change as a result you know we had a personal interest we used to talk about it quite
02:02:39 interest we used to talk about it quite a lot and another chat called matt rosendale who was a watch officer on the green watch at brixton at the time i think who again had a real personal interest and attended the fire i believe um so it was the subject of discussion
02:02:52 um so it was the subject of discussion we talked about it quite a lot in the borough right the packages just for your chronological interests were rolled up to
02:02:59 to station-based staff and senior officers in august 2014. we've seen those already with
02:03:07 with former commissioner danny cotton and also
02:03:09 also gary reason who was the then director of operations resilience and training and i don't need to go back over that ground with you unless of course there's anything you'd like me to show you in it
02:03:20 anything you'd like me to show you in it what i do want to do is ask you about the absence from that package of reference to external panels or facade fires or indeed fire behavior that is inconsistent with the compartmentation
02:03:31 inconsistent with the compartmentation principle
02:03:33 principle including rapid internal fire and smoke spread beyond the compartment of origin now we asked annie cotton about the gaps in the package and although she didn't have specific knowledge of uh of the package or involvement in his
02:03:46 uh of the package or involvement in his development she did accept that the team that developed the package should have used the exercise as a better opportunity to explore the issues i've just referred to
02:03:57 i've just referred to she did that at day 109 page 37 lines 10 to 15 that's for our reference um now there's a long question i'm afraid do you agree with what i've put to you principally that that the team that developed it should have used the
02:04:09 that developed it should have used the exercise as an opportunity better to explore
02:04:12 explore the the areas where there are gaps because i can't recall in entirety that the package i can i can't see it in in my head now i think it's difficult to speak to all
02:04:23 i think it's difficult to speak to all of the detail but the letter you showed me previously you know demonstrates that we knew about a risk in relation to external cladding that i would have expected to be reflected if one part of the
02:04:34 reflected if one part of the organization had known about it in that training package so it may not be this may be another example of not so much the the team that put the package together but the fact that we had not
02:04:45 together but the fact that we had not made all the information available to that team that would be my suspicion at that point and that would have been a missed opportunity yes
02:04:56 opportunity yes so does it come as a surprise to you as a matter of dismay to you the training package developed after lachenal the case study ostensibly as a means of addressing the learning points arising out of that
02:05:08 learning points arising out of that incident omitted entirely any mention of the key features of that fire i've i've described
02:05:13 described and without looking at the case without looking at the course notes that sit underneath whatever slides the presentation um i mean perhaps it might be worth taking you to that would that be
02:05:24 taking you to that would that be possible it would be possible um but we could do that um i mean we've got the notes the only reason i asked mr miller is because i i think it's difficult for me because i was based in southwark i remember the
02:05:36 was based in southwark i remember the fire i remember the fire having a profound
02:05:39 profound impact on the brigade and i remember what i took from the fire right um
02:05:44 um well let's try that yeah so what i took from the fire was that buildings might react in a way you did not expect that you almost certainly could experience unexpected failure of
02:05:56 experience unexpected failure of internal compartmentation that you shouldn't take as read when you turned up at a block that what you thought the layout might be would be the layout there's a lot of um focus on the layout of the block scissor
02:06:08 focus on the layout of the block scissor blocks where you might mean you know have to make access at a higher point to get to a lower point the the the truck the effects of traveling smoke and combustion um these are the things i remember from
02:06:20 um these are the things i remember from it and i remember the pictures in the powerpoint and thinking that looks like a really unusual fire spread as well you know sort of diagonal not vertical you know it was unexpected
02:06:32 not vertical you know it was unexpected so
02:06:33 so what what i took from that presentation was that buildings might not behave the way you you thought they might that you couldn't rely on on the construction to act as it
02:06:45 rely on on the construction to act as it should have done that you had to be very aware of complex layouts when you were committing firefighters into an incident involving
02:06:53 involving you know a residential block of that kind
02:06:56 kind um and and actually i do remember particularly the issue of the windows for some reason so these are the things that these are the things that i remember in particular yes and let's see if we can get this in a
02:07:07 and let's see if we can get this in a slightly different way because i'm not going to cover the same ground we've covered with other senior witnesses um
02:07:13 um do you accept this proposition that the latino case study should have addressed uh the failure of compartmentation on a widespread scale and the question of
02:07:24 widespread scale and the question of external fire spread yes yes yeah indisputably because they were both critical factors in that fire and if we knew about it in one part of the organization and hadn't shared the
02:07:36 the organization and hadn't shared the full detail of that and that wasn't expressed
02:07:38 expressed in the presentation that that itself was a missed opportunity yes and would you also agree that if it if it omitted any reference to the fact that there had been fire spread as a result of non-compliant facade panels
02:07:51 a result of non-compliant facade panels that was also a failure to learn a lesson
02:07:54 lesson yes absolutely can i then turn to uh gra 3.2 and policy 633 and cladding um
02:08:06 now we've heard at some length from earlier witnesses in this module namely peter cowep and pat utting patrick utting
02:08:15 utting about the process by which both gra 3.2 and policy 633 were developed and drafted in the period 2010 to 14 for gra 3.2 and 2013 to 15 i think for policy 633
02:08:29 2013 to 15 i think for policy 633 i'm not going to ask you about specific drafting points commissioner i have a more basic question and it's this do you agree that bearing in mind the lfb's own
02:08:40 that bearing in mind the lfb's own latino investigations and the findings in relation to panels as we saw communicated by commissioner ron dobson to sir knight in the december 2009 letter we've just
02:08:52 the december 2009 letter we've just looked at
02:08:53 looked at the risk of cladding fires was a matter that should have been identified by the brigade both in its own work on the revision of gre 3.2 and
02:09:04 own work on the revision of gre 3.2 and its amendment of its own high-rise firefighting policy 633 yes because it was clear that that that was a risk factor and it should have been
02:09:12 been included within the risk assessment that underpinned the the gra now we we've seen from earlier versions of gre 3.2 particularly the 2008 version
02:09:23 of gre 3.2 particularly the 2008 version which was the edition immediately before that of february 2014 the cladding risks of cladding were referred to in that building as a as something that may
02:09:35 that building as a as something that may promote abnormal or rapid fire spread um do you know why cladding had been identified in the national guidance the gra as far back as 2008
02:09:47 guidance the gra as far back as 2008 do i know why yes no i don't i was i wasn't part of that process
02:09:53 process did you know at any time before june 2017 that that
02:09:59 that uh one reason why cladding systems were referred to was because there had been a pre-existing history of clouding fires in the united kingdom uh
02:10:08 uh notably perhaps most notably uh the nasally heights fire in 1991 and the fire at garnet court in 1999. so i was aware of garnet call not the not the other fire you just referred to
02:10:21 not the other fire you just referred to i was certainly aware that there but again it's hard sometimes to separate out your own professional interests from what you've been told over a very long career i certainly wasn't aware
02:10:32 i certainly wasn't aware um
02:10:33 um until later years that that was referenced within the national gra right
02:10:39 right now nobody i say nobody neither mr carp nor mr artie were able to explain in any detail at least how or why lfbs policy 633 omitted any reference to
02:10:50 policy 633 omitted any reference to clatting notwithstanding the express reference
02:10:53 reference as we saw in the at least the february 2014 version of gre 3.2 are you able to explain uh how it came about that the lfb simply
02:11:04 uh how it came about that the lfb simply hadn't
02:11:05 hadn't grasped despite lachenal the fact that cladding was a known risk and needed to be addressed in policy and training that narcan and clearly it shouldn't have been omitted from our own policy
02:11:23 uh now i think from an exchange you had with the chairman earlier you would you would also accept that the risk of cladding systems uh
02:11:31 uh uh imposing a risk of rapid an abnormal fire spread was something that had was on ron dobson's radar but also from the fire safety department's perspective given
02:11:42 safety department's perspective given the existence by at least july 2016 of the tall buildings facade slideshow yes i would accept that it was known in various parts of the organization even
02:11:53 various parts of the organization even if it hadn't been communicated effectively to the front line yes and you i think you've already covered this a little bit but do you accept that well do you have any insight into why it was or how it came about but the knowledge
02:12:05 or how it came about but the knowledge about those matters held in certain parts of the brigade hadn't filtered through to the departments responsible for the development of guidance and policy following lachenal i think if i think
02:12:17 following lachenal i think if i think about it in the context of my role now and what we've changed i i think a lot of this falls to the governance we had in place so for example individual directorate boards
02:12:29 example individual directorate boards that that sat as a director of board you know almost in a silo whereas now we have cross-cutting boards that involve all directors for example i think
02:12:40 i think processes that need to be explicitly in place to gather information from every single part of the organization and a team dedicated to do so so i think much of this is about system and governance and just being
02:12:52 system and governance and just being clear that if we are going to continue to be a learning organisation as we aspire to be that we continue to improve we have to explicitly put in place frameworks
02:13:04 put in place frameworks and processes that enable that information to be lifted from different parts of the organization communicated as a matter of course right so let's just break that up a bit um cross cross-cutting boards it's
02:13:16 cross cross-cutting boards it's something you refer to in your answer what is that so for example um when i took the london fire brigade over in january 2020 we had um
02:13:27 um boards that sat chaired by the individual director with their heads of service
02:13:34 service that related only to the business within that directorate so whether that was operations or corporate services and where we've gone to now is a place
02:13:45 and where we've gone to now is a place where we have generic cross-cutting boards and as exists in lots of other organizations like the nhs or local authorities so for example we have a people board which deals with all matters related to hr
02:13:56 deals with all matters related to hr people development of our people health and safety all directors sit on that and all the relevant heads of service who need to bring forward decisions into that environment will come to that board it means that directors have to
02:14:09 means that directors have to share information from inside their own directorates with other directors and be challenged before they arrive at a recommendation for decision to bring to me by establishing um
02:14:21 to me by establishing um a research and development function at the moment is purely focused on operational risk but is actually likely to expand
02:14:30 to expand that that team's job is to proactively search
02:14:35 search in those departments most likely to hold the information information around emerging risk and then bring it in to the operations board for example which again involves all the directors
02:14:46 which again involves all the directors sitting on it and and hearing to matters of risk and therefore what mitigation we might bring to bear on him right so i can understand that better i mean take the example of the risk of
02:14:58 take the example of the risk of rapid and
02:14:59 rapid and abnormal fast bread presented by modern methods of construction materials cladding
02:15:06 cladding where would that question sit who would address that using your crop your cross-cutting board system depends where it wrote i mean this is the point so i think it falls ultimately to the director of operations to take
02:15:18 to the director of operations to take that responsibility because that individual has the span of the operational information gathering you know available to them so if it arose in fire safety i would expect as a
02:15:30 arose in fire safety i would expect as a matter of course the individual running fire safety to make that identification of a new risk um
02:15:37 um clear to their directory to be considered as part of the risk management process we've now got in place so we now have a detailed risk management process in place that that move you know that
02:15:49 place that that move you know that ranges from an understanding of tactical risk up to the strategic uh and i would expect it to be exposed through the application of that risk management process across all areas of
02:16:00 management process across all areas of the business and if we're talking specifically about operations if i'm the head of fire safety you know and a good example would be the
02:16:10 the growing understanding of the risk around battery technology so we're starting to see
02:16:14 see fires involving electric scooters which are presenting a risk on the london underground you know quite
02:16:19 quite a specific risk but that has been identified through um
02:16:26 um post-fire analysis as to the cause of the fire it's been escalated within the fire safety department is now recorded on their departmental risk register because you can see that this is a bit
02:16:37 because you can see that this is a bit of technology that's expanding at a rate of knots
02:16:40 of knots there's now been that's now been brought into the directorate board to then ask back down the other way well colleagues in operational policy are you aware of this what are we doing have we even got
02:16:51 this what are we doing have we even got the capacity to start to plan procedural change is there an immediate safety note that needs to go out for example so it's i think it's all about joining up the different bits of information i think
02:17:02 different bits of information i think that's perhaps um
02:17:05 um where the the greatest kind of change can be bought to ensure that we don't find ourselves in a position where i'm looking at a letter from 2009 that reasonably should have
02:17:16 2009 that reasonably should have informed the presentation we gave operational crews and officers yes it's helpful i mean we've been able to put together a number of structure charts which may or may not be correct in the
02:17:27 which may or may not be correct in the course of our investigations which i'm not going to share with you um but presumably you would be in the position would you at the end of this module when your council closes uh to be able to provide us with a detailed structure
02:17:39 provide us with a detailed structure chart to show the changes indeed and it's fundamental change so we've gone you know we've evolved continuously so we have
02:17:46 we have five directorates sitting across areas of strategic priority so we have um a transformation directorate people directorate dealing with matters of people culture hr health and safety etc
02:17:59 people culture hr health and safety etc operations um
02:18:03 um finance and corporate services and then something that's really a department but it is important if we think about the credibility and reputation of the brigade communications so those are our directors and director responsibilities
02:18:15 directors and director responsibilities and they all sit in in in
02:18:19 in in in cross-cutting boards so that you don't lose anyone part of those priorities when you're making decisions and i think that's not unusual to many organizations it's just something we hadn't
02:18:29 hadn't properly embedded in governance previously in the london fire brigade now have you let me try this differently the redesigning of governance that you've been describing in the last five minutes or say a commissioner is that
02:18:40 minutes or say a commissioner is that something is that design something that's come from within the brigade or is that something on which you've taken external professional advice no we've taken considerable external professional advice because when i took over in
02:18:52 advice because when i took over in january 2020 what was immediately clear to me
02:18:55 to me was that for all the you know fantastic public servants we employ people who are just prepared to put themselves at risk repeatedly on a day-to-day basis we have
02:19:06 repeatedly on a day-to-day basis we have been somewhat inward-looking and that our structures even to me and i would include myself as somewhat uneducated at that point did not feel particularly modern so we bought in professionalism skills
02:19:19 so we bought in professionalism skills and capability at director level so example we employed our director of transformation was previously the director of transformation at network rail my director of people previously ran an ahs
02:19:30 ahs trust
02:19:31 trust um
02:19:32 um you know known as head of people at nhs trust
02:19:35 trust before that our director of communications has worked across government and policing for example so and we haven't sort of rested there the the creation of an independent audit committee is particularly important
02:19:47 committee is particularly important chaired again by really experienced people
02:19:50 people from the private and public sector who provide independent external advice to me on issues that you know refer to best
02:20:01 on issues that you know refer to best practice as experienced elsewhere you know the frameworks we've built around risk management and business assurance are based on models employed elsewhere in
02:20:11 in government and industry so i think we've really embarked over the past two years on a desire to look outwards from ourselves and and kind of seek to learn from other organizations and bring into the brigade
02:20:23 organizations and bring into the brigade practices that really kind of um give good faith to the covenant i think we owe with our firefighters in particular put themselves at risk every day i think that's what they deserve i think we owe
02:20:34 that's what they deserve i think we owe it to ourselves to do that and in those efforts
02:20:37 efforts have you found yourself able to carry people with you or have you found a degree of resistance in certain corners of the organization a mix i think fundamental change is always really difficult particularly in
02:20:49 always really difficult particularly in an organization where perhaps there hasn't been that level of external scrutiny previously that the inspector has now brought to the fire and rescue sector
02:20:57 sector where people are very used to the orthodoxies of doing what they've always done so i think at times um it has been difficult for people to experience that change and i have to say transparently i don't think we've always
02:21:08 transparently i don't think we've always effectively communicated it if i was to mark my own scorecard from the past two years i think something we need to improve on because i don't think we've been effective is our internal communication our empowerment of
02:21:19 communication our empowerment of officers to communicate that change positively and it's an area we're really kind of working on i think it's been an enormous process of learning that will never end if we really consider
02:21:30 will never end if we really consider ourselves to be one of the great london institutions who is responsible for carrying into full full effect ensuring that there is carried into full effect the observations and recommendations of
02:21:42 the observations and recommendations of the hmi frs hmicfrs reports and also the independent audit committee you've referred to well ultimately me because i'm a corporate soul so i hold the ultimate
02:21:53 soul so i hold the ultimate responsibility on behalf of london and londoners to deliver them a service they they deserve so i think the buck stops with me in terms of the organization itself it's my director of transformation he's responsible for
02:22:05 of transformation he's responsible for liaison and analysis of her majesty's inspectorate's recommendations and because she does not hold responsibility for delivery actually
02:22:15 actually she's the she the first kind of um
02:22:19 objective line of assurance outside of line management delivery internally as well so she's there to assure our progress
02:22:27 progress against those recommendations andy bell who i know is well known to the inquiry has that responsibility as assistant commissioner working to that director to both bring together the recommendations from phase one of this inquiry alongside
02:22:40 from phase one of this inquiry alongside the recommendations arising from inspection which together total in fact 66 in number and which we accept in completeness and it is his job
02:22:51 and it is his job rigorously to interrogate other parts of the organization as to our progress and our ability to sustain that change that that is that that is a never-ending process and it you know it ebbs and it
02:23:02 process and it you know it ebbs and it flows but i think the intent is very clear who is the director of transformation it's a fiona dolmen and what's her background she came from network rail she was in a very senior
02:23:13 network rail she was in a very senior position in network rail responsible for change and transformation so transformation specialist
02:23:20 yes and sorry i don't think we've seen a record of it is it dull man dolmen d-o-l-m-a-n thank you but i think i think we could usefully supply you with the current structure charts of the brigade and and
02:23:32 brigade and and perhaps a summary of the changes that have evolved over the past two years because actually as we've learned more that they haven't remained static i think i think we've been on a journey really of
02:23:43 been on a journey really of understanding how to operate effectively at a corporate level you know i can certainly reflect on that person it's been it's been an enormous learning for me to start the point i did in january 2020
02:23:55 in january 2020 to get to where i am now and i certainly didn't know what i know now when i took the post and i continue to learn i think it's an enormously challenging position whether it's me or my predecessors and
02:24:06 whether it's me or my predecessors and that you you cannot be complacent enough to think you have all the answers you i think you've got to constantly seek to improve both yourself and the organization and coming back to one of the questions
02:24:17 and coming back to one of the questions that i
02:24:19 that i um
02:24:20 um i directed at you at the very beginning of your evidence but didn't want an answer to as part of the process you've been describing commissioner have you been asking yourself or directed others who are charged with
02:24:32 directed others who are charged with change in the brigade to ask themselves not just how we can learn the lessons of grenfell but why we never learn the lessons of lachenal yes we've gone back and looked at it because there is a lesson in that
02:24:44 because there is a lesson in that because i recognize having been in the brigade at the time that there was genuine intent from the leadership you know ron dobson i i i don't i don't know how it was communicated but i can only tell you what i experienced but i'm
02:24:55 tell you what i experienced but i'm fairly sure he put out messages around here there was a very strong sense in the brigade that this had been the most awful tragedy that had impacted you know the most vulnerable in society once
02:25:06 know the most vulnerable in society once again
02:25:07 again and that there was a great intent to drive change and learn from him to find all these years later that that change had not been sustained in every aspect that not
02:25:17 that not all of the lessons have been captured i think will be heartbreaking for some of the firefighters who are involved in that particular fire so it would be remiss not to turn back to lack at all and ask those general questions of when
02:25:29 and ask those general questions of when something significant happens you know it's not necessarily about unpicking every detail of lacking but it's that challenge to ourselves which is when something significant happens whether it's grenfell seven seven you know the tram crash um lachenal
02:25:42 you know the tram crash um lachenal how do we capture the learning and certainly deliver improvement but more importantly and to be fair this is the challenge of the inspectorate to me as well they've been very clear is how do you sustain that generationally how do
02:25:53 you sustain that generationally how do you continue to embed that change how do you build upon it because if i was to focus on something i think as a result of lack of all we didn't do effectively it was to sustain that learning
02:26:03 learning and we cannot afford to do that again certainly not in the face of a tragedy of this scale uh and you may already have provided the answer to this next question that last answer but are you
02:26:15 question that last answer but are you able to tell us what you what what the answer to the question is why the brigade never learned the lessons of latino
02:26:23 latino i don't think there's any one factor that there's not a simple answer to say why i think it's a mixture of um
02:26:31 um a governance that didn't encourage working beyond departmental or directorate walls so actually the structures themselves i think sometimes something in our culture around looking in rather than facing
02:26:43 around looking in rather than facing challenge out i think an erosion of professional standards not just in the brigade but nationally that had occurred over many years
02:26:52 years i think the challenge of to be fair to previous commissioners managing repeated industrial disputes that sucked enormous energy and was so damaging in the context of relationships between
02:27:03 in the context of relationships between officers and frontline crews and therefore meant even gathering the learning quite difficult i think also i think it's multi-layered i think it's in the culture i think it's in the systems i think it's in the governance and i think it was slow it was incremental
02:27:16 think it was slow it was incremental and it sometimes happened without people probably being aware that it was happening until we got you know to this most awful end point thank you commissioner mr chairman is that a convenient moment yes i think it
02:27:27 that a convenient moment yes i think it is if that suits you as well thank you very much that doesn't matter commissioner i think that's a good point at which we'll end for the day so we'll stop there um we'll resume
02:27:38 so we'll stop there um we'll resume please
02:27:39 please at 10 o'clock tomorrow i think you were expecting to come tomorrow weren't you in any event absolutely yes so 10 o'clock tomorrow and in the meantime please resist the temptation if it presents
02:27:50 resist the temptation if it presents itself to talk to other people about your evidence or anything relating to it all right so thank you thank you thank you very much and if you go the archer schuler castle thank you
02:28:10 thank you mr millet uh 10 o'clock tomorrow then please mr chairman thank you