Evidence from Scott Hayward on London Fire Brigade's control room training, Exercise Florian failures, and inadequate preparation for multiple fire survival guidance calls following Lakanal House.
00:00:28 you good morning everyone welcome to today's hearing today we're going to continue hearing evidence from mr scott hayward so would you ask mr taylor to come back
00:00:39 so would you ask mr taylor to come back in please
00:00:50 good morning ms taylor good morning sir hope you're well i hope you're ready to carry on i am indeed thank you thank you very much yes mr village good morning mr chairman good morning members of the panel good morning mr hayward morning before i start may i just mark the day
00:01:02 before i start may i just mark the day by saying that this is day 200 of the oral evidence of this phase of the inquiry
00:01:08 inquiry can i ask you uh by way of starting day 200 about exercise florian in december 2012.
00:01:16 2012. uh exercise florian you may remember took place on december the 20th of that year some 10 months after the publication of policy number 790 in february 2012.
00:01:28 february 2012. now
00:01:29 now we have a witness statement from som ben bagnell
00:01:33 bagnell who says that it was an exercise that involved a number of control officers in the control room receiving calls from other brigade members acting as callers in potentially fsg situations that's
00:01:45 in potentially fsg situations that's what he says in his witness statement and i'll just give the reference lfb00122821 page 15 paragraph 54 do you agree uh with his summation of
00:01:59 do you agree uh with his summation of that exercise that i've just read out to you i'm not overly familiar with exercise florian to be honest with you have you got some more detail on that please uh well
00:02:10 please uh well did you have any involvement in the planning or delivery of the exercise i i probably did i just don't don't record don't recall the exercise we did a few exercises
00:02:21 exercises right well let's uh let me see if i can help you
00:02:24 help you answer the question you've just asked me thank you and could we go to nfb double zero one two two eight two seven
00:02:33 this is the facilitator briefing for
00:02:36 for exercise florian dated the 15th of november 2012 a month or so before it took place and that's page one if we go to page two uh there's a question why
00:02:47 uh there's a question why uh first bullet point lack of house fsg policy full policy requires exercising audit purposes do you remember uh whether the
00:02:58 whether the exercise was attempting to remedy deficiencies found during the latter house incident so forest concerns fsg i believe it was cs right can we go to page six
00:03:09 page six we could see that it was a high-rise scenario
00:03:12 scenario scenario high-rise fire seventh floor maisonettes location tbc three fsg calls four persons you see that yes do you know can you help me why a decision was
00:03:23 know can you help me why a decision was made to include only three fsg calls when at latino there were five
00:03:31 no i can't i can't explain why it but why we would have gone to that i think i think it was just the fact that we used free fsg course perhaps because of the um the amount of staff that were doing
00:03:42 um the amount of staff that were doing doing it at the time i can't i can't recall exactly why it was only three right so does that tell us and if you can't remember you can't remember but does that tell us that the number of fsg calls identified for the purposes of the
00:03:55 calls identified for the purposes of the exercise
00:03:56 exercise was
00:03:57 was calculated on the basis of the staff available on the day no i don't i i can't answer that question i don't think it was i think three was just uh was just the number that they chose at the time for the exercise right who chose
00:04:09 time for the exercise right who chose that number do you know i i don't know do you know who was involved in designing this exercise as far as the control room element was concerned the sombagno and rst i would suspect
00:04:23 now if we go to page two again you'll see that it says as i read to you full policy requires exercising and then audit purposes um
00:04:34 um can you tell me what that means full policy requires exercising
00:04:40 um although checking the policy and make sure make sure it's valid let's go for going through the exercise oh i see not that the policy itself requires an exercise but the exercise is needed in order to yeah to test the
00:04:52 needed in order to yeah to test the polishing yes i see uh and and ordered audit purposes do you know why or perhaps by whom the policy or the efficacy of the policy was being
00:05:03 or the efficacy of the policy was being audited at that time i i think i think what was being said there is the fact that it was being it's been tested and then feedback to see if there were any deficiencies so you know to or audit
00:05:15 deficiencies so you know to or audit maybe not the right terminology but i think it was just to test and make sure the policy made sense and worked i see so was it the case that the purpose of this test
00:05:26 test or this exercise was to test policy 790 which was only 10 months old at this stage for the purposes of being able to perhaps defend it or explain it in the lack of house inquest which was due to
00:05:38 lack of house inquest which was due to start
00:05:39 start a month or two later in the january of 2013. i'm not i'm not sure that was the purpose i think we were just exercising the policy right did you attend the exercise i don't i don't i don't know i can't
00:05:50 don't i don't i don't know i can't recall now looking at page three um the exercise objectives was about the fsg information transfer and recording there
00:06:00 there not call handling itself and that's consistent with what we've seen from
00:06:05 seen from policy 790 already isn't it it is yes um
00:06:09 um said for example there was no exercise on how to handle a buildup of concurrent fsg calls
00:06:15 fsg calls in the in the uh in the control room no nor how to um go about organizing a revocation of stay put and what advice to give callers thereafter that's
00:06:27 to give callers thereafter that's correct for me um do you know why there wasn't
00:06:33 i don't think it was considered can we then go to lfb double zero one double zero two eight three one
00:06:48 this is an email chain from immediately after the exercise
00:06:54 exercise lfb double zero one double zero two eight three one
00:07:04 thank you now if we look at the second email on page one on the screen in front of you here is an email from vic bagnol to
00:07:12 to mer ost the ost merton 21 december 2012 at 706 in the morning subject live exercise incident 20th december 2012.
00:07:25 exercise incident 20th december 2012. and he says uh morning ost yesterday 20th december 2012
00:07:30 2012 at approximately 1355 hours a live exercise called exercise florian took place at brigade control and a live pro card incident was created
00:07:41 and a live pro card incident was created and live calls were made into the control room live interactions also took place between brigade control and appliances stroke officers by telephone and on both channel 2 and channel 1.
00:07:53 and on both channel 2 and channel 1. as a matter of urgency can you please collate all associated recordings for this incident both emergency and operationally urgent calls and all associated radio traffic the exercise ran for approximately one hour these are
00:08:05 ran for approximately one hour these are not to be provided to any other staff without talking to senior managers in the first instance that came through to m-o-m-e-r-o-s-t it was also copied to you as you can see
00:08:16 was also copied to you as you can see and you respond a little bit later that morning morning vic can you also ask liz jackie alex and chris for any feedback from their point of view i'm i am looking at lessons learned
00:08:28 view i'm i am looking at lessons learned for us in particular that i can report back at the next lack of board i think we have already identified the issues with the exercise itself and first who were liz jackie alex and
00:08:40 and first who were liz jackie alex and chris
00:08:41 chris they were the on watch team at the time was chris chris sharp uh
00:08:47 uh no
00:08:48 no i think that was chris bobby but i can't i can't be 100 bobby yeah he was an operations manager right and alex was that alex norman she was an assistant operations manager i
00:09:00 was an assistant operations manager i believe at the time in fact chris bobby might be the night assistant operation major yes and lizzie's was the operations manager and jackie can't remember a surname i think she was
00:09:11 can't remember a surname i think she was an assistant operations manager right were they the uh four cross or mock cross who handled the fsg no they would have been
00:09:20 have been in charge the or they would have been the supervisors in the room for the exercise
00:09:26 exercise did they provide feedback to you i can't recall but if i asked for it i suspect they did do you remember what the issues that were that you had identified i don't i'm afraid
00:09:37 identified i don't i'm afraid because you say we have already identified the issues yeah would you do you know who you carried that exercise out with
00:09:44 out with i'm afraid i don't do you know why the feedback was to be reported to the latter house board
00:09:54 i'm sorry i don't i don't recall at all do you know whether there was any feedback to the lachlan house board um
00:10:02 um i don't now the next lack of house board meeting
00:10:07 meeting didn't in fact take place after this until the 30th of september 2013 so some nine months later can we go to the minutes of that meeting
00:10:18 can we go to the minutes of that meeting uh lfb triple zero five zero six four four
00:10:27 now this shows us two things
00:10:32 uh here is the latino board minutes 30th of september 2013 and you can see um that
00:10:44 you are not present in fact at that meeting but um if you go to item four uh on that page um minutes of last meetings which is the
00:10:55 um minutes of last meetings which is the first thing we take from it 14th december 2012 minutes confirmed as accurate and the point is and i'd invite you to accept um that the that meeting took place before exercise florian and
00:11:07 took place before exercise florian and therefore this next meeting was the next meeting thereafter okay yes
00:11:12 okay yes um now um
00:11:14 um now um we've found no reference in this minute to any feedback from exercise florian take that from me is it right if that is
00:11:25 is it right if that is if i'm correct about that that you didn't in fact in the end provide any feedback to the latino house board about the outcomes of exercise florian from the control room perspective i don't i don't know it's the answer
00:11:38 i don't i don't know it's the answer do you remember whether you provided feedback to anybody else for example ac brown
00:11:43 brown um
00:11:44 um again i i i don't record the the the exercise at all so except for the emails you show me i really can't give any more information sorry now can i ask you then to go to nfb
00:11:57 now can i ask you then to go to nfb double zero double one eight nine five eight
00:12:05 uh this is an email uh to dave brown from david lindbridge on the 9th of january 2013. so shortly
00:12:16 on the 9th of january 2013. so shortly after his
00:12:17 after his uh his review and report that we've already seen subject re-exercised florian discussion and the first paragraph says all
00:12:28 and the first paragraph says all uh
00:12:29 uh and i just should point out to you that you were one of the recipients of that email if you can see that thanks as well as vic bangla and he says all in summary of our discussion today the following observations were shared for further
00:12:40 observations were shared for further consideration i have structured these comments around the relevant policy stroke documentation but as the owners you may feel they would be better addressed elsewhere and then in relation to pn 790
00:12:52 and then in relation to pn 790 he says halfway down the page explain the use he says explain the use of airwave introduce a means to distinguish main scheme comms with the icp etc and then he says this provide
00:13:04 icp etc and then he says this provide detail around the use of secondary comms networks and the need to avoid multiple simultaneous lines of communications now
00:13:15 now did that refer to the communication exchange
00:13:19 exchange about fsg calls between control and the incident ground no i believe it's a it was to do with how
00:13:26 how what what communication methods we will use so
00:13:30 use so telephone or the flood ops channels or mobile phone and i think and we had a we established a um
00:13:40 a um a direct dial interface line on our and our communication system that they could dial directly into and get a supervisor so i think it was about the the amount of the amount of information
00:13:52 the amount of the amount of information coming through on different different communication mediums right
00:13:57 right it was
00:13:58 it was quotes the need to avoid multiple simultaneous lines of communications unquotes an aspect of the of the exercise
00:14:07 exercise not that i'm not aware of no i mean was it uh was it a topic or problem or issue if you like that had come out of the exercise i think i think the issue the issue was was the fact that we weren't we're
00:14:18 was the fact that we weren't we're trying to contact the cu perhaps and if we couldn't get them on one communication meeting we would try another
00:14:23 another so and with only two in the in the command unit they may have been overwhelmed uh with you know not i've been unable to answer those calls right can we take it looking at this email and doing the best you can with your memory that
00:14:35 you can with your memory that the exercise florian had identified a problem with communication between the control room and the command unit on the incident ground which had resulted in multiple
00:14:47 ground which had resulted in multiple simultaneous lines of communication
00:14:52 yes for the communica communication mediums yes yes do you know what was done by
00:15:01 by the brigade to cure or address that problem yeah i i think we established this direct dialogue so that the command could ring the back of the desk directly on a on a
00:15:14 the back of the desk directly on a on a specific line
00:15:18 the back of the desk sorry the supervisor's desk where they control the supervisor's control room
00:15:27 uh anything else was that what was done that was i believe that's what was done yeah
00:15:33 um if you know sorry to interrupt you but um
00:15:37 but um that would provide them um for information coming from command unit 2
00:15:43 2 control room yes you a moment ago talked about the difficulty of getting the command unit to pick up and then using alternatively yeah anything done to try and solve that problem i only only try
00:15:54 and solve that problem i only only try to try to use one particular method of communication and that would be the flops channels thank you
00:16:02 thank you yes
00:16:08 and am i right in thinking that the multiple symmetry simultaneous lines of communication problem arose
00:16:16 arose when using only
00:16:19 only three fsg calls as the exercise yeah i think it was because we were passing obviously passing information down and the command unit staff having to record that information and pass that
00:16:31 to record that information and pass that information on so if and of course that that that may happen regularly
00:16:37 regularly you know on on the same call you know things might change and they'll bring it through or radio it through yes would it follow from that but if you increase the number of fsg calls above three
00:16:48 above three uh the greater the risk of multiple simultaneous lines of communication
00:16:55 yes some more information comes down comes down yes um if you look a little bit lower down the email it says exercise documentation consider
00:17:04 consider suitable owner of the exercise documentation for implementation into a real regular training program and then it says reduce the volume of radio traffic from
00:17:15 reduce the volume of radio traffic from the incident consider the benefit of running future exercises in a training environment rather than a live control room do you know what discussion there was about the need for a regular training
00:17:26 about the need for a regular training program for control in relation to pn790 and the rifs
00:17:37 um the regular training program um i believe was the command unit training
00:17:45 training where we used where command units would come to control and carry out the exercise on the command unit in in the car park in merton and control would run it from the
00:17:57 and control would run it from the from the control room and you say the regular training program how regular was that from january 13.
00:18:08 how regular was that from january 13. um it run for around two years there was a direction that come out that all command unit crews are to be trained and station managers to be trained in um communications in the communication
00:18:20 um communications in the communication between control rooms this is what i'm this is what i believe i'm talking about right you say it ran for around two years when did it when was the first of those i think it was mid mid 2013 and it run
00:18:32 i think it was mid mid 2013 and it run till
00:18:34 till 15 it stopped in 15 and then restarted it was an ongoing program why did it stop because of vision
00:18:41 vision because the vision when did it restart um mid-2016 i believe but i can't be 100 sure
00:18:47 sure uh and how how regular was it was it monthly or yearly uh it was availability of the cu so that's the cus were released on strategic resource which is a system that operational staff used to
00:19:00 a system that operational staff used to release appliances and crews for training
00:19:03 training and then they can cover it with other appliances so it was run through that system so
00:19:08 system so i'm not quite sure the regularity it was quite quite regular right now um in relation to the riffs uh
00:19:18 uh if you look up the email it says consider a rewording of the rift to support the completion of the control information form or casualty information poster
00:19:28 poster what about that was there any rewording done in order to support the cif the
00:19:34 cif the the
00:19:35 the control infra the control information form or the casualty information form wasn't wasn't mandated to control because they collated all the information on the system so it was written into the system so whilst it was
00:19:47 written into the system so whilst it was discussed and it's available i don't believe it was it was taken up was that because it was already recorded on on pr on the systems
00:20:09 north shore i'm really following the the the
00:20:12 the um the rif recommendation here is that
00:20:17 is that you should call one should consider a rewording of the rift to support the completion of the control information form my question was was that rewording actually ever
00:20:28 was that rewording actually ever considered as a fact i i don't recall but the rift does lay out what information to to provide
00:20:40 well was the riff reworded at any stage in light of this recommendation
00:20:49 i i don't know is the answer
00:20:53 can i then turn to the lingeridge review again january 2013 lfb triple zero three three nine three page six
00:21:07 and i'd like to look with you at article 14 or action 14 which is the creation of policy for communications from control to the fire ground
00:21:17 ground and it says this control staff perceive pn 790 as an operational policy for frontline personnel specific observations made as a result of this review have been fed back to the ac opr and will be considered in a
00:21:29 ac opr and will be considered in a forthcoming review of control fsg policy were you told what these specific observations made to ac brown as a result of gm lindrich's review
00:21:41 as a result of gm lindrich's review actually were i don't i don't i don't remember do you know whether the forthcoming review of the control fsg policy referred to actually took place
00:21:55 i don't know but i would have thought so if it was a if it was if it was considered a lot of thought something will be done about it but i don't recall i don't recall i'm sorry i mean it's
00:22:07 i don't recall i'm sorry i mean it's strange that you don't recall given your position at the time can can you just help me
00:22:11 help me with that
00:22:12 with that well it was a long time ago and and lots lots has happened in that time and unfortunately i i don't i don't recall
00:22:21 recall um
00:22:22 um i don't recall what happened at that time right well let's see if i can push you a little bit okay this is this is now january 2013. try and cast
00:22:33 this is now january 2013. try and cast your mind back the lack of house inquest has started or is about to start within a few days uh there's been the lacanal review for the past four years with the lachenal
00:22:45 the past four years with the lachenal house board and and uh
00:22:48 uh now the inquest is on foot here is an audit report or a review of the 34 actions by group manager lindridge with recommendations
00:22:59 lindridge with recommendations he says here that there will be a forthcoming review of control fsg policy
00:23:07 policy can you remember any review of control fsg policy which took place
00:23:13 place after january 2013. i think the control the policy was was updated to um to reflect the gap analysis and the changes to
00:23:25 the gap analysis and the changes to um
00:23:27 um and the changes that were made to the policy there so that's that's the changes that were made i'm not i don't recall what what this what this part of it was right
00:23:43 uh if we go to page 13 of this same document
00:23:48 document the lindridge review as we will see addresses action 14 uh in the review process findings and group manager lindrich says this
00:23:59 this uh entry on action log fsg policy for communications with the fire ground expected outcome standardized the protocols for sharing fsg information between control and the fire ground and
00:24:10 between control and the fire ground and also for maintaining updates from the fire grant control and then he goes on to say under review process findings as follows pm 790 was authored by representatives from
00:24:22 authored by representatives from incident management policy and control the procedures describes the two-way exchange of fsg information this was tested in an exercise at stratford 16 june 2011 with feedback shared with the
00:24:33 june 2011 with feedback shared with the authors overall it was a success but did identify that fsg is resource intensive at control the control room trainers explained that the exchange of information within the incident ground
00:24:45 information within the incident ground works well using the template do you know mr hayward who it was who provided group manager lindridge with the information that the exercise on the 16th of june 2011 which was the heygay challenge as
00:24:58 2011 which was the heygay challenge as we've seen had identified the fact that fsg is resource intensive at control um
00:25:06 um i don't know who passed the information but but it's a it's a fact that fsg is resourceful because it requires two people for one fsg call to cut the the
00:25:17 people for one fsg call to cut the the call handler and the supervisor or a super trained control officer to support them
00:25:23 them now you were present as we established yesterday at the haygate challenge exercise in june 2011 do you agree with the observation made here by group manager lindridge
00:25:34 manager lindridge uh yes
00:25:35 uh yes did you recommend any change either to policy 790 or to control resourcing or otherwise instruct anybody to investigate that issue once you've seen it
00:25:45 it in group manager lindridge's action reference 14 recommendations no because it was a it was a finding and it was a success but fsg is resource intensive and i agree with that it is
00:25:59 intensive and i agree with that it is but but i i don't know we didn't do any more with it we know that that's the case yes
00:26:07 yes so i i i is the fact is this simply telling you something you already knew yes
00:26:16 um you see the way it's phrased is overall it was a success but did identify that fsg is resource intensive control would i be right in thinking that that is a a that the
00:26:28 thinking that that is a a that the success was qualified and qualified by the presence of a potential problem namely the resource intensiveness of fsg at control
00:26:40 intensiveness of fsg at control i i don't necessarily read that why i read it it was a success but we know that it and fsg calls are resource intensive
00:26:49 intensive well can we leave it this way then for the for the present that it was well known by you and uh
00:26:57 and uh others in control of command uh in command of control at that time um that the resource intensiveness of fsg calls within control was a risk
00:27:13 yes can i ask you then about ac chandler's involvement can we look back at an email we looked at i think yesterday lfb triple zero
00:27:24 at i think yesterday lfb triple zero four two zero eight one
00:27:34 this is an email from you to vic bagnall on the 9th of may 2013. you remember it yesterday we looked at the first paragraph closely uh and
00:27:46 uh and you look at it again i'll read it to you again
00:27:49 again during my regular meetings with richard yesterday we discussed the training issue and the fact that whilst the database is on the system and has a good layout it is not dynamic and does not provide staff and management with a picture of the state of training for
00:28:00 picture of the state of training for control staff for the next year to 18 months
00:28:03 months you see the words training issue there what was the training you see there
00:28:14 just reminding you this is now may 2013. yes
00:28:19 uh i i think the issue the issue is the fact that we hadn't had a um a training a robust training plan in place yes
00:28:28 yes and then you go on to say uh in the next paragraph this is now a priority for you to talk to the ost and get the database populated
00:28:41 and then in the next paragraph down you say training to consider when populating the database and you've got a number of things in a list one day fsg a full-back exercise an exit exercise with wyfrs
00:28:54 exercise an exit exercise with wyfrs i think that's west yorkshire isn't it yeah and then f3 fsg exercises like the one martin goodall set up late last year this will test fsg calls and the information exchanges between us and
00:29:05 information exchanges between us and operational colleagues um now you you refer to martin goodall was that in fact tom goodall
00:29:13 um possibly
00:29:16 possibly i think there were two godors in in the brigade so that may have been martin but i'm i'm not quite sure right um now you say
00:29:27 now you say like the one martin goodall set up late last year that would be late 2012 was that exercise florian yes right was that an exercise that you had discussed with ac chandler
00:29:40 discussed with ac chandler possibly i don't i can't remember but that would have been a makes it would make sense right did you discuss with richard chandler the day before this email
00:29:49 email that
00:29:49 that the idea of three fsg exercises like florian
00:29:56 possibly when you said in the the sentence i've just read to you this will test fsg calls what did you mean by that a chest exchange of information that that was that was the idea of the of
00:30:08 that was that was the idea of the of those exercises is to test the information exchange between the fire ground and control i see so as per florian yes as opposed to call handling
00:30:20 florian yes as opposed to call handling yes we'll call hannah will be will be part of that process because it'll have to go through the process of of having receiving the call and making the
00:30:28 the um and then passing that information down
00:30:31 down they're linked aren't they call handling is intrinsically linked to the passing of information yes to the command unit and vice versa yes
00:30:42 how are the exercises that you were discussing before the day before this email with richard uh chandler going to going to test fsg calls what did you
00:30:53 going to test fsg calls what did you have in mind well that very a very similar um process to florian i think i think the operational idea was is to set up 12 pump fires around different boroughs
00:31:05 around different boroughs and then
00:31:07 and then use the opportunity to exercise pn790 did they happen um
00:31:13 um i certainly remember one that did occur but i know that officers would come and ask whether we could facilitate uh the exercise which was the one that did occur i i
00:31:24 which was the one that did occur i i don't remember the names and whether they were named it was just the different boroughs so they'd just been the station manager or the group manager would have would have contacted control
00:31:35 right
00:31:37 so just looking at the proposal for three fsg exercises
00:31:42 exercises um was there actually a program that you established whereby there would be three fsg exercises or were they left ad hoc to be arranged um between the station manager or yes they would add hot
00:31:53 manager or yes they would add hot because it was availability of of getting those appliances um released to carry out that exercise was there any um template for the exercise or any design so that you would
00:32:04 exercise or any design so that you would identify precise things that needed to be tested and outcomes that were desired no we would have used the the florian as a template florian as a template so those fsg exercises would not have
00:32:16 so those fsg exercises would not have involved any more than three fsg calls no i would have thought not did any was any thought given either by you privately or during your discussions with richard chandler the day before
00:32:28 with richard chandler the day before this email or at all or with vic bagnol at any time as to whether the three the number of three fsg calls in these exercises would sufficiently test what you wanted to test
00:32:39 you wanted to test uh no no can we look then at lfb triple zero six zero seven zero one email 28th of june 2013. so a month on
00:32:50 email 28th of june 2013. so a month on also from this one this is an email from ac chandler to you at the very top of the page in which he forwards to you
00:33:02 in which he forwards to you scott for info an email that he had sent to ac brown which is the second email on the screen on page one there do you see that i do
00:33:13 that i do and um
00:33:17 in that email as item 14 if we turn the page
00:33:20 page to page two uh that says item 14 fsg policy for communication with the fire ground you see that yes uh and underneath that he writes
00:33:32 uh and underneath that he writes completed 23rd february 12 yes this is now in place it was last amended in may 2013 that is due for review in february 2015.
00:33:46 that is due for review in february 2015. uh i would have a question if this should be an operational assurance policy or a mobilizing policy see item five although this policy is in place and the interaction between control ort and operational crews is improving there
00:33:58 and operational crews is improving there is still further progress to be made and then there's some recommended action uh and
00:34:04 uh and we'll look at that in just a moment before i come to that did can i just ask you this did you discuss
00:34:11 discuss this action at all with ac chandler uh
00:34:20 not that i'm wet not aware of it was sent to me for info so it would have gone to
00:34:25 gone to dave brown right
00:34:31 um were you involved at all in their discussions about this action not not i recall do you know what progress he felt there was still to be made no
00:34:43 was still to be made no did you yourself do anything to achieve the progress that is is hinted at at least here
00:34:53 he says in the at the end of the the piece i've just read to you there is still further progress to be made did you were you involved in that well yes because the command unit exercises set up to improve to improve that that
00:35:05 up to improve to improve that that communication exchange i see so that's that that was how you understood the progress to be achieved yes command unit exercises right and if we then if we look at the recommended action underneath it it says
00:35:16 recommended action underneath it it says this focus to be made on the future integrated control training courses recommended in the rule 43 response to the coroner towards improving and harmonizing the language used between control and the fire ground a greater clarification perceived
00:35:29 a greater clarification perceived controlled triggers and perceived fire ground triggers for fsg exploration of control staff forming an integral part of command unit crews at larger incidents clarification on who can declare an incident persons reported
00:35:42 can declare an incident persons reported now on the first recommendation there focused
00:35:46 focused uh to be made on the future integrated control training courses and was that done again the command unit the command unit courses was whilst it was
00:35:57 courses was whilst it was um operational staff control staff were involved and and they worked if they worked together to understand pn 790. so so the answer to that is
00:36:08 so the answer to that is the command unit courses that you say started in 2013 stopped in 2015 and restarted in 2016 is that that's that's what you say yes um
00:36:17 um then let's um let's just look at uh your statement uh at lfb double zip triple zero 55191 your first statement please
00:36:28 please page 26
00:36:30 page 26 and let's look together at paragraph 78.2.2
00:36:37 on page uh 27 i think that should be no 28. thank you lovely uh where you say this the nfb introduced training for all command unit staff and associated
00:36:49 command unit staff and associated station managers issue 20 of operational news published in november 2011 contained an article on the fsg policy which was to be published later in issue 24 published in march 2013 included mandatory training for all
00:37:02 2013 included mandatory training for all operational watch-based staff shx this was not training for control officers as part of the training command units came to the control unit control room in
00:37:13 came to the control unit control room in merton and took part in exercises about issues such as two-way communication between control and the incident ground it took about two years for all command unit crews to complete this training
00:37:25 unit crews to complete this training so that's the training i think you've been referring it is this morning the command unit training um
00:37:31 um so that's the can we take it that that was the integrated training that ac chandler was referring to yes it was yes so not therefore contraining training for control well maybe a poor choice of words it wasn't
00:37:43 maybe a poor choice of words it wasn't it was set up to it was set up operationally to test the command unit integration uh communications but control staff were involved in that although it weren't specifically
00:37:55 specifically targeted for control but the actual training itself did include control and did include call taking call handling yes now you say in that last answer that it wasn't
00:38:06 that last answer that it wasn't specifically targeted for control work and the control staff who were involved in the test uh assessed was what they did examined and assessed
00:38:17 was what they did examined and assessed yeah so so they would they would receive calls and it was as it was scripted but they received calls and then the the trainers would ask them um questions about about uh the call
00:38:29 um questions about about uh the call handing them what they would do as well as system as well as system issues who designed uh the uh the command unit training i think it was
00:38:41 the command unit training i think it was a joint a joint venture between the operational support team and operational staff i don't recall who the operational staff member was
00:38:53 and you say that
00:38:56 that it was scripted what part was scripted the the calls the actual um the calls to the command units
00:39:07 right so does that tell us that in this in these exercises the call handler didn't have any discretion uh to use their own judgment about what they told the command unit um they could they could do
00:39:19 um they could they could do they they could make their own minor but they did it within the within the scripts there were what they could tell the command unit as a guide
00:39:28 a guide and in these exercises was there somebody playing the role of caller yes the op support team would do that so the exercise would involve three points
00:39:39 the exercise would involve three points of communication with it the caller the call handler the cro and the command unit and then yeah the information flow between those two right and was the caller's
00:39:50 was the caller's words were they scripted uh that they knew that they they knew the addresses of where those incidents were
00:39:59 were where they were going to be for information to pass down the command units uh and i think there was a a nudge on what they could say but the the call just made the call to the call handler
00:40:11 just made the call to the call handler based on the information that was there so anything outside of that so address you know where's the fire and the like the actual how they respond was was up it was up to them
00:40:22 them right was there any element of that at part of the exercise namely the discussions and communications between the caller and the call handler which tested
00:40:34 the call handler which tested appendix one of policy 539 emergency call management fsg calls yes um
00:40:42 not that specific no i don't i don't believe it it did
00:40:48 and was that element of the exercise assessed by anybody in the control room it was it was assessed in the fact that they were asked questions as to as the calls went through
00:41:00 calls went through can we then go back to lfb triple zero six seven
00:41:04 six seven six i'm sorry lfb triple zero six zero seven zero one the email name we were looking at before and back to page two this is the uh the chandler brown email
00:41:17 and uh you can see under the recommended action there under the second recommendation he says a greater clarification of perceived control triggers and perceived fire ground
00:41:28 triggers and perceived fire ground triggers for fsg um was that clarification obtained do you remember not not i recall no where's that
00:41:36 that i'm i'm not sure i'm not sure what the control what perceived control triggers were that if you go to the bottom the clarification on the person's reported that would be a trigger that was subsequently introduced later on
00:41:47 was subsequently introduced later on right
00:41:49 right i see
00:41:50 i see and on the third recommendation control staff forming part of command units at larger incidents was that ever explored yes it was explored and i believe it was around 2016 2017
00:42:03 around 2016 2017 we um
00:42:05 we um we invited control staff to go out onto commanders to as to observe um
00:42:11 um it
00:42:13 it it was explored and when i left it wasn't implemented but control stuff were observing going out see if there's any benefit of control going out there uh and you said they were invited did
00:42:25 uh and you said they were invited did they actually go yeah they did yeah but they were there to observe were they they were rather than actually be involved in the incident itself right
00:42:35 uh now can we please go to uh som smith's statement to the metropolitan police on this topic met 3080606
00:42:49 i'll show you the first page of her statement to identify the document and then i want to go to page 17 in it please
00:43:02 there's the first page and you can see that this is her police statement of the 16th of september this year 2021 and if you go to page 17 she says this in the last two paragraphs on that page
00:43:13 last two paragraphs on that page i recall that essex frs had a system whereby control room officers of any rank would crew a command unit on incidents with five or more pumping appliances were in attendance
00:43:24 appliances were in attendance the control officer would work from the command unit and carry out tasks similar to if they were in a control room this would include logging calls and radio messages creating plans and mobilizing appliances or responding in in the
00:43:36 appliances or responding in in the appropriate way to the incident this meant that control room officers were familiar with what happens on the incident ground and with the cu systems of working i believe other frs may use this system but when i transferred to
00:43:48 this system but when i transferred to the lfp they did not i wrote a paper in 2016 on this topic as i felt this was a good method of working and i had previous experience of working with cus i believe i sent this report to
00:43:59 with cus i believe i sent this report to my colleague scott hayward in 2016 and i would have expected him to pass this on to dave brown who was assistant commissioner ac at that time dc webster has requested a copy of this
00:44:11 dc webster has requested a copy of this report but unfortunately i cannot locate a copy of this report i'm not certain that i sent this report by email therefore although i've checked my emails i cannot produce the 2016 version of this report
00:44:23 of this report i recall that my colleague scott hayward thought my idea was quotes ambitious on quotes and that the idea was not taken forward at that time [Music]
00:44:33 [Music] now first do you remember some smith sending you a report with that proposal in 2016. i do not but i know she certainly talked about it because i
00:44:44 certainly talked about it because i remember talking about that essex had that
00:44:47 that had that system in place so you don't recall a written document containing her proposal i i don't but i know because we spoke to uh mr george about it because he was he was
00:44:59 about it because he was he was in control then and like i say the outcome of that was to put control officers uh at certain instances i think it was above eight pumps if we could if we could uh spare them to
00:45:11 if we could if we could uh spare them to go to go and observe command unit work right now just breaking that up a little bit first when you say you don't recall a written document are you saying you don't recall one way or the other or but
00:45:23 don't recall one way or the other or but you that um you can say with confidence that you didn't receive it because you don't remember it i i can't i can't recall one way or the other but i know there was a lot of discussion about it discussion about it now
00:45:35 discussion about it now um
00:45:36 um she
00:45:37 she uh gives the date of 2016. you refer to talking to mr george about it you'll recall that i should because i showed you yesterday tom george's assistant commissioner george's
00:45:48 commissioner george's root and branch report of july 2016. do you remember whether these discussions with joe smith about
00:45:57 about this exercise and her report predated or post dated his report
00:46:07 i'm not sure i'd say pre-dated because it was a it was a topic for discussion and was the topic of discussion with with tom george in the context of his root and branch review no it was just it was a separate it was
00:46:19 no it was just it was a separate it was a separate discussion is it right that you considered her idea to be ambitious only ambitious in the fact of getting our staff onto command units ambitious in the sense of getting
00:46:30 ambitious in the sense of getting control room staff out to the command unit yeah why ambitious because
00:46:36 because because it hadn't happened in london before
00:46:39 before i don't think i don't think um i i wasn't dismissive of the idea i thought it was a good idea and the fact it's using other frses
00:46:50 and the fact it's using other frses but i think london had now control officers integrate operation like that before um hence why when i i took it to um
00:47:01 um mr george
00:47:03 mr george um for him to take it forward i see so your your view was that it was ambitious but just on that why if essex could do it could london not because they're they'd already
00:47:14 because they're they'd already established it within their from what i understand it was already established within their control establishment to release staff to do the command unit as well there's a control staff establishment number on
00:47:26 control staff establishment number on there in london control there wasn't so it would have been to do that would have been a um we'd have to establish posts to be able to do that to do that why not do that well i i
00:47:39 that to do that why not do that well i i i'm not saying that you couldn't do that um but the but it would require funding obviously to do that uh another project to set up and and of course training and how that would work
00:47:50 how that would work um in real terms i suppose in in london yes did anyone or did you think about even looking into that to see if you could as it were do an essex uh well no because because joanne
00:48:01 uh well no because because joanne already did and she said she produced a report i don't recall seeing a report but that's not to say she didn't do one was it her report was in favor yes absolutely she was very well in favor of
00:48:13 absolutely she was very well in favor of doing it
00:48:14 doing it it was a good idea you say you took it to ac george i'm sorry to interrupt you sorry it's my fault um uh you say you took it to ac george what did did do you remember having a discussion about it specifically yes and he's and he said
00:48:27 specifically yes and he's and he said let's let's let's do some testing and put and put control staff out on the command units which is which is what we did that's as far as it went before i left
00:48:40 um can i then ask you about another exercise
00:48:44 exercise exercise penfold in november 2013 which took place on the 14th of november 2013 at lexum house st margaret's embarking okay do
00:48:55 house st margaret's embarking okay do you remember anything about that possibly when we go through it right um let's go to lfb triple zero five zero four eight seven
00:49:12 uh and uh this is an email string which uh
00:49:20 if we pick up at the foot of your screen comes from paul true on this 27th of june 2013 to you copy to vic bagnall
00:49:31 june 2013 to you copy to vic bagnall paul true was the borough commander for barking and dagenham and uh he says hello scott i will wait to hear from vic and what that is about is on page two
00:49:43 two if you go to that please and look at the foot of the page he says
00:49:49 he says this in an email earlier that day to lindsay turner copied to you subject temp exercise hi lindsay one of my watch managers is organizing a ten pump exercise embarking on the 13th of
00:50:00 pump exercise embarking on the 13th of november the scenario is a high-rise incident with multiple seats of fire persons on various floors trapped and far survival guidance calls in progress ac brown and dac mills have agreed to
00:50:11 ac brown and dac mills have agreed to take part in this event i would really like to involve control to make it as real as possible and ensure as many staff as possible gain from the training can you please let me know if you are able to facilitate this
00:50:22 able to facilitate this and your reply uh
00:50:25 uh above that is morning paul lindsay's left the authority we would like to support this event and your point of contact will be vic bagnell were you involved any further in the planning or the delivery of that exercise
00:50:37 exercise um
00:50:39 not directly no
00:50:42 uh if we go then to lfb uh triple zero five zero seven two one you can see an email from
00:50:53 you can see an email from uh
00:50:54 uh vic bagnell so embankment 5th of november 2013 to the merton operations managers uh and copied also to paul true subject exercise penfold managers it starts
00:51:07 exercise penfold managers it starts exercises are the best way for organizations such as ours to practice procedures stroke protocols in a controlled and safe environment but they also provide a good vehicle to assist us with learning and honing our skills
00:51:19 with learning and honing our skills brigade control has participated in exercises from a facilitation perspective in the past but it is anticipated that we may become more involved in the future now first do you agree
00:51:31 now first do you agree that exercises were are important to practice procedures and protocols in order to learn and hone skills yes yes and what did you understand
00:51:42 understand the comment to be uh whereby he says that the control had participated in exercises from a facilitation perspective in the past i think this is where we're establishing
00:51:54 i think this is where we're establishing pn 790 in the fact that we were facilitating that exchange to to get operational officers to understand about passing information back the control room
00:52:04 room so hey gate challenge and exercise florian would it be right to characterize controls involvement as facilitation no i'll just i'll said there was more there was more to it than that right and um how is it anticipated
00:52:15 that right and um how is it anticipated that control would become more involved
00:52:20 as it says it is anticipated that we may become more involved in the future do you know what um maybe uh i don't i i can't interpret but i would make the assumption that because we'd be doing more of these exercises so
00:52:32 we'd be doing more of these exercises so we'll be getting more involved in them i see
00:52:37 i see and and had there been discussion by this point was this was that does was this put it this way was this reflective of the
00:52:45 of the impression that you had gained from ac tom george's enthusiasm for carrying forward
00:52:51 forward uh joe smith's proposal this this was before mr george and and the command unit so
00:53:00 so was this something that had been anticipated even at this early stage
00:53:05 stage yeah i i i believe um that it was when uh jan returned from see fowler that the issue around commanders but i believe she's brought it up before then
00:53:16 believe she's brought it up before then and when she come in from essex she did talk about why aren't london on command units but that do you know why
00:53:27 do you know why that has not happened before 2013. i i don't i don't know well before 2012 in fact as we've we've seen can we go then to um mr bagnall's statement at nfb double zero
00:53:38 bagnall's statement at nfb double zero one double two eight two one
00:53:45 if we go to page 14 in that statement lfb
00:53:50 lfb double 0 1 2 2 8 2 1 page 14 paragraph 52 and this is under the heading exercise penfold paragraph 52 says this the exercise
00:54:02 paragraph 52 says this the exercise involved four fsg calls made by control staff attending the training exercise site and required crs to respond to the fsg calls by following the fsg raf for guidance and relaying information via
00:54:13 guidance and relaying information via radio and telephone to the command units on the incident ground there were initially three fsg calls and during the training exercise there was an inject where a fourth fsg call was made to
00:54:24 where a fourth fsg call was made to reflect the development of the incident i exhibit a copy of the three initial fsg scenarios to this statement and a copy of the inject for the fourth fsg call and aom is available in the control
00:54:36 call and aom is available in the control room to assist the cras with responding to the fsg calls now
00:54:41 now we've seen exercise florian which involved three fsg calls do you know why a decision was made only to carry out four fsg calls again given that lachnal uh had at lacknow
00:54:53 given that lachnal uh had at lacknow there had been five no i don't why not go for it and have 10 or 15 and really test the system because we the london hadn't experienced or you know around the country hadn't
00:55:04 know around the country hadn't experienced any more than that at that time that i was aware of um so you know we when we talk about multiple fsg we're talking up to around five you know based on on
00:55:15 up to around five you know based on on the lack of hours of previous incident but except if it was based on latin as a previous incident you would have five why three up to four i don't know right um now
00:55:28 in his statement he explains in the next paragraph in fact
00:55:33 fact that following the completion of exercise penfold nikki o'shea in the ost team provided feedback
00:55:41 feedback which she shared with you and paul true who had been the exercise leaders we've seen
00:55:47 seen do you remember that feedback do you remember seeing it not
00:55:52 not not
00:55:58 do you remember sharing
00:56:01 sharing any feedback with the operational side i did speak i believe i spoke to paul true after the after the incident but not specifically for the incident itself
00:56:13 can i show you lfb double zero one two two eight two six
00:56:19 see if this triggers a recollection
00:56:24 this is this is the feedback document fsg exercise penfold 14th november 2013. feedback regarding the operational side do you see that yes i do do you remember seeing this document i don't you don't
00:56:37 seeing this document i don't you don't you can see that the first back is feedback regarding the operational side and the second part is under the suffering feedback for us to consider is the us can you help the controlled
00:56:49 is the us can you help the controlled side i would suggest it is yes right uh and then it goes on to say let's see how far we go with this if this isn't a document you've ever seen before um
00:56:59 um the question is why not well i i don't i don't recall seeing it before it's not to say i didn't it was a quite a while ago on the assumption that you did uh can you help me then with the first bullet point under feedback for us to
00:57:10 bullet point under feedback for us to consider it says the cif form does not ask the right questions do you remember speaking to nikki o'shea to obtain further clarification as to what that meant
00:57:21 what that meant no i'm not sure what a sif form is you're not sure what a sift form is no well it could be controlled information form or casualty information casual information form yeah so you do know what i said yes i do i
00:57:32 so you do know what i said yes i do i didn't know the acronym that was all i've only seen in full but that that's um
00:57:39 okay i i don't i don't recall speaking to nikki about that but but that's not so i didn't do
00:57:46 do do you know what the questions were that she was suggesting were wrong or should be put right
00:57:57 um his chemistry in the senior control workshops control need more questions to help keep conversations without being repetitive so this is the development of the
00:58:08 so this is the development of the of the scripts because obviously um controller the control
00:58:14 control the call handler would take an fsg call and they would get so far and if it's an ongoing to maintain the exercise it just as the information becomes a bit stale
00:58:25 as the information becomes a bit stale so i think control wanted to develop some more
00:58:28 some more questioning in those in those workshops to to to keep the conversation going uh was the cif form changed thereafter so that it did ask the right question
00:58:40 so that it did ask the right question yeah i don't but as i've said previously i believe i believe the the cash of the information form or the forms were optional for control i'm not sure they picked them up because they were already
00:58:51 picked them up because they were already putting that information onto the mobilizing system in the free text so it's already written there for them and then they pass that to the command units right
00:59:02 units right only she's put this in as an issue for control to consider rather than for the operational side to consider so the fact that they were optional for control doesn't seem to have made much of an impact on nikki o'shea when she
00:59:14 of an impact on nikki o'shea when she did her feedback does it
00:59:17 does it well that that was something for us to consider not not to not to mandate or implement i believe there was further discussion about the use of the uh information forms and like i say i
00:59:28 uh information forms and like i say i believe
00:59:29 believe they were optional because of the information that's already created so in effect the control should be duplicating work because it's already on the on the command system yes but if it was if it
00:59:40 command system yes but if it was if it wasn't if it was already on the command system
00:59:43 system uh and the cif was duplicating work why was it necessary for nikki o'shea to consider the feedback in respect of the cif formula well because at the time we were obviously
00:59:54 because at the time we were obviously looking at those forms and and she identified that they weren't asking the right questions i don't know what those questions were because i don't remember and you don't remember whether any action was taken to remedy that
01:00:07 well like i say i believe i believe they were left they were left optional for control staff to use and then if you go to page two of this document you see under the heading
01:00:18 document you see under the heading suggestions there's a suggestion that in the first bullet point the aoms and om are more involved in order to practice their role within the fsg procedure such as
01:00:29 within the fsg procedure such as liaising directly with the fsg cu and sm
01:00:34 and sm command unit and station manager is that something that was actioned in any future training exercise hereafter
01:00:47 i i would i would suggest this is not this is not um
01:01:02 so the io the iom that's um that would be supporting the control officer would necessarily liaise directly with the fsg command unit
01:01:14 the fsg command unit because of the nature because obviously that pro that process is he is the call the call handler would would pass information and then the aom or
01:01:26 information and then the aom or that supervisor would make sure information was passed to the cu so that's the that's the involvement i'm not sure the om uh would want to involve more unless
01:01:37 uh would want to involve more unless they're talking about just the practice as opposed to live well um
01:01:44 well um the suggestion that's made is that the aoms and the om should become more involved
01:01:50 involved for the purpose that you can see my question is did that happen well as i said the the aom is involved because obviously they're the
01:02:01 involved because obviously they're the link between uh between the call handler and the communication line the om i don't believe so but then i'd expect the om to be have more of a
01:02:12 the om to be have more of a a bigger picture right let me let me see if i can get it slightly differently here are two suggestions on the page by way of feedback from this exercise do you know whether anything was done in response to the first bullet point
01:02:23 response to the first bullet point suggestion there
01:02:26 not actively no right do you know why it wasn't
01:02:31 wasn't because as i said the aom already does already does that part integration i don't know whether they're suggesting it for the exercises or for real
01:02:42 or for real did anybody in the command structure either at your level or above who received this feedback look at that suggestion and say no we don't need to take that forward
01:02:53 take that forward not that i'm aware of i know
01:02:59 would i be right in thinking that overall on what we've seen from this document this is feedback on the exercise exercise penfold not on deficiencies in the policies or the capabilities of the control room staff
01:03:10 capabilities of the control room staff which were revealed by it
01:03:15 yes can i then go back to uh
01:03:21 uh group manager lindridge and we've seen that his review was dated the 4th of january 2013. do you remember that he then carried out further work
01:03:32 that he then carried out further work during the course of 2013 and produced a further report later that year
01:03:41 i i know he was doing some work i don't know i don't recall the report as i've seen it right let's go to lfb triple zero eight three nine seven eight
01:03:52 email string november 2013 if we go to page four in that email string we can see the second email on page four
01:04:00 page four is an email from ac brown to you copied to
01:04:05 to david lindbridge as well as to
01:04:08 to som bagnol and som diamond 15th november 2013 scott it says i've just met with dave lindridge to discuss whether there are any outstanding pieces in the latino action plan as a result i've asked dave
01:04:20 action plan as a result i've asked dave to discuss with you the following issues to ensure any outstanding issues are completed and then if you cast your eye down beyond actions 10 and 12 we get to action 14
01:04:31 action 14 creation of policy for communications from control to the fire ground it seems there might be some specific observations made as a result of dave's review that need to be considered in future reviews of fsg policy we need to
01:04:44 future reviews of fsg policy we need to confirm what these observations are has a review of fsg being completed whether these observations have been considered if not then why not now first did you meet with group manager lindridge to discuss these
01:04:56 manager lindridge to discuss these issues i've i've spoke with mr lindridge on a number of occasions i can't recall this exact but i have spoken to him yes right did did group manager lindrich have any specific observations about what would need to be considered in
01:05:08 what would need to be considered in future reviews of fsg policy i do not recall you don't remember do you know whether they had been considered whether they were after this considered
01:05:25 i don't i don't remember when he asks the question has a review of fsg being completed
01:05:38 has a review of fsg being completed at the very end of the that uh section on action 14. what did you understand ac bring ac brown to mean
01:05:46 um post lacquer now whether we've updated our whether it updated our policies after the lack of now incident and not after the gap analysis have been completed
01:05:58 completed say is that what you understood him to mean by review of fsg i believe so right had such a review been completed by this point
01:06:09 i believe so yes
01:06:15 and in what form did that review or the final review take was there a final report no i think it was just going for the policies and making sure that the changes that were that were actioned
01:06:27 changes that were that were actioned that were
01:06:28 that were in the
01:06:30 um a gap analysis were were put into the documents
01:06:35 documents now then let's look at his his updated review in november 2013. this is nfb triple zero eight three nine eight eight
01:06:47 let's have page one up on the screen this is group manager lindridge's updated review november 2013
01:06:57 and if you go to page 13 you can see
01:07:03 action 14 the very foot of the at the very foot of the page
01:07:08 the page and in that text over on page 15 sorry over on page 14
01:07:18 under review process findings you'll see a new paragraph that was not in the january 13 version of this review report and it's the second paragraph in review process findings and it says an exercise
01:07:31 process findings and it says an exercise package has also been developed and tested 20th of december 2012 to involve control room operators command command unit staff fire crews and senior officers
01:07:42 staff fire crews and senior officers this proved to be successful and utilized all the communications methods now looking at the date would you agree that that the reference there is to exercise florian
01:07:54 25th december yes yes 2012 yes was the intention to repeat that exercise
01:08:01 not not that i'm aware of no it was about it was about having these exercises at different boroughs you know 10 pump fires and utilizing the the fsg element of that to practice it
01:08:13 practice it right
01:08:14 right and was was exercise penfold intended to be a repeat of exercise florian yeah it is similar in its process yes right but was it designed to be a repeat of florian not specifically i don't
01:08:26 of florian not specifically i don't believe no
01:08:32 can i then turn to gra 3.2
01:08:38 uh and just ask you some questions about that before the break and mr chairman we'll get but we'll get this done i think before that yes sir greg and i want to ask you about gra 3.2 in the context of
01:08:50 the context of uh policy number 790. now just by way of a bit of background you may have heard some of the evidence earlier in this module of this inquiry the generic risk assessment gra 3.2 was published at the end of february 2014
01:09:04 published at the end of february 2014 but as we've heard the lfb had some responsibility for the process of drafting and consultation on it for a number of years before that now the published version
01:09:15 now the published version uh contained a new section which had not appeared in previous sections entitled evacuation and fire survival calls fsg calls i can show you gra 3.2 if you if you
01:09:27 i can show you gra 3.2 if you if you like
01:09:28 like perhaps we just ought to have it up um it's at lfb four zeros one two five five
01:09:38 at page twenty nine
01:09:49 and at the very foot of that page you can see on your screen a section evacuation and fast survival guidance calls you see that i do now if we go over the page to page 30
01:10:01 now if we go over the page to page 30 you'll see that it continues with the number of unnumbered paragraphs about the responsible person the rro what the incident commander should do by way of following the evacuation plan
01:10:12 way of following the evacuation plan devised as part of the premises fire risk assessment and
01:10:18 aspects of the stay put policy were you
01:10:23 were you made aware before gra 3.2 was published in february 2014 that changes were going to be made to that gra so far as they related to far survival guidance calls and
01:10:35 far survival guidance calls and procedures not the oracle so is it right that you at least were never consulted on
01:10:42 on this aspect or this introduction into three point into gra 3.2 not oracle
01:10:49 did you yourself make any inquiries as to whether there was likely to be anything in the new forthcoming version of gra 3.2 that would affect our survival guidance calls generally or
01:11:00 survival guidance calls generally or policy number 790 or for that matter 539 appendix one in particular not not that recall now when it was published did you or anybody else in control
01:11:11 did you or anybody else in control undertake a review of gra 3.2 to see if there were any matters in it which might impact
01:11:17 impact uh it might affect the way control worked no
01:11:20 worked no or which might necessitate any changes either to prpn 539 or 790. no did you ever consider anybody instructing anybody in control to undertake a gap analysis between the new
01:11:32 undertake a gap analysis between the new gra 3.2 and the existing policies 790 and 539 to confirm that both of those policies remained consistent with gre 3.2 no
01:11:43 why is that i was not aware that of the gra 3.2
01:11:51 gra 3.2 was out there and published
01:11:55 did you ever so it would follow from that well let me ask you when was the first time you became aware of gira 3.2 dated february 2014 and
01:12:06 of gira 3.2 dated february 2014 and particularly the fact that it had a section in it relating to first survival guidance
01:12:11 guidance uh whilst preparing for this inquiry right thank you very much mr chairman i think that's a convenient moment
01:12:18 moment right thank you very much
01:12:25 well at that point um mr hayward we'll have our break for the morning we'll come back please at half past 11 and again please then talk to anyone about your evidence okay right thank you
01:12:37 about your evidence okay right thank you very much thank you
01:12:49 thank you mister minute half austin
01:31:03 right
01:31:05 would you ask mr haywood to come back in please thank you
01:31:18 right statement yes
01:31:20 yes yes thank you very much mr chairman um mr hayward uh can i then ask you about pre inquest action number nine the subject of which is the rifs the
01:31:31 the subject of which is the rifs the reference information files and can we begin with lfb404801 please at page 13. this is the assurance report
01:31:49 out from 2018
01:31:52 which we looked at yesterday and under action 9 on the right-hand side of the screen towards the bottom of page 13 it says this
01:32:02 this action 9 revise the reference information file used by control officers when delivering fast survival guidance
01:32:08 guidance in order to ensure that they comply with national guidance so that we're familiar with what a reference information file or rif or rif is let's just read on it says below that
01:32:19 is let's just read on it says below that action point reference information files provide control staff with a concise summary of the key actions that should be taken for an incident when handling emergency calls first do you agree with
01:32:30 emergency calls first do you agree with that yes yes and then if we go to your statement your first witness statement of page seven please
01:32:38 this is within paragraph 20. you deal with action 9 here on the screen in that bullet point and you say action 9 the operator and supervisor fsg rifs
01:32:49 operator and supervisor fsg rifs were revised by lindsay turner and the operational support team ost to comply with national guidance fsc 10 1993 and 54 2004. you see that yeah
01:33:03 10 1993 and 54 2004. you see that yeah did you have any role yourself or involvement yourself in revising the rafs
01:33:08 rafs only only with the the gap analysis to make sure that it was included in in the rifts right so you didn't supervise the work that was carried out no the ost by way of revision no no
01:33:19 no the ost by way of revision no no can we then go to what s.o.m smith says joe smith says in her statement lfb double zero one two one two one nine page eleven paragraph twenty six
01:33:36 uh what she says is this and this is in answer to the question please detail your involvement with the revision of the fsg riffs for cras and control supervisors and she says this
01:33:47 supervisors and she says this uh i i was involved in the first revision of the fsg rafs for cras and the introduction of supervisor rafs i recall that in september 2010 i proposed a redraft of the rifs i recall that
01:34:00 a redraft of the rifs i recall that scott hayward and i discussed the types of useful information to obtain from callers and therefore to put on the raf um is she right about that did yeah we
01:34:12 um is she right about that did yeah we put a discussion we would have discussed it on the back of on the back of um during the lack of inquiries yeah so yes we would have done do you remember what you discussed with some smith
01:34:23 you discussed with some smith uh no
01:34:24 uh no did you approve her updates to the raf i don't recall but i i would have done she is the in my opinion the subject matter expert for it right did they need to be reviewed or approved by anybody else for
01:34:36 reviewed or approved by anybody else for example ac brand um
01:34:39 um not that i'm aware of now do you know whether whether they needed to or not that they they would have gone to the they would have gone to the board to say that they've been updated and they are available to the board to to have a look themselves whether they did or not i
01:34:51 themselves whether they did or not i can't i can't confirm when you say the board do you mean the latter half black and a house board sorry yes so you think they went to the latino house board for uh approval or just for information just to say that they'd been
01:35:03 information just to say that they'd been revised
01:35:04 revised right um was that just a piece of information or whether it was the national house board actually shown the texts
01:35:10 texts the text of the raf that they i believe they would have been given a copy of the of the rift it was available to them as all the documents were for the lack of board right what about the training department
01:35:21 training department did were they provided with the revised riffs yeah the train department i wish t yes
01:35:27 yes right that's say ost but not not beyond ost
01:35:30 ost no operationally no not operationally no can we then look at your third statement please um lfb double zero one two one one seven six
01:35:41 one seven six at page 13 and i'd like to look with you please at paragraph 49 where you answer the question at 5c please explain what consideration if any was given to the challenges posed by incidents involving
01:35:53 challenges posed by incidents involving multiple fsg calls as part of the revision of the rifts and your answer at paragraph 49 is this i believe the latino house fire involved at most around five concurrent fsg related calls
01:36:06 around five concurrent fsg related calls following the fire at lachlan house it was not considered that multiple quotes fsg calls would likely exceed five concurrent fsg calls in relation to a residential high-rise fire therefore revisions of the rifts did not consider
01:36:19 revisions of the rifts did not consider circumstances in which the control room was receiving more than five concurrent or multiple fsg calls
01:36:27 from the the year 2009 until june 2017 mr hayward do you recall being made aware of any incidents that involve more than
01:36:38 of any incidents that involve more than five fsg calls um
01:36:41 um not concurrent so i believe there was a fire at their house was uh was a fsg fire
01:36:51 fire um but i don't believe and i believe there was um seven or nine fsg's but i don't believe they were concurrent
01:36:59 a dare tower was the 31st of october 2015.
01:37:04 2015. have you seen any documents uh or reports of that fire to lead you to the belief that none of the seven to nine fsg calls were were
01:37:14 were not concurrent only the only the um
01:37:20 the log the um post action log the control did i'd like to ask you about a fire in poplar in november 2010 at the marriott
01:37:32 poplar in november 2010 at the marriott hotel which was a 10 pump fire do you have any recollection of that there were a lot of fires in the in that area so
01:37:40 area so i'm aware that what there were fires not that particular fire right um do you do you remember that the fact that there were 17 fsg calls received during the course of that
01:37:51 calls received during the course of that firm no
01:37:53 firm no um can we go to lfb double zero double one zero seven eight five
01:38:08 um if you uh look at page two in that email run please this is uh an email from andy hickman right at the very bottom of the screen
01:38:19 very bottom of the screen and over to the top of page three it's dated 12th of november 2010 from andy hickman to you and dave brown copied to uh peter cowep rita dexter and ron
01:38:30 uh peter cowep rita dexter and ron dobson and it's the daily bulletin and if you go over the page he says this with regard to last night's 10 pf that's pump fire as i'm sure you've been made aware this
01:38:41 as i'm sure you've been made aware this was a particularly challenging incident for control given the number and nature of fire survival calls that they handled some of which went on for over an hour despite the pressures the
01:38:52 over an hour despite the pressures the way information was passed to the fire ground enabling searching and in some cases rescues to be undertaken seemed excellent
01:38:59 excellent i visited control after i left the incident about 3am and thanked keith diamond and his staff for all their efforts it seems some of them really own their money last night and you may wish to look into whether it deserves formal recognition
01:39:11 recognition do you remember why it was a quote particularly challenging incident for control given the number and nature of fire survival calls unquote i do not
01:39:21 now we know that s.o.m smith sent you an email about this incident a little bit later in november 2010. can we go look at that it's at lfb triple zero three three two
01:39:32 three two one three
01:39:34 one three three three two one three and on page one
01:39:41 she says to you that this is 30th of november 2010 hi scott i've asked redwatch to carry out a debrief of this incident in anticipation of a prc where we can either attend or feed back information
01:39:52 either attend or feed back information relating to the communications i imagined the outcomes from the prc then being looked in looked at in line with fsg work and any recommendations then being taken to the board for approval as i was in attendance on the night and i
01:40:04 i was in attendance on the night and i have already taken some relevant issues and discussed them with pat at last week's meeting it is really the information flow that pat and i are working on thanks joanne do you remember whether you responded to
01:40:15 do you remember whether you responded to that email we haven't been able to find a response i i don't i don't recall i mean i would have done it did if she'd emailed me right do you remember whether you took any action in in reply to it
01:40:26 any action in in reply to it uh well she's already said that she's work it's about the information flow so i assume it's the the fact that there's um the flow from the control room to the fire ground and vice versa
01:40:37 vice versa so she's talking with pat who was a dac i can't remember his second name now is that nothing no no um
01:40:47 manager oh it may it may be it may be if they talk about information like it could be pat hutting but i can't i can't be sure but from the from the information there
01:40:58 from the from the information there she's she's already taken action so she's just telling me right i mean to help you on the pat question if you look a little bit or scroll a little bit lower down page one you can see that the email which comes
01:41:10 to you through this email which is in the next in the string which is from peter callup to you it also goes to pat utting right so probably is patton yes
01:41:25 now um you don't remember then taking yourself taking any action in response to this no no just to be clear now let's then look at a spreadsheet from the incident monitoring database or imd at lfb triple
01:41:39 monitoring database or imd at lfb triple zero three three six five four and we'll need the native version of this please
01:42:01 that's lfb triple zero 33654
01:42:10 and if you go to line 34 in the spreadsheet
01:42:26 you can see that on the 11th of november 2010
01:42:30 2010 uh there is a primary fire with the reference 191579101
01:42:38 and if you scroll across to column l it's a four plus pump fire and ops monitoring ort in column m
01:42:49 and ops monitoring ort in column m and then if you look um across to column v you can see the comment identified need to systematically manage
01:43:00 to systematically manage fire survival calls appointed dedicated sm to deal and provide command support and resources in the form of an additional cu and appliance crews now
01:43:11 now did you ever see this spreadsheet at the time do you think i may well have done i don't i don't recall seeing it but i may well have done right were you aware of the need at the time to quote systematically manage
01:43:22 the time to quote systematically manage fire survival calls yeah and i think again this is about the passing of information of fire surviving calls
01:43:29 calls this is a
01:43:31 this is a this is an ort so they'd have been on the fire ground monitoring um information coming into the fire ground right does this tell us whether there was any problem in control about managing fire
01:43:45 problem in control about managing fire survival calls systematically
01:43:49 i would say no because it's an ort report so
01:43:53 report so they're reporting on on the receipt on the fire ground not in control was there a debrief or performance review of
01:44:02 review of this incident for the control room uh that we would have been invited to one i suspect i don't i didn't go to it or whether joanne did or keith keith being the
01:44:14 joanne did or keith keith being the officer at the uh duty you may well have attended
01:44:18 attended now given that this incident had 17 fsg calls
01:44:21 calls um
01:44:22 um is it fair for us to conclude that the brigade at least recognized that an incident could generate many more than five fsg calls
01:44:34 many more than five fsg calls if if that's the case if it was if there were 17 concurrent fire survival calls on that incident i'm surprised it's not flagged up anything more because i i don't remember 17 five
01:44:47 because i i don't remember 17 five survival goal guidance calls well um even if they were not concurrent that's but all sequential and and given that some of them lasted for more than an hour i would suggest you that was
01:44:58 an hour i would suggest you that was unlikely
01:45:00 unlikely given that the email we've seen about the efforts made by som diamond's team on the night even if they were all sequential an incident generating 17 fsg calls
01:45:13 an incident generating 17 fsg calls i would suggest you would be something which would lead you to think wouldn't it that you needed to train for many more than at least many more than five and and
01:45:21 and and you know five survival calls coming in many different guises certainly back then
01:45:27 then where if we if we provided a little bit of advice to a a caller we'd mark it down as fire survivor guidance coin and subsequently nothing else happens or that person
01:45:39 nothing else happens or that person evacuates so so it's it's also about um you know sustained fire survival guidance because i i i agree but i think it's sometimes the interpretation of fire
01:45:51 the interpretation of fire of the calls themselves so
01:45:54 so yes i would agree we would do but i'm i'm not i don't recall this incident i certainly don't recall 17-5 survival guidance calls um but by is this right by um
01:46:06 um but by is this right by um late 2010
01:46:09 late 2010 policy
01:46:10 policy 539
01:46:12 539 although it had been revised quite substantially in september 2010 as you may remember still had appendix one and and a detailed definition of what a
01:46:23 and and a detailed definition of what a far survival guidance call was i believe so and
01:46:29 and part of that definition for good or ill was that it was a call where the uh control room operator remained on the line giving advice continually to the caller where that
01:46:40 continually to the caller where that caller was trapped trapped therefore it would be difficult wouldn't it to mistake a an uh
01:46:48 a an uh a call for an fsg call when it wasn't um
01:46:56 in that situation i'd agree but but i do i do
01:46:59 i do yes okay have you seen any information or any evidence to suggest that of those 17 fsg calls any of them were not properly fsg well so i mean some people aren't necessarily
01:47:10 so i mean some people aren't necessarily trapped but they're that they just want a bit of advice from from a call handler you know if they're if they're in a um
01:47:19 um if they're in a high-rise and they're not affected by heat smoke or fire but they're still a bit unsure about something that could have may offer a little bit of advice and that may well go down as far as survival going because
01:47:30 go down as far as survival going because we're giving some sort of guidance but it's not necessarily not necessarily a far survival guidance in in the fact that the caller is trapped well that would if that's the case that would indicate wouldn't it that there's some
01:47:41 indicate wouldn't it that there's some kind of mis recording of of the nature of calls i'm i'm talking now back back then i mean it's obviously revised since then and we're and we're i think we're a lot clearer on what our fire survival
01:47:52 lot clearer on what our fire survival and guidance call is well correct me if i'm wrong mr hayward but i don't believe there were any substantial revisions of the of policy 539 emergency call handling uh between
01:48:04 539 emergency call handling uh between uh september 2010 uh and uh some time at least after this event and in fact as at the date of the fire although there were subsequent revisions okay
01:48:14 okay um
01:48:16 um coming back to the point do you know um whether you considered asking ost to update the the rifts to account for more than five fsg calls
01:48:29 than five fsg calls or planning for this kind of event within brigade control no i didn't why is that
01:48:34 is that um
01:48:36 um i don't i don't know can we then look at pre-inquest action 11 and this is initial fsg training can we start going back to the lack of
01:48:48 can we start going back to the lack of assurance review of 2018 lfb404801
01:48:57 and i'd like to go in that document please to page 14 and look at pre and quest action 11 left hand side halfway down text in red deliver initial first
01:49:09 text in red deliver initial first survival guidance fsg training which complies with the national guidance to control room officers cro in order to develop the performance of the cras when handling fsg calls
01:49:22 and then underneath that it says this the brigade reviewed fire survival guidance training conducting a gap analysis of current training with national guidance fire service circular 1093
01:49:34 1093 training of fire control staff before developing a suite of training presentations covering fire behavior building structure types and concepts fast survival and emergency call handling techniques to meet the
01:49:45 handling techniques to meet the requirements of both national guidance and brigade policy these training presentations were initially delivered to all control staff between july and september 2011.
01:49:57 now just pausing there if i can
01:50:02 if i can what did the initial 2011 fsg training consist of
01:50:09 what presentation wise well what did what was yes what were the elements of the initial training in 2011 uh so it was a fire fire survival guidance
01:50:21 fire survival guidance presentation
01:50:25 there was a presentation on fire behaviour and building structure
01:50:33 and
01:50:35 there was a further presentation but i can't recall what it was right i think we could i can help you a little bit okay um let's let's see if we can get to this a little bit more quickly if you go to your statement your first statement
01:50:46 to your statement your first statement of paragraph 20 on page seven
01:50:52 you say
01:50:55 uh towards the bottom of the page uh
01:50:59 uh you say under action 11 following the review of training as part of the gap analysis see action five the revised initial fsg training was delivered to control officers between july and
01:51:10 control officers between july and september 2011. i proved i provide further information about fsg training below
01:51:16 below now we'll look at those presentations uh in detail later on in your evidence but just for the moment i just want to establish with you what the presentations were that made up that initial
01:51:26 initial fire survival training given to new entrants
01:51:29 entrants um
01:51:30 um can we go to your third statement lfb double zero one two one one seven seven six
01:51:37 seven six please at page three and i'd like to go to paragraph thirteen in that statement and you say this
01:51:46 uh in answer to the question query 1b little roman one where the assurance review refers to a suite of training presentations please confirm how many different presentations are included in that suite
01:51:57 that suite and you say i understand that the suite of training presentation consisted of three separate presentations uh
01:52:05 uh and
01:52:06 and if you then identify those in paragraph 14 if we turn the page
01:52:13 and you can see three there building types and concepts fast survival guidance and fire survival training introduction to fire and human behavior 10th march 2010
01:52:23 were those the three elements of the initial training for existing control stuff yes
01:52:29 stuff yes just to be clear initial training i i may have misled you by calling it new entrance training but by initial training initial training do you mean is that for new entrants or for existing staff it exists no it's for new entrants
01:52:41 staff it exists no it's for new entrants and existing staff so it was right it was training for it was training documentation for fsg whether or not they were new entrants or whether they were already employed i believe so yeah i see
01:52:52 i see did you have any involvement in in relation to the development of any of those elements of that training no
01:53:01 now
01:53:07 let's
01:53:10 look at lfb triple zero two eight two five eight page two
01:53:16 page two bearing in mind your last answer
01:53:23 at page two at the bottom of that page is an email from
01:53:27 from chris sharp on the 22nd of february 2010 to you
01:53:33 to you som turner some steve ads and others providing notes of a meeting that you had on the same date and the email is entitled fast survival planning meeting 22nd of february 2010. if we look at the
01:53:45 22nd of february 2010. if we look at the paragraph under background right at the foot of the screen it says this pom scott hayward identif explain the background for the need for more fast survival training and that elements identified in the gap
01:53:57 and that elements identified in the gap analysis between 1093 and bcts training have to be covered sh to send copy of gap analysis to m a
01:54:09 now this was at a time when you hadn't yet completed but we're about to complete i think your gap analysis in the april of that year 2010 isn't it
01:54:20 the april of that year 2010 isn't it i believe so yeah do you know what prompted this meeting uh the post lack now
01:54:28 you say post lacking so so after the after the
01:54:31 after the after the obviously we were doing pre-increased work anyway to identify um
01:54:38 um if there were shortfalls in our fire survival guidance so
01:54:44 we preempted that and started looking at it in more detail to try and improve improve the training so was this part of what would become a recommendation in the ga in the gap analysis yes
01:54:57 uh and were you directing what information had to be included in the training packages i was providing the gap analysis for him to include into so i i mean i was merely
01:55:09 include into so i i mean i was merely taking or looking along with along with joanne and and um mr cut bill and mr davis looking at what was what was not in our own training compared to the
01:55:20 our own training compared to the national guidance at the time right
01:55:25 so you were comparing or examining the content of the training yes yes let's then look at the first email in the same doc document run page one we see
01:55:36 we see uh an email that you sent back to chris sharp by way of response copied to lindsay turner and joanne stevards as well as robin hannon and you say good morning having reviewed
01:55:47 and you say good morning having reviewed what was discussed yesterday i am still not totally convinced that our particular part of the training package is right the purpose of the training is to provide a good grounding for control officers to enable them to provide fsg
01:55:58 officers to enable them to provide fsg to a caller when required i thought the fs aspects of the day are very good
01:56:04 very good paul jenkins presentation was particularly interesting and relevant however out of the full day's training we only provide perhaps two hours worth of training a bulk of that listening to calls
01:56:13 calls i agree with joanne as joe smith that some sort of role play should be introduced the following day or as part of an assessment at the end of the week to consolidate the day and to give the
01:56:24 to consolidate the day and to give the students an opportunity to attempt to provide that guidance in a controlled environment and i'll read a little bit more of this email to you i would also like to see the presentations beefed up with
01:56:35 the presentations beefed up with excerpts of fsg calls to reinforce the statements we are giving the examples of proactive questions have not been changed it has been noted that two of the questions are in fact statements and offer no advice or assistance to either
01:56:46 offer no advice or assistance to either the officer or the caller proactive questioning is about assessing the situation gathering intelligence and providing direct assistance to the caller whilst proffering information to
01:56:57 caller whilst proffering information to gain an insight into the environment the caller is in the examples provided on the slide do little to highlight the fact i suggest we revisit 1093 and review our current
01:57:08 we revisit 1093 and review our current training presentation to be honest in comparison to the fs input we fall behind a little can we make the subject more punchy i do not mean to sound negative and i know that a lot of work has been done to
01:57:20 know that a lot of work has been done to improve the training packages so far this particular subject is obviously of great interest in all quarters at the moment and likely to be until outcomes of the inquiry i want to make sure we're providing the most up-to-date and
01:57:32 providing the most up-to-date and relevant information available to our staff
01:57:35 staff in the meantime we'll be putting together a letter to clg etc
01:57:40 etc now that email suggests do you agree that you were providing feedback on the initial fsg training yes yes
01:57:47 yes yes why did you do that um
01:57:50 um again it was our you know we we were looking at what happened at lac now and what could be done to improve it we looked at the original training materials
01:58:01 materials and
01:58:03 and um
01:58:04 um that that was my feedback do you know what is mine that was our feedback right do you know whether your feedback was taken into account before the presentations were finalized um
01:58:15 um yeah i believe they were some of it i mean i think i went back again because they did make some revisions it still weren't quite the way it could have been it could have been better so i believe i did send further
01:58:26 better so i believe i did send further communication or spoke them verbally about some more tweaks right did you sign off or approve the training packages um
01:58:37 training packages um not not not i didn't sign anything i mean
01:58:40 mean i i i saw the last the last presentation and it was agreed that they were they were good to go you say it was agreed that they were good to go yeah i mean presumably you
01:58:52 good to go yeah i mean presumably you provided your agreement to that yes had you not agreed that they were good to go they wouldn't have gone no so in that sense am i right to suggest to you that you did have
01:59:03 you that you did have yeah okay i i i agreed along along with my experts that it was uh it was it complied with 1093 and your experts were joanne smith lindsey turner yes
01:59:16 were joanne smith lindsey turner yes and did you get approval specifically from uh ac brown to sign off no packages no did you continue to oversee the detailed
01:59:28 did you continue to oversee the detailed development of the fsg training hereafter not not the detail note i next want to turn to the question of when this initial training first took place after the latter house fire
01:59:39 place after the latter house fire can we go back to your first statement please
01:59:42 please uh at paragraph 74 on page 25. that's nfb 0055191 page 25 paragraph 74 the foot of the page under the heading chronology of
01:59:53 the page under the heading chronology of fsg training you say this in 2010 a full day's fsg training took place as was confirmed to the board on the 15th september 2010 uh all available staff
02:00:04 september 2010 uh all available staff those on those not on long term absence received this training now the board here is the latin house board i think it is indeed yeah uh and we'll come to examine that board in a little bit more
02:00:17 examine that board in a little bit more detail later on but when you say this training
02:00:21 training uh all available staff received this training was that all three of the presentations that you've identified i believe so and did
02:00:33 and did all staff receive all three presentations on all occasions
02:00:39 during this period yes i believe so have you been able to identify which training was delivered in which years after or it was in and after 2010
02:00:52 um no
02:00:57 why is that i'm i'm not sure what you're what you're what you're asking you request put that question again please well you've got this training these three packages yeah you say were were delivered yeah
02:01:08 delivered yeah to all available staff yes
02:01:13 after 2010 was that training delivered to all staff except the call handling the call handling would have only gone to or
02:01:22 or um behavior cool behaviours have only been delivered to new entrants because obviously the existing staff are you know familiar with
02:01:33 you know familiar with cool behaviour because they do the cut they take the course every single day so
02:01:38 so you say call handling is that which one is that is that far survival guidance or fast survival training introduction to fire and human behavior the
02:01:47 the human behavior right so that one was only for new entrants but the other two uh were
02:01:54 uh were or the idea was that they would be delivered to all staff yes on a continuing basis yes is that right i believe so yes okay now did it take a full day in 2010
02:02:06 now did it take a full day in 2010 to deliver those three presentations to the staff we allocate a full day um
02:02:15 we allocate a full day so yes did it did it take the full day no it wouldn't have taken the full day obviously there was breaks and and lunch so probably four or five hours well we call
02:02:27 probably four or five hours well we call that a full day yeah okay all right that's a full day then right how are they presented uh for them to fill a full day allowing for breaks and lunch
02:02:40 what do you mean
02:02:44 [Music] run me through what happened with the presentations were were presented where they before a group of eager students yes and then slowly they were taken through it such that it would take
02:02:56 through it such that it would take the sessions would take up the day uh they are taken through it and then now and obviously there it's an interactor like all training it's interactive and we want feedback from staff so you know the
02:03:07 staff so you know the the presentations could last you know an hour hour and a half and it would depend on on the interaction of the staff
02:03:15 the staff you know whether that whether that rolls over or goes longer or not right so they were teacher-led yes
02:03:21 yes and interactive in the sense that students could ask questions yes
02:03:27 was there any role play involved in those yeah it was
02:03:34 now i'd like to look at some email correspondence about this uh can we go to lfb double zero one zero seven four eight four please
02:03:50 now before i ask you about this just just to pick you up on or pick up a question
02:03:55 question um the the one day's training how did you find the time to do that whilst on the watch
02:04:01 the watch or was it done off the watch it was done off the watch at this this particular time so there was no difficulty in 2010 was there in uh having this training delivered off the watch no i had four watches 24 per
02:04:13 the watch no i had four watches 24 per watch
02:04:15 watch uh but there came a time when that became problematic it did yes can you identify a a date i think we could probably do it from what you've told us so far obviously when we went to the new shift
02:04:26 obviously when we went to the new shift patterns
02:04:27 patterns it was 2011 wasn't it yeah and then and then we started we lost five to cams and then we lost so around 2012. i see yes now i'm looking at this the email
02:04:40 yes now i'm looking at this the email run can we go please to the bottom of page one and look at the second email there which is an email from uh chris sharp to various staff date of the 21st of january 2010
02:04:52 date of the 21st of january 2010 uh
02:04:53 uh and copied to gvp control training and lindsay turner would you have seen this document
02:04:59 document not if it wasn't sent to me well it says gdp control training now i'm not i wasn't gvp controlled training um and she sets out the plan
02:05:11 plan uh
02:05:12 uh for the new entrant day on the 10th of march 2010. if you turn over the look at the turn over the page you can see that halfway down your screen it says the the
02:05:25 halfway down your screen it says the the date for the first new entrance day is wednesday 10th march day 43 of the course to be conducted at southwark and skyline house
02:05:37 and then she identifies the plan
02:05:41 just help me with day 43 of the course does she really mean day 43 uh potentially yeah it's a nine week course nine week course yep
02:05:52 yep uh and then the plan for the silent fire survival new entrant day is and she identifies six items one call handling techniques conducted by control trainers two basics of fire
02:06:03 by control trainers two basics of fire and fire development conducted by fs and fs stands for fire safety yes three fire development in the fire house at swk i think that's suburb yes
02:06:14 swk i think that's suburb yes conducted by fire safety fs four building types means of escape conducted by fs five case studies human behaviors conducted by fs six fire survival guidance the policy
02:06:25 six fire survival guidance the policy and rif conducted by control trainers that that was am i right the itinerary or plan for the new entrance initial fsg training in 2010
02:06:37 training in 2010 um
02:06:42 yes for new entrants for new entrants now
02:06:47 now four of those six elements were to be conducted by members of the fire safety team because you can see the fs is there that's two three four and five uh
02:07:00 if we then go to lfb triple zero nine two seven one nine i'm going to show you an email about
02:07:09 about this later in that year this is an email from chris sharp to control staff some of whom may be familiar to the panel
02:07:20 panel debbie real alex norman as well
02:07:24 as well as uh vic bagnall and others and also lindsey turner and joe and steven stibbards and you mr hayward as we can see yep
02:07:33 see yep now the subject is far survival training hello everyone for your information we still have spaces for the following dates and there are a set of dates and spaces there set out and some joining instructions underneath
02:07:44 and some joining instructions underneath that
02:07:47 if you
02:07:51 look a little bit further down you can see she says
02:07:59 she says just
02:08:00 just above
02:08:01 above the bottom of the page it is imperative that we complete this training as soon as we can the following is still to be nominated
02:08:07 nominated see that yes and then there's a long list over the next few pages of people to be nominated if we then go to lfb triple zero nine two seven two zero
02:08:19 two seven two zero these are the instructions document that she attached to that email let's look at that
02:08:29 it's entitled joining instructions for fast survival guidance training the structure of the day is start time 8 30 finish time 16 30 and um then you can see
02:08:40 and um then you can see various details there location uniform equipment etc and then the course consists of
02:08:47 and there are some bullet points um call handling techniques an interactive session looking at general challenges presented to call takers conducted by bcts
02:08:56 bcts fire and behavior of bil of people building construction fast survival policy
02:09:02 policy and then um if you um look at the last bullet point practice inputted by bcts this session is not accessible and is designed for people to practice in a safe and
02:09:13 people to practice in a safe and supportive environment was that the role play yes
02:09:17 play yes why was it not accessible uh i don't know what it should have been yes
02:09:24 uh indeed and you say it should have been maybe we can keep this short am i right that you say it should have been because the home office training document from 1994 keeping people safe said it should yes yes i can keep that
02:09:36 said it should yes yes i can keep that short then now let's go then on to or back to the latin assurance report lfb quadruple zero four eight zero one page 14
02:09:48 we've already looked at this section of the of the report dealing with pre-action for pre-inquest action 11 but just i just want to pick it up with you again um
02:09:59 um at the bottom of the first paragraph as we've seen it refers to the initial training being delivered between july and september 2011. we've been looking at 2010. are you able to tell us why it speaks of
02:10:10 are you able to tell us why it speaks of 2011 rather than 2010. i i it may just be an error a typo i mean it clearly says that we did did a train in 2010 and i believe we did the train in 2010 and we've seen the documents indeed
02:10:22 documents indeed so you could can you account for how that error came into this document no i had no input in this document uh now
02:10:32 uh now can we then look at your
02:10:35 second witness statement please lfb triple zero eight six two one three
02:10:43 page 7 paragraph 34 answering the question please set out details regarding the name and content of the refresher fsg training that was
02:10:54 of the refresher fsg training that was carried out between 2010 and 13 and detail to whom it was delivered and paragraph 34 you
02:11:03 you exhibit some documents for details of individuals who attended refresher fsg training between 2010 and 2015 please note the title of courses attended varies between entries
02:11:16 attended varies between entries are you able to clarify whether it was just new entrants that received that training in 2010 or existing control staff also i believe existing control staff also so even
02:11:28 existing control staff also so even though we saw the march new entrance day that training was also rolled out was it to
02:11:33 to uh existing staff yes yes and i think the joining instructions that we saw attached to the september email had a whole lot of people who were already members of staff yes yes
02:11:44 already members of staff yes yes so
02:11:45 so is it right that in fact there was a new entrance day in march but a an old entrance day if you like yes existing staff later in the year yes same program i i can't confirm if it was the same
02:11:57 i i can't confirm if it was the same problem but a similar program right
02:12:01 then i want to ask you next about pre-inquest action and that's the role of fire safety officers in the development and delivery of fsg training packages we've seen the reference and you've
02:12:13 we've seen the reference and you've confirmed the reference to fire safety in
02:12:17 in in a number of the elements of the new entrance and existing staff training in 2010
02:12:24 2010 can we look back at the assurance report please lfb404801 page 13 action 8.
02:12:35 action eight is include an input from fire safety officers
02:12:40 officers in control officers fire survival guidance training in order to ensure that training for control officers complies with the requirements of the national guidance fire service circular 1093 training of fire control staff
02:12:52 1093 training of fire control staff and underneath that it says this initial training and training for new entrants to the control room officer role in the fast survival guidance includes fire safety issues covering fire behaviour building structure types
02:13:04 fire behaviour building structure types and concepts and far survival in accordance with the national guidance this training material was designed by fire safety officers fire safety officers deliver training presentations on fire behavior for our survival and
02:13:16 on fire behavior for our survival and building structure types and contents to new entrants to the control room officer role
02:13:22 role the fire survival guidance presentations used for refreshing staff on the principles of fire survival guidance calls cover the basic elements of the national guidance with respect to escape
02:13:33 national guidance with respect to escape from different types of properties and basic fire survival techniques to protect callers from the effects of flames heat and smoke although recommended by the national guidance fire safety officers are not involved in
02:13:45 fire safety officers are not involved in delivering fire survival guidance refresher training now i read that all to you was there any fire safety officer input into training
02:13:56 into training before the occurrence of the lack of house fire in july 2009 not no
02:14:03 not no so at that date it would follow wouldn't it that the 1993 national guidance was in this respect not being followed i would agree with that um this fire safety input was introduced
02:14:15 um this fire safety input was introduced because of what the national guidance document 1093 recommended yes
02:14:21 yes namely that the training should be presented jointly by fire control and fire safety personnel yes yes and just for our reference purposes that's lfp four zeros three six one seven page six we don't need to turn it up
02:14:33 we don't need to turn it up can we
02:14:34 can we go to your first statement uh again paragraph twenty page six this time at the foot of that page
02:14:48 and that
02:14:52 that says this action 8 fsg training was amended to include input from fire safety officers within the new entrance training who provided an overview of fire behavior and returned the page building construction
02:15:04 building construction as part of that training the new entrants receive a presentation from fire safety officers in 2010 all staff not just new entrants received a presentation from a fire safety officer as part of the fsg training providing an
02:15:17 as part of the fsg training providing an overview on fire behavior and building construction this was intended to take place every other year as part of the refresher training this was the same presentation as that provided to new entrants
02:15:30 now were the packages with input from fire safety officers designed solely by fire safety officers or was it a collaborative exercise between fire safety officers and the ost i think the
02:15:41 safety officers and the ost i think the ost
02:15:42 ost um collaborated but i think obviously that the the the content was fire safety because it was about fire safety issues but i think the what was to be inputted
02:15:53 but i think the what was to be inputted would have come from rst as well right and why was it after latino so important to have fire safety officers input into the creation and delivery of of fsg training i think it was felt that to
02:16:04 training i think it was felt that to give control officers uh an overview of building types um and um and fire behaviour i mean clearly not simply for the purposes of closing the
02:16:15 simply for the purposes of closing the gap between lfe practice and national guidance there was a tangible benefit yes yes now in the last line of the same paragraph
02:16:24 paragraph uh you say
02:16:27 this was intended to take place every other year as part of the refresher training this was the same presentation as that provided to new entrants when you say this was intended to take place every other year what was the this
02:16:39 every other year what was the this the fire safety training so the fire safety officers would create and also deliver
02:16:45 deliver presentation on fire behavior and building construction yes and and that was going to be part of the refresher training for all cras yes yes
02:16:55 yes that intention clearly changed at a later stage didn't it or rather the realization of that intention yes yes and we'll come to that i i want before we do come to that later to ask you some questions about the
02:17:07 to ask you some questions about the content now the fsg training presentations that we've looked at um you'll recall that not long ago this morning i asked you about an email sent by chris sharp in january 2010 that
02:17:19 by chris sharp in january 2010 that identified the three packages for the new entrance um
02:17:24 um let's just go back to that if we can lfb double zero zero [Music]
02:17:30 [Music] page two
02:17:33 and i just want to see if i can line these up with your exhibits um
02:17:37 um if we go to the first of those uh
02:17:45 uh it's call handling techniques conducted by control trainers
02:17:51 trainers now that's what she says there let's look at your sh exhibit which we find at lfb 0086219
02:18:04 just have that on the screen
02:18:10 call handling techniques operational support team training that's your exhibit 21 i'm can we fairly assume that that's the same well that is the presentation referred to by chris sharp in the email
02:18:23 referred to by chris sharp in the email it's the same or similar this is op support so in 2010 it would have been bcts
02:18:29 bcts i see so it would have been broadly the same but um it's obviously been updated so bcts was the forerunner the gay control training team yeah right now
02:18:40 control training team yeah right now that's right now um did you see this at the time this presentation do you think uh something similar to this yes right uh
02:18:49 uh the second one that she refers to in her email
02:18:53 email which i don't need to go back to
02:18:57 uh is basics of fire and fire development conducted by fs
02:19:04 now we don't hold a copy of the standalone presentation with that title have you seen one you think no i i i believe that the the the present the fire safety presentation whilst that's been she's
02:19:15 presentation whilst that's been she's broken that down into elements of i think that one presentation does cover those elements right
02:19:23 right the third one she refers to is fire development in the firehouse at southwook conducted by fire safety now we don't again hold we don't hold a copy of a standalone presentation with
02:19:35 copy of a standalone presentation with that title i i think i think that was a visit to the firehouse and they had a uh on the handout there was a um like a
02:19:45 um like a floor plan of the of the firehouse i believe which is part of the same presentation so right
02:19:54 right was that training about lachnal no i don't i don't think it was specific to lachen right was that just the new entrance or was it also for the refreshers i think that was just a new end i think at that at that stage we
02:20:05 end i think at that at that stage we were just doing a new entrance to see what it looked like right the fourth one she refers to in her email is building types means of escape conducted by fire safety
02:20:13 safety um i'd like just to tie that to your exhibit 17 if i can lfb triple zero eight six two two eight is that the i'll wait for it to come up
02:20:27 building types and concepts there it is is that
02:20:30 is that um
02:20:31 um the presentation to which chris sharp is referring yes or certainly broadly similar to and again did you see that at the time i believe i did
02:20:40 did the next one number five that she refers to is case studies human behaviors conducted by fs fire safety we think we've identified that as
02:20:51 lfb3041028 can we have that up
02:21:00 it's dated 10th of march 2010 which would configure with yes the new entrance day is that the presentation she's referring to i believe so and does that include basics of fur and
02:21:12 and does that include basics of fur and fire development um
02:21:14 um i'm not sure i'll have to scroll up if we scrolled through i could uh we can do that actually yes if we go to a page two
02:21:23 two and three
02:21:24 and three i might give a hint introduction to fire yes and then page two let's just quickly look at that summary of objectives define combustion etc
02:21:34 etc so can we take it that that element was contained within this presentation looks like it
02:21:39 like it and then her last one her sixth was fast survival guidance the policy and riff conducted by control trainers you have exhibited at uh
02:21:50 uh sh219
02:21:52 sh219 a document at lfb triple zero eight six two one four i just want to see if that document is the document to which chris sharp was referring
02:22:04 uh in her email
02:22:12 that's lfb triple zero eight six two one four five survival guidance brigade control training session you see that yes
02:22:22 that yes again is that is that the document it looks assignment broadly similar to right and again you saw that at the time so to be to be clear we've got four i think of the six march 2010 training
02:22:34 i think of the six march 2010 training presentations referred to by chris sharp of ost or bcts as she was yes yes
02:22:41 yes yes uh
02:22:42 uh and you saw those at the time right that that's been helpful to identify what we're looking at can we then start with the presentation at uh on the screen
02:22:53 on the screen which is lfb triple zero eight six two one four
02:22:57 one four uh
02:22:57 uh fast survival guidance and it starts in the text below the box why are we doing this training incidents have occurred where control staff have been faced with a caller who is trapped by fire and are
02:23:09 a caller who is trapped by fire and are in a distressed condition a fatal fire in the west midlands highlighted that the control officer was unable to give the correct advice as they had not been given the training for such situations the home office decided
02:23:21 such situations the home office decided that we should all get this training now that west midlands fire that was in the early 90s was it that was the mary hill fire in 91 i believe yes and it was what led to the 93 circular did
02:23:34 what led to the 93 circular did and the 1994 keeping people safe documents yes now why does this introduction not include a reference to the latino house fire
02:23:43 fire um
02:23:45 um i don't know uh is the answer um this this was
02:23:51 i don't know is the answer would it not have been helpful to have mentioned that fire a london fire with six deaths so as to bring home to all controlled staff how important yes yes you would have
02:24:02 how important yes yes you would have done i believe there's an update to this presentation to reflect the black canal there is an update which we can think date to 2012 which we may come to we will come to okay
02:24:14 will come to okay but just focusing on this one where it says
02:24:17 says the home office decided that we should all get this training did it occur to you or anyone in your team that by saying that that might reduce the significance of the course for some control staff because it makes it sound
02:24:29 control staff because it makes it sound as if it's something that they just have to get done i i agree uh i i think i mean these aren't notes so the staff wouldn't have seen those notes they're obviously attached to the presentation that anybody seen the
02:24:40 presentation that anybody seen the presentation so i would like to think that it wasn't communicated that way um but i can't i can't answer it no but but unhelpful isn't it yes indeed put a
02:24:51 unhelpful isn't it yes indeed put a sentiment like that into the hands of trainers and you agree with me i think that it would be better to say that the reason for delivering the fsg training is to make sure that control officers were fully able to deal with fsg calls if they arose yes
02:25:03 if they arose yes do you know why this training does not refer to fsc 5404 which was the or part of the extant guidance at the time
02:25:12 time um
02:25:14 how we interpreted 5404 was about the three phases which weren't adopted by london fire so we didn't include it in the pre-need in the um
02:25:25 the um documentation i mean to be fair to you your gap analysis although on the verge of being completed hadn't yet been completed
02:25:32 completed yes now if we go to page 17 there's a slide entitled passing information to crews and it says always maintain effective
02:25:43 and it says always maintain effective communication with responding appliances keeping appliances informative of developments eg location of persons trapped will be essential throughout the call to aid rescue
02:25:54 call to aid rescue and then some text underneath it any subsequent relevant information must be passed immediately to the ic
02:26:03 it gives as you can see now assistance or guidance about how a control room officer should go about that does it well the control officer the most
02:26:14 well the control officer the most information that's passed at this stage information past the fire ground was via radio so a control officer would would um create the message in on procad which
02:26:25 um create the message in on procad which would be sent to the radio operator the radio operator then communicate that to anybody on the fire or the person at the fire ground at this stage it was only one-way communication so control would pass information down to the fire ground
02:26:37 pass information down to the fire ground we didn't necessarily get feedback from that if we needed information we had to try and call so there was no established communication at that point so
02:26:47 so we pass information down and that's that's where it stopped and this is in the days before uh
02:26:54 uh draft 155 actually became policy 790. yes
02:27:01 so just to be clear this is addressing a an existing structure
02:27:06 structure of communication systems whereby the caller receive sorry the call handler receiving information from the caller yes would do no more than type it into procad it would go to the radio operator and the radio operator would
02:27:18 operator and the radio operator would communicate that to the commander in in the control room that we were in at that time in the isle of dogs it was that close that they would go back you've got a message to pass so information will be passed and of course
02:27:30 information will be passed and of course that will be available to the supervisor desk as well to make sure the information was going to go right yes when you moved to merton was any consideration given to the way the layout might have undermined that
02:27:42 the layout might have undermined that process
02:27:43 process it was
02:27:44 it was i mean the the controllers were built without they were being built during the fire control project so that had already been decided um there was and it wasn't until we moved into
02:27:55 was and it wasn't until we moved into martin
02:27:57 martin that we realized that the the space was a lot bigger and people were further away and it was a problem to begin with about communicating because obviously control staff were used to communicating
02:28:08 control staff were used to communicating verbally being in the old control room and now we had this huge space um and we had to look at other ways to communicate they got around it um you know they'd still shout across the
02:28:19 know they'd still shout across the control room so they did get around it and got used to it but it was an issue that was raised can you please remind us of the precise date when you moved into the merchant control room um i believe it was
02:28:30 control room um i believe it was february the 4th 2012.
02:28:37 now if we go to page 21 there's a slide entitled reassure
02:28:44 the ffs are on the way they know where you are the ffs are there and the speaker note says this will help to reassure the caller keeping them calm and will help to keep the conversation
02:28:55 and will help to keep the conversation flowing
02:28:56 flowing do you agree that the slides do not take account of the warning in secular 1093 that quotes the normal procedure of calming the caller may not be appropriate and may even be dangerous in
02:29:08 appropriate and may even be dangerous in some circumstances i'd agree
02:29:12 and in fact looking at it that training was directly contrary to national guidance wasn't it
02:29:19 why is that i don't know as i say this presentation was updated so maybe the presentation that we're seeing is is not the presentation that was given on on 2010
02:29:32 presentation that was given on on 2010 but of course as as my evidence shows the um
02:29:37 the um we moved away from the bonding which is what the reassurance is here because of that reason and moved some more to reassess which doesn't seem to be displayed in this presentation
02:29:50 we know that come the conclusion of the internal investigations that led to the november 2012 black animal control report that the problem had been identified
02:30:02 problem had been identified that fire that um callers were being told by call handlers that fire crews would reach them quickly and that that was problematic because it created uh false reassurance
02:30:15 uh false reassurance can you tell us why that wasn't recognized or reflected in this training at this earlier stage as as i said i i i believe this may not have been the presentation that was delivered in 2010 because it doesn't
02:30:28 delivered in 2010 because it doesn't reflect the changes that we'd offered up right so because you know as i said we were quite clear and it was raised in our initial investigation that that we
02:30:40 our initial investigation that that we did
02:30:41 did um rely on bonding too much and not on on reassessing the the uh the fire yes do you accept this much that at least come november 2012 once the lessons of
02:30:53 come november 2012 once the lessons of latino house had been uh
02:30:56 uh understood and drawn by the brigade it should have been obvious that that facet of this training was wrong i i think there's a i think there's a place reassurance i think the
02:31:08 place reassurance i think the the onus we put on reassurance at that time was wrong if we go to page 15 of this training back a bit in it to uh assessment
02:31:20 there's a box that says assess which says this do you know where the fire is what's on fire which room are you in where is this in relation to the fire which floor are you on questions will be dependent on the
02:31:31 on questions will be dependent on the type of property cfsg riff and then the next slide at slide 16 says assess for example establish
02:31:41 establish if the room the caller is in is located at the front stroke back of the property is anyone else in the property straight where are they in the property record essential information and looking at that we know there was a
02:31:53 and looking at that we know there was a problem at latino where control officers tried to get information about the layout of the flats to establish the safest place in which the caller could be protected but that proved problematic because
02:32:06 but that proved problematic because in some flats there wasn't a safe room or callers were moving around remember that yes yes do you agree that those two slides i've just read under assessment don't acknowledge that problem or attempt to tackle
02:32:17 attempt to tackle to tackle it not in detail no no let's next go to um the next slide show which is building types and concepts at lfb 0086228
02:32:33 this is the training delivered by the fire safety officers as we've agreed and you've told us you were familiar with it or at least broadly familiar with something similar yes um
02:32:45 with something similar yes um in fact if we go to uh lfb double zero one zero eight zero two seven
02:32:53 seven we can see that you actually had provided comments on this presentation in march 2010 if we go
02:33:01 if we go to that email string and look at this second email on a page one uh you can see that here is an email from chris sharp to steve willit copy to
02:33:12 from chris sharp to steve willit copy to you and lindsay turner building construction pp presentation that's powerpoint presentation and
02:33:19 and it says hi steve i've received feedback on your presentation from my pom scott hayward and he has asked for more work to be done on it and then if you go to um
02:33:30 um uh
02:33:31 uh page two
02:33:32 page two well but before me let me ask you before i go there um in general what was the purpose of that presentation building types and concepts to give control staffer an overview of
02:33:46 to give control staffer an overview of of how buildings are built building constructive and any and and sort of the fire
02:33:51 fire um risks associated with them was it intended to cover the lessons learned at least thus far at latino i i don't recall but i would say yes yes
02:34:03 i i don't recall but i would say yes yes and now onto page two if we may
02:34:10 uh and i'm sorry i don't mean page two of the email run can i get back to the presentation itself nfb triple zero eight six two two eight
02:34:22 uh at page two in that presentation it says this
02:34:26 says this introduction evacuation systems and the building design considerations that support them just to be clear was that presentation intended to give control room officers training on how to
02:34:38 control room officers training on how to handle calls well let me let me let me put it more clearly was it uh intended to train them on how to handle calls or
02:34:51 to train them on how to handle calls or simply teaching them or training them on the different evacuation systems and building types yeah it was just giving them an insight an overview of of you know building design
02:35:03 you know building design uh you know and evacuation systems in buildings and you just explain for us if you would why that was important information or experience for cras to have well just to
02:35:14 experience for cras to have well just to make them more more aware they were very much
02:35:17 much control oriented and we wanted to you know give them a little bit more understanding so when when things are happening on the fire ground that they get an understanding of of why they're why they're doing or asking for what
02:35:28 why they're doing or asking for what they're asking for now
02:35:30 now we have examined this presentation in some detail and we can't find anywhere where it explains anything about rapid fire spread or how firefighters tackle a fire in a high-rise building
02:35:43 high-rise building and in fact that joe smith identified that very fact when she came to review this document in the august of the following year 2011
02:35:52 year 2011 which we may need to look at later um we may just look at in a moment but but
02:35:58 but is that right why is that why does is there no explanation in here about rapid fire spread or how firefighters tackle a fire because i don't think i didn't think that that control
02:36:10 i didn't think that that control officers would would necessarily what what would they do if if they knew how a firefighter tackled a fire in their role their role is to is to take information from a caller
02:36:23 take information from a caller uh and to pass that information to the fire ground you know the idea of these was to was to give an overview and just just you know let them know what happens out there rather than
02:36:34 know what happens out there rather than you know the detail of how a how a firefighting team going and do search and rescue for example we're focusing on rapid fire spread given the experience at lachnal can you explain why the presentation explains nothing about rapid fire spread
02:36:47 explains nothing about rapid fire spread the risks involved and what to look out for no i can't um i i mentioned to you a moment uh some smith's review in august 2011. perhaps we should look at that
02:36:58 perhaps we should look at that now
02:36:59 now um lfb triple zero two eight four four three
02:37:05 this is an email if you go to the bottom of page one
02:37:12 from jo stibbards as she then was to you 29th of august 2011 hi scott
02:37:19 hi scott i finally got around to reviewing quite quotes the fsg training it may be a good exercise for us all to do as my review is pretty scathing exclamation mark
02:37:30 exclamation mark um now we can we will look at the rest of that
02:37:34 of that in some detail perhaps with you but certainly with her at some point but if you look at the attachment please that is at lfb3083547
02:37:54 she attaches comments on each powerpoint as you can see from the second paragraph of the email and if we go to lfb triple zero eight three five four seven
02:38:03 seven here is her commentary on the training packages
02:38:09 and if you look at page one you can see uh
02:38:17 uh you'll need to scroll down a little bit further to two thirds down the first page
02:38:22 she's dealing with uh
02:38:31 uh i'm so sorry just scroll back up again it's got lost presentation two building types
02:38:43 uh and she says there under that presentation um slide two evac strategies lots and lots of information with very little to hold interest
02:38:53 and goes on defending place generally flats and advice does not emphasis government guidelines and actions no visuals no mentioned high-rise flats normally have alternative escape routes balconies leading to fire rates etc
02:39:06 balconies leading to fire rates etc uh and then there's a point about slide 15 and then there is no current fire safety advice in here and high and high rise flats advice is wrong and contradicts the advice given
02:39:17 wrong and contradicts the advice given on previous slides this needs replacing with
02:39:19 with current government fire safety advice for high-rise dwellings uh
02:39:25 uh can we look to how to streamline this do you know what d did you do anything with that specific set of criticisms in relation to this to this specific presentation the
02:39:36 this specific presentation the presentations were subsequently updated this is this is 2011 now so the presentations were updated and they were they will continue to be updated
02:39:46 updated do you know how it came about that the defects came into those presentations in the first place um i believe they were exist they were existing there were legacy presentations
02:39:57 existing there were legacy presentations from
02:39:59 from uh from before i i can't exactly remember when no right did nobody when considering what powerpoint packages to roll out to the new entrance
02:40:10 new entrance in 2010 or to existing control staff in later in the same year did nobody check what was going on in the lachenal house investigation and seek to reflect
02:40:24 house investigation and seek to reflect in the training what had thus far been learned
02:40:28 learned subsequently yes it did yeah subsequently but why not at the time i i can't i can't remember i can't recall i don't know why i mean given that
02:40:39 i mean given that uh you had completed your gap analysis in
02:40:43 in april 2010 and realized that the lfb was in
02:40:48 in they got the training was inconsistent with the national guidance and given that you were investigating what had happened at latino house can you explain why there was no system whereby the training that you were
02:40:59 whereby the training that you were rolling out uh in 2010 did not reflect thus far what you'd learned
02:41:05 learned about what had gone wrong at latin house so far as control was concerned
02:41:14 um i can't i can't i mean the i think i think the um
02:41:23 um joanne obviously went back and reviewed the powerpoint presentations she's picked up significant um um
02:41:32 um issues there which were subsequently updated
02:41:36 updated later on
02:41:37 later on at at the time um bearing in mind that the no i can't no and although they were updated later on as i was will come to see
02:41:49 as i was will come to see later on was 2011 and after once it had become much more difficult to train people on the watch yes and and once it had been problems with the cbt
02:42:01 once it had been problems with the cbt had arisen and the absence of fire safety and role play yes but at that time we weren't aware of those issues they developed as time went on so as the presentations got better the
02:42:12 so as the presentations got better the system for delivering them got worse yes
02:42:16 yes let's go to lfb double zero one zero four five seven eight please
02:42:27 uh this is
02:42:30 is the fire and human behavior presentation referred to in uh chris sharp's email and this is dated 10th of march 2010. we saw it earlier
02:42:42 we saw it earlier um
02:42:43 um i think this presentation covered both the basics of fire development and human behavior case studies uh element of the list in harim and if we go to page three we can see
02:42:54 and if we go to page three we can see the objectives set out in summary summary objectives um by the end of the session you'll be able to define combustion explain the triangle of fire explain three ways the
02:43:05 triangle of fire explain three ways the fire spreads explain the terms flashover backdraft appreciate the relevance of human behavior in fire
02:43:14 i think this was another presentation delivered by fire safety officers or was it not no i believe this was delivered by training that's just by training
02:43:26 now we can go through it but would you agree that it doesn't provide and it or didn't provide cros with any training on how to handle far survival guidance
02:43:34 guidance calls
02:43:36 calls in in this presentation no it doesn't no and doesn't include details about rapid external fire spread no no
02:43:47 and thus far what we've seen do you agree that the packages weren't enabling control room staff to prepare to understand how modern building construction features such as a cladding system could contribute to rapid and unusual upwards
02:43:58 contribute to rapid and unusual upwards fire spread no it didn't and would do you agree that in order to prepare for a worse worst-case scenario involving such fire spread it would have been necessary to produce the
02:44:09 been necessary to produce the photographs and explanations of the clatting fires that have taken place thus far in the uk and overseas um
02:44:17 um as an as an overview i i don't think i don't think if if control staff would have had that information information you know in my view the control staff take information
02:44:30 view the control staff take information from from callers and the information that caller's giving them not not visual rep presentations on on tvs of of a fire spreading up a building
02:44:42 tvs of of a fire spreading up a building if that's what you're what you're asking me i the idea of the fire safety was to give an overview to control staff not to give them tools to
02:44:52 to act on
02:44:54 act on on this these sort of situations well it's really just a question of giving control room operators a visual prompt this is what a cladding fire looks like uh and giving them the means to at least
02:45:06 uh and giving them the means to at least understand what they're dealing with if one occurred was that was that ever something that was considered no why is that i don't know can we then look at another presentation
02:45:17 can we then look at another presentation call handling techniques this is exhibit 40 to your first statement uh nfb 3055232
02:45:37 and if you just look at that on the screen and look at page two the aim which is to examine challenges
02:45:49 which is to examine challenges encountered by control staff when dealing with emergency calls now
02:45:54 now if we
02:45:55 if we look at your third statement we don't need to go to it i don't think in fact but you say that at paragraph 16.3 on page five that this was given to new entrants only
02:46:06 was given to new entrants only is that right uh i believe so yeah i'd like to see a bit more of a presentation too let's go to go to page three please objectives at the end of this session you'll be
02:46:17 at the end of this session you'll be able to identify possible difficulties understand caller's difficulties recognize the skills required to deal with a difficult call or caller think on page four there's a picture of a
02:46:28 there's a picture of a another brain think what makes a difficult call and then various other aspects of communication styles and matters of that nature yes i believe this is just given to new entrants well we've identified
02:46:41 to new entrants well we've identified from the metadata that
02:46:44 that the file name includes refresher can you help with that
02:46:50 no i mean is it possible that this was in fact
02:46:54 fact also delivered to existing stuff it may it may well have been but it wasn't a requirement to deliver this to um existing staff because of course they get it in new entrants and then on a on a day-to-day
02:47:05 entrants and then on a on a day-to-day basis on when they're on shift that they're doing they're learning this all the time because of course every call is different and people's behavior are different so it doesn't you don't need to go over the you know
02:47:16 you don't need to go over the you know they establish the parent child and you know those processes on a day-to-day basis on the job right now um looking at the presentation we found no mention of any proactive techniques that you identified in the
02:47:28 techniques that you identified in the gap analysis that should be included in the training you'll recall we saw that yesterday yes do you know why that was i don't
02:47:36 i don't you talking about proactive questioning yes
02:47:39 yes in in this present in this presentation this presentation i i think this is just about i think that's in the in more the fire survival guidance presentation where they talk about sort of questions you can ask whether they're proactive or
02:47:51 you can ask whether they're proactive or reactive depending on the on the caller i think i think the this um is about it's about how you know what sort of calls can be
02:48:02 you know what sort of calls can be expected from people depending on their on their current state of mind for example i see um i'd like to ask you about the changes that occurred to the content of the training
02:48:11 training uh after this year 2010 we
02:48:16 we looked uh
02:48:17 looked uh a moment ago at joe smith's email to you of the 29th of august 2011. where she said that her review was pretty scathing
02:48:28 pretty scathing let's just move back to that email chain nfb triple zero two eight four four three
02:48:46 that was at the foot of the page uh i think i got as far as the first sentence yep and she said that her review was pretty scathing uh and her embarrassment because
02:48:58 uh and her embarrassment because avon fire and rescue service had asked to see it and she approved that and then she says i've i've attached comments on each powerpoint and that's the document that was attached to be looked at she says this shall we
02:49:09 looked at she says this shall we generally discuss them at our weekly meeting if ronald reach saw what we had put out as training i think they would go nuts
02:49:16 go nuts and at the top of the email chain
02:49:21 she sends you [Music]
02:49:25 [Music] another email um correcting the
02:49:29 the uh one which she sent you about the recommendations as opposed to the riff so there seems to have been a problem with the document she sent you um
02:49:38 um did you ask her to perform this review on the training yes when did you ask her to do that i don't recall she says i finally got around to
02:49:49 she says i finally got around to reviewing the yeah training she puts reviewing in quotation marks do you know how long you were waiting for it i i don't recall
02:50:00 for it i i don't recall do you remember prodding her i i always asked her to to review the training documentation um
02:50:09 um because obviously of their uh background in control did you ask her why she had taken so long to get around to reviewing the fsg training no
02:50:18 no why is that because we have lots of we have lots of tasks to do um i don't i don't remember when i asked her to do it or how long it took for her to do it
02:50:29 it took for her to do it um you know if she's i've just got around it could have been a couple of weeks i don't i don't know exactly when it was right what was the purpose of that review to review to review the training the
02:50:40 to review to review the training the training packages and make sure they were they were um aligned with 1093 right now the gap analysis we know was you put out or finalized in april 2010
02:50:53 you put out or finalized in april 2010 this is now excuse me 18 months or so later august 2011
02:51:00 2011 and the training we saw rolled out in march 2010 to new entrants in september 2010
02:51:05 2010 to existing staff so that's a year but a year
02:51:09 year on
02:51:10 on what had happened in the in the in that time
02:51:13 time to
02:51:15 prompt you to ask her to review the fsg training i i don't record i don't recall did you discuss her opinions about the training that she expressed in the
02:51:27 training that she expressed in the recommendation yes yeah you know i i don't remember exactly what we said but i'm sure we discussed it because the there there were issues with the with training and the documentation the presentations
02:51:40 and the documentation the presentations you know
02:51:41 you know you've seen previous emails where i've asked for it to be beefed up and to be more punchy so and i've obviously asked joe to review on the back of that to see that it's been done and clearly it wasn't
02:51:53 been done and clearly it wasn't and
02:51:54 and what was done or was anything done to improve the training packages in line with her comments as to be able to give effect to her views i believe that the packages were updated again
02:52:06 so there was an update program was there yeah i think i think that then we tried to review the packages as often as often as as needed but obviously obviously after or after lacquer now and
02:52:18 obviously after or after lacquer now and the updates that we we aligned to 1093 um
02:52:23 um that was the last update i was aware of we are going as we go through your evidence
02:52:29 evidence to come to the training as it evolved from these beginnings through 2011 2012 and thereafter okay so we'll we'll see what was done okay um
02:52:41 what was done okay um before we do that let's uh let's go to another topic which is role play uh mr german i'm unlikely to finish this topic
02:52:49 topic before lunch but i'm quite willing to start it and use the can you get to a sensible point i think so can you all right well i'll try to carry on uh can we then go back to the lack of assurance report please
02:53:01 to the lack of assurance report please lfb404801
02:53:04 and i'd like to look at action 11 on page 14 again
02:53:16 we looked at this earlier this morning and the last paragraph i think i read to you but i just want to show you again this learning was supplemented uh for a number of control staff with a far survival guidance role play a number of
02:53:28 survival guidance role play a number of fire survival guidance scenarios were developed with the purpose of embedding learning and allowing controlled staff to practically explore this learning in a realistic situation now that role play on my right was
02:53:40 that role play on my right was introduced in order to comply with national guidance 1093 yes and if we look again at the 1994 document
02:53:50 document keeping people safe at lfb404750
02:53:54 page 28.
02:53:58 we saw this yesterday but i'll just show it to you again to remind you of it
02:54:06 uh the this is training presentation the training package to be presented jointly by fire control and fire safety personnel and to comprise a lecture session of one to one and a half hours
02:54:17 session of one to one and a half hours followed by a practical role play the role play will assess the instruction given by measuring the student's ability to do four things establish whether the caller can get out and stay out
02:54:28 caller can get out and stay out recognize unusual responses determine the location and situation of the caller and follow the sequence of prompts devised to give appropriate guidance to the caller and then there are nine subjects
02:54:40 subjects and the ninth of which is practical session role play as you can see there yes the instructor there was fire control and fire safety you see that no it's just off the page but i did
02:54:52 no it's just off the page but i did briefly see it beforehand you're right there it is now thank you i apologize
02:54:58 apologize nine practical session role play fire control fire safety yes yes
02:55:06 so the national guidance as we can see recommends active role play where the cro would need to carry out the role play itself yes yes and that should be assessed yes
02:55:19 and that should be assessed yes now can we go to your first witness statement
02:55:21 statement please at page 24 paragraph 69
02:55:30 you say in the first sentence or two sentences during the full days fsg training it was intended that staff members should undertake role play exercises i believe
02:55:41 undertake role play exercises i believe that active role play i.e role play in which staff members took part was used in 2010.
02:55:48 in 2010. did you ever observe an active role play session yourself no
02:55:53 no nothing i recall anyway why is that why didn't you um i don't know i don't know i i it was it was it was training detail i
02:56:05 it was it was it was training detail i didn't i saw an overview of the of the presentations and the fact that role player being it but i didn't sit and observe
02:56:12 observe control start actually doing it would it not have been helpful to have seen how that part of the training was being delivered
02:56:20 delivered in in what in what way because i i've done active role play so i know that i understand the benefits of active role play so from that perspective i i was i was happy that it was a good
02:56:33 i i was i was happy that it was a good positive way of training yes but exactly and therefore would it not have been helpful to you in in your role uh
02:56:41 uh overseeing training uh to have seen how that element recommended by national guidance uh was being delivered in hindsight yes but i i don't i don't recall doing at the time
02:56:52 don't i don't recall doing at the time right do you remember how long each role play exercise lasted at least when they were carried out uh i i don't but but i wouldn't have thought very long
02:57:02 very long no
02:57:03 no um now can we go to lfb double zero one zero four five three eight uh
02:57:16 i think you've told us in your second statement
02:57:20 statement your sorry your third statement at paragraph 19 that you couldn't find a copy of the role play exercise used in 2010 no
02:57:27 2010 no and you don't you don't remember whether anything was written down we we have identified this document from march 2010 fire survival scenarios so far survival role play do you see
02:57:38 so far survival role play do you see that yes
02:57:39 that yes um do you remember this document no looking at it now no no it's certainly one that you weren't able to locate or the lfb will note right
02:57:48 right uh it says far survival role play non-accessible why was it not accessible i i don't i don't know it should have been accessible yes and
02:58:00 it should have been accessible yes and if we scroll through pages two to five we can see that there were four scenarios of just skull scroll down to one
02:58:05 one scenario one able to escape from romford road scenario two trapped in bedroom possible escape by a window in the old kent road scenario three
02:58:18 three sapphire in flat next to call us flat caller unable to escape in black prince road in sc1 at page
02:58:26 at page five scenario four fire and kitchen in a bungalow very bad fire for debris falling from ceiling in streatham and if you um look at all of those is it is it
02:58:38 um look at all of those is it is it right do you remember that each of those would be practiced by the cro
02:58:44 the cro do you know how this would have worked yeah the trainer would have would have rung the cro and and gone through you know and acted out as a as a caller
02:58:56 you know and acted out as a as a caller going through this process right so the trainer would play the caller yes uh and the cra would play themselves and another trainer behind them to to watch them do it and maybe give advice
02:59:07 watch them do it and maybe give advice uh and at the end on page six it says learning outcomes
02:59:13 uh and there are some headings there were those the learning outcomes against which the crows uh should have been assessed it hadn't been accessible
02:59:29 yes and if you look at the last line on page six which i think we need to scroll down for
02:59:35 for call handling you see that yes uh
02:59:39 uh very last line was a relationship built with the caller you see that yes now this gap analysis that you did was completed in april 2010 yes so about a month after this role play document
02:59:50 month after this role play document um
02:59:51 um so to be fair to you the gap had only been
02:59:53 been finally identified then but were you concerned that this reference to building a relationship with the caller might be contrary to national guidance which discouraged creating an emotional link with the caller
03:00:04 link with the caller as i said i i think i think the the reassurance element and the the building particularly if it's a long fire survival call the building relationship with call exchange names is appropriate
03:00:16 with call exchange names is appropriate um it's just that i think that what what we did prior um to la canal is that we bonded too much and we got too much in the conversations with the caller about family and things that
03:00:29 caller about family and things that perhaps
03:00:30 perhaps detracted away from the fact that we should be looking to assess and see what what else we can do to help so i don't think i don't think it's it's wrong i just think we we used it
03:00:42 wrong i just think we we used it too much if that makes sense right can you tell us with any degree of certainty or confidence whether this role play document that's on the screen was actually used in 2010 or not i can't i
03:00:53 actually used in 2010 or not i can't i can't say whether it was or not you don't know what it was but the date fits so
03:00:58 so i'd like to think it did right um
03:01:02 um let me just show you one or two parts of your of your third statement then in paragraph
03:01:06 paragraph 20 if we can go to that on page six and mr german i'll i'll just cover this off before the before the break yes all right
03:01:15 right you say in paragraph 20 on page six uh in answer to the question if you have been unable to obtain a copy of the role play exercise used in 2010 or if the exercise was not documented are you able
03:01:26 exercise was not documented are you able to recall what it involved the trainer would call this is your answer the trainer would call the cras participating in training from a separate room the trainer would then act out an fsg call and the cro would be
03:01:37 out an fsg call and the cro would be expected to respond to the fsg call there were no required points to cover however the trainer would be expected to ensure the trainee followed the structure of the fsg reference information form riff the trainer would
03:01:48 information form riff the trainer would be an experienced assistant operations manager aom and would draw upon their experience to improvise a role play scenario for the mock call now in the light of the document from march 2010 that i've just shown you
03:02:01 march 2010 that i've just shown you would
03:02:01 would would you like to revise that paragraph in any way
03:02:08 i think fundamentally that's exactly what happened the trainer that the fact that the
03:02:13 that the the fact that the um the trainer had a script to run from potentially um
03:02:20 um it doesn't detract from the fact that the the trainer could like they do with other calls not necessarily fsg would for new entrants would call would call a caller and make up a call on the
03:02:32 call a caller and make up a call on the you know as they go because that's what they do as part of their their role you say there were no required points to cover here in paragraph 20 but in fact if the march 2010 document was used as
03:02:43 if the march 2010 document was used as the basis for role play that's not right is it no but but they're to follow the rift so the point to be be highlighted on the rift they're they're the points aren't they if they're following the rift down so what had i seen that
03:02:55 rift down so what had i seen that document then yes obviously there are points to cover but i think in this situation
03:03:01 situation the um
03:03:02 the um the new entrant will be sitting there with a riff up in front of them on the screen and they will be following that riff because that's what we train them to do
03:03:10 to do but but yes in that situation if there were no points to cover there clearly were but i hadn't seen that i wasn't aware of that yes thank you very much mr chairman is that a convenient moment i'm sorry we've gone a little bit longer no don't worry um but that is a convenient
03:03:23 don't worry um but that is a convenient moment i think it's time we had some lunch
03:03:25 lunch they would say we'll stop now uh we'll come back at five past two please and please remember not to talk to anyone about your evidence when you're out of the room thank you very much thank you very much
03:03:44 thank you mr millet five past two please
03:05:00 you