Evidence session examining the London Fire Brigade's response to the Grenfell Tower fire, including operational decisions, command structure, and lessons learned.
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00:00:30 Good morning everyone. Welcome to today's hearing. Today we're going to continue hearing
00:00:36 evidence from senior officers of the London Fire Brigade. Yes, Mr Kerr.
00:00:42 So may I call Mr George? Thank you.
00:00:53 Good morning Mr George. Good morning sir.
00:00:54 I understand you're going to make the affirmation. Yes, absolutely.
00:00:57 The words are on the screen. Would you read them out please?
00:01:00 I do solemnly, sincerely and truly declare and affirm that the evidence I shall give
00:01:05 shall be the truth, the whole truth and nothing but the truth.
00:01:09 Thank you very much. Now please sit down and make yourself comfortable.
00:01:19 Alright. Yes, Mr Kerr, when you're ready.
00:01:22 Thanks sir.
00:01:23 Would you please confirm your name for the record?
00:01:25 It's Philip Thomas George and in the fire service I was always known as Tom George.
00:01:29 Thank you. Three things before we start. First of all, if at any time during your evidence
00:01:33 you require a break, that's not a problem. Simply indicate that you'd like one.
00:01:37 Secondly, if you could keep your voice up whilst giving evidence, that allows the shorthand
00:01:42 writer to capture everything you say and capture accurately. And finally, although my questions
00:01:48 are intended to be short and clear, it doesn't always work out that way. If I have not made
00:01:53 myself clear, please say so and I'll rephrase the question so you know what I'm asking.
00:01:58 Now, you've provided two witness statements for the inquiry. The first is dated the 15th
00:02:03 of February 2019, which can be found at LFB, trouble zero, 32823. Is that it?
00:02:13 Yes.
00:02:14 And the second is dated the 13th of December 2019, which can be found at LFB, trouble zero,
00:02:22 38884. Is that the second statement?
00:02:25 Yes.
00:02:26 Have you had the opportunity to read both of those statements recently?
00:02:29 Yes, I have.
00:02:30 And are their contents true?
00:02:32 Yes.
00:02:33 And are you content for those two statements to stand as your evidence to this inquiry?
00:02:37 Yes, I am.
00:02:38 Thank you. Have you discussed your statements with anyone before coming here today?
00:02:43 Only with my legal team.
00:02:45 Both statements have a number of exhibits. Have you reviewed those exhibits before coming
00:02:49 to give evidence today?
00:02:50 Yes, I have.
00:02:51 Thank you. Now, I'd first like to discuss with you your professional background and
00:02:56 the positions you held at the LFB. You joined the LFB in 1987, is that right?
00:03:03 That's correct.
00:03:04 And between 1987 and May 2013, as you advanced through the ranks of the LFB, you held a number
00:03:10 of roles, including the head of community safety, borough commander for Barnet, group
00:03:16 manager in the central operations team and programme manager in the leadership and management
00:03:21 team. Is that right?
00:03:23 Yes, that's correct.
00:03:24 And between May 2013 and February 2016, you were the deputy assistant commissioner for
00:03:31 the south-west area of London. Is that right?
00:03:33 Yes, that's correct.
00:03:34 And in that role, you were responsible for day-to-day operations, including responding
00:03:38 to emergencies and fire prevention work in the eight south-west boroughs. Is that right?
00:03:44 Yes.
00:03:46 During that time, so May 2013 to February 2016, is it right that you reported to Dave
00:03:51 Brown?
00:03:52 Yes, that's correct.
00:03:53 And you reported to him, first of all, in his capacity as head of operations, prevention
00:03:58 and response, and then from April 2015, in his capacity as director of operations. Is
00:04:03 that right?
00:04:04 Yes.
00:04:05 And in March 2016, you were promoted to the rank of assistant commissioner, and between
00:04:10 March 2016 and March 2017, you served as the AC operational response. Is that right?
00:04:17 Yes.
00:04:18 And in that role, you also reported to Dave Brown. Is that right?
00:04:21 Yes.
00:04:22 And ultimately, in March 2017, you succeeded Dave Brown as director of operations. Is that
00:04:29 right?
00:04:30 Yes, I think it was the beginning of April, 1st of April, I think was the date that I
00:04:32 started that post.
00:04:37 Is it right that before your appointment as AC operational response, you had not previously
00:04:41 held a role within brigade control?
00:04:43 That's correct.
00:04:45 And so flow from that, that before undertaking your review of brigade control in December
00:04:50 2015, and starting as AC operational response in March 2016, you hadn't had any day-to-day
00:04:57 experience of brigade control?
00:04:59 That's correct. I mean, I'd visited control throughout my career at various times, but
00:05:03 certainly I had no responsibility for control at all.
00:05:07 Or any day-to-day experience of its operations?
00:05:09 No.
00:05:10 Now, the next matter I'd like to talk to you about is handovers from your immediate predecessors
00:05:15 as you proceeded through the relevant ranks. Now, before your appointment as AC operational
00:05:20 response in March 2016, was brigade control the direct responsibility of Dave Brown as
00:05:26 director of operations?
00:05:28 Yes, with principal operations manager Scott Hayward performing the role of head of control,
00:05:35 but oversight was with Dave Brown, yes.
00:05:38 And when you started as AC operational response, did you have any handover discussions with
00:05:43 Mr Brown about control specifically?
00:05:46 Yes, we did.
00:05:48 And can you give us the gist of the discussions that you had about control?
00:05:54 I think Dave, I was aware of some of the issues within control. I certainly knew about the
00:06:00 lead up to vision because I'd been in the same meetings as Scott Hayward, and some of
00:06:04 those meetings were chaired by Dave Brown. So I was aware of, let's say, more recent
00:06:08 issues, but Dave had been responsible for control for a number of years, maybe back
00:06:13 to 2009, 2010, I can't remember. So Dave explained to me what the different roles were
00:06:20 in there, how the support worked for the resource management centre, which had not, it had fairly
00:06:29 recently been moved from Stratford to Merton, so Dave would explain how those things worked.
00:06:34 So it was a rough overview, and then it was for me to go in there and see for myself.
00:06:38 Issues can sometimes be used as a euphemism for problems. Did Mr Brown identify to you
00:06:45 in these discussions the problems as he perceived to exist in brigade control?
00:06:51 No.
00:06:54 And so the issues as you described them, were they predominantly to do with the lead up
00:06:58 to implementation of vision?
00:07:00 Yes, and at the time I started, we'd gone past implementation, go live of vision was
00:07:06 actually 17th of November 2015, exactly six years ago today. So at the time I started,
00:07:13 vision was three or four months into the path to go live.
00:07:18 Can I take it from what you've said, that neither of you discussed control's response
00:07:23 to the actions identified as necessary following the Lacknell House fire?
00:07:27 That's correct, we didn't discuss that.
00:07:29 When you started as AC operational response in March 2016, can I ask you about your familiarity
00:07:36 or knowledge of certain documents, if I can go through those documents. First of all,
00:07:42 one manager Kelly's report entitled audit of quality management systems fire survival
00:07:47 training course, brigade control training department, dated the 3rd of August 2010.
00:07:52 Were you familiar with that document?
00:07:55 No.
00:07:56 Secondly, the Lacknell control report dated November 2012.
00:08:01 No.
00:08:02 Thirdly, review of the Lacknell action plan produced by group manager David Lindridge
00:08:07 in January 2013, which was effectively an audit of the actions taken following the
00:08:14 Lacknell House fire.
00:08:16 No.
00:08:17 Were you aware of the updated report that Mr Lindridge produced in November 2013?
00:08:23 No. The only thing I recall from seeing from Lacknell were the principal management board
00:08:30 meetings that Dave Brown shared and his actions would come up at those. So I was aware that
00:08:38 in brief of some of those actions that have fallen out of the Lacknell House actions,
00:08:42 but none of the reports you've said so far.
00:08:45 Thank you. We'll come on to the minutes and the actions following in due course. But finally,
00:08:49 were you aware of a document entitled the ELFIPA governance performance and audit committee,
00:08:55 so GPAC, their internal audit, the progress report for quarter three 2014-2015?
00:09:02 No.
00:09:04 And starting in post as AC operational response, did you discuss FSG training at all with Mr
00:09:10 Brown?
00:09:12 No.
00:09:16 And we can take it from your previous answer that Mr Brown didn't refer to station manager
00:09:21 Kelly's report on control and FSG training in particular from August 2010?
00:09:26 No, he didn't.
00:09:28 Thank you.
00:09:29 Now we've established those preliminary matters, Mr George. What I'd like to now deal with
00:09:34 is control and in particular your role as AC head of operational response. And first
00:09:40 of all, the scope of your role and your command responsibilities. Now if we can go to it,
00:09:46 you say in paragraph 15 of your first witness statement, which can be found at LFB trouble
00:09:52 zero three two eight two three forward slash four, you say at the end of the first line
00:10:00 that your role of head of operational response was a newly established one. How did your
00:10:06 role differ from that of your predecessor, assistant commissioner Richard Chandler?
00:10:13 At the time that Richard Chandler was AC within control, I wasn't really too sure what his
00:10:22 role was because I had no dealings with Richard. I knew Richard as an officer but didn't know
00:10:26 what work and his role was really. Certainly he left LFB for another fire rescue service.
00:10:34 His role in control was not replaced. And I think, so I didn't take over from Richard.
00:10:38 I think there was a number of years, maybe three or four years before I came in. So I
00:10:43 don't know in terms of how it differed. My role as I was given by Dave Brown was to,
00:10:51 in the main lead, a review of control, a cultural review. I was actually given that role before
00:10:57 I was made assistant commissioner. It was to be kind of an extra to the role I was doing
00:11:03 as a deputy assistant commissioner. We'll come on to that in due course Mr George. So
00:11:07 in essence, you're not able to help us because you lack the knowledge of what Mr Chandler
00:11:13 was doing to explain how your role differed to his. That's correct. Now can we turn to
00:11:17 control room and really the position of control within the LFB command structure? And in
00:11:23 his first statement, and we don't need to go to it, but the reference is at LFB 00321
00:11:29 66 forward slash three and it's paragraph seven, Dave Brown explained that between May
00:11:35 2012 and October 2013, control and mobilising became a department in its own right. Why
00:11:42 had control and mobilising ceased to be a department in its own right when you succeeded
00:11:47 as head of operational response in March 2016? I didn't know that it hadn't. I believe that
00:11:54 control was a department in its own right with Dave Brown as the head of service. So
00:12:00 Dave almost had a dual role, head of service and the AC for service delivery had various
00:12:06 titles. Is it right that when you started as head of operational response, your primary
00:12:11 responsibilities included first of all, brigade control and mobilising. Yes. The resource
00:12:16 management and logistics centre. Yes. And the UK fire and rescue services national coordination
00:12:22 centre. Yes, that's correct. Are there any other primary responsibilities I've not referred
00:12:27 to that were formed part of your job? There were two or three projects that were included in
00:12:33 the job, but in terms of responsibility for teams, the ones you've named are correct. Thank
00:12:38 you. If we can now turn to general oversight and particularly management of you by Mr Brown.
00:12:45 Now, as we've discussed as operational as AC operational response, you reported to Dave
00:12:50 Brown as director of operations. First of all, how would you report to Mr Brown? So
00:12:55 there were a number of one to one meetings. And I would speak to Dave on almost a daily
00:13:04 basis. And that had been the norm from when he managed me as a when I was in an area of
00:13:09 DAC as well. And the one to ones, were they the formal structure in which you reported
00:13:13 to him and supplemented by daily meetings as and when? Yes. And how frequently would
00:13:19 you report to him, for example, in the context of one to one meetings, would it be monthly
00:13:23 or quarterly? Oh no, more than quarterly. I think it was monthly. How would Mr Brown
00:13:31 manage your work and performance? He certainly had an oversight of everything I was doing,
00:13:37 the work, you know, what I was working on. He knew when I was working on the review,
00:13:44 I would give him regular updates of how that was progressing. Now, the minutes of the
00:13:51 brigade control management meeting show that AC Chandler either attended or sent apologies
00:13:57 as the need arose. Now, on our reading of the minutes from when you were in charge,
00:14:02 you don't appear to have attended those meetings. First of all, is that a correct reading of
00:14:06 your attendance of them? I recall going to one or two, but I don't think I was a regular
00:14:12 attendee unless there was something that the group needed an update on. And put differently,
00:14:18 if you didn't attend, why didn't you attend? I think it was a meeting of the middle managers,
00:14:25 and I felt it was the responsibility for Joanne and Keith Diamond and Scott to manage
00:14:32 those. It wasn't a senior management meeting, if you like. Now, you referred to Mr Haywood
00:14:38 earlier in your answer. Can we now turn to management of Mr Haywood? And if we can turn
00:14:43 to paragraph 42 of your first witness statement, which can be found at LFB 0032823 forward
00:14:51 slash 10. That's paragraph 42 at the bottom of the page. You say this. As director of
00:15:01 operations, I delegated responsibility for all matters relating to brigade control to
00:15:06 the POM. That's P-O-M. We had regular one-to-one meetings at which we discussed performance
00:15:12 as well as any issues that either of us had. And you also say in paragraph 41, so immediately
00:15:19 above that, that as director of operations, you had informal meetings on an almost daily
00:15:25 basis with Scott Haywood, as well as a number of one-to-ones. Now, how frequently were your
00:15:31 one-to-one meetings with Mr Haywood? I think they were fortnightly, if I remember rightly.
00:15:40 Were they only with Scott Haywood or would others attend? No, only with Scott. Sorry,
00:15:46 I think there may have been one or two times that we, during that meeting, we pulled someone
00:15:51 in that we needed something specific, some specific advice on or something maybe. The
00:15:56 clues in the title of one-to-one, then? Yes. And was the training brigades controlled,
00:16:01 the CROs, a recurring item in your meetings with Scott Haywood? Not particularly training
00:16:08 of the CROs, but training was certainly a discussion point, yes. Was vision also a recurring
00:16:15 item in these discussions? Definitely. Throughout my time in 2016 and when I was managing Scott
00:16:21 going into 2017 and 2018, vision was the primary discussion. What type of decisions would you
00:16:28 usually delegate to Scott Haywood? I had to have trust in my managers and Scott was my
00:16:34 manager that oversaw control. It depends if you're talking about the time when I was the
00:16:38 AC or the director, because the relationship changed slightly. Dealing first of all with
00:16:43 Scott Haywood, what time was AC? As AC, I was predominantly based at Merton, so in that
00:16:47 time I would meet with Scott far more regularly. We would see each other on a daily basis.
00:16:52 But what decisions, what type of decisions or areas of operation would you typically
00:16:56 delegate to him? I think I didn't change anything in terms of what he had responsibility
00:17:06 for from when I was given the AC role. So before I took the AC role, he would report
00:17:11 directly to Dave Brown. I didn't take away any of his decision making from that point,
00:17:17 but he knew that I wanted to be kept abreast of the type of decisions he was making. So
00:17:22 he put crudely, he ran control on a day-to-day basis? Yes. Would he ask for your advice and
00:17:29 guidance on particular matters? Yes. Can you give us an idea of what type of areas he'd
00:17:35 seek your advice on? Of the more strategic nature. If he needed some, let's call it
00:17:42 extra weight, added to a particular issue that he wanted me to speak to, maybe another
00:17:47 head of service? Now, Mr Brown told the inquiry when he gave evidence a few weeks ago, sorry,
00:17:53 in his witness statement, that quotes, he relied on the management structure and control
00:17:58 led by POM, Scott Haywood, to schedule and monitor the completion of the FSG refresher
00:18:04 training, which he tested at monthly management meetings. And the reference for that is that
00:18:09 Mr Brown's first witness statement, paragraph 66, LFB, trouble zero, three two one, double
00:18:15 six, forward slash two one. Did you delegate training or brigade control staff to Mr Haywood
00:18:21 as well? Yes, I did. But I wanted to be aware of what was taking place, especially when
00:18:28 I was an AC. I was based at control and I wanted to fully immerse myself in the role
00:18:33 of control. I felt as being given the AC for operational response, there's very few
00:18:38 operational officers, which is what I was, that were given the opportunity to work in
00:18:44 control, which was a different group of staff from the bulk of LFB staff. And I wanted to
00:18:51 really have a feel for their world. Just following on from that answer, do you know why you're
00:18:56 one of the few operational officers who were translated to run control? Because control
00:19:02 is a very different world. You know, it's very different from firefighting in the operational
00:19:08 arena. And it's very different from the non uniform side of the brigade, predominantly
00:19:13 who work at headquarters. Control was that separate group of staff just by the nature
00:19:18 of what they did. I put this deliberately impressionistically, but the impression arising
00:19:23 out of the evidence that we've heard over the past few weeks was that control was an
00:19:28 island unto itself, separate from operations and other aspects of the LFB's operations.
00:19:34 Is that a fair observation to make? Yes. Can you help us as to why it was an island unto
00:19:43 itself? Yes, I mean, certainly the control staff, the reason for being sent in there
00:19:50 to carry out a cultural review was because of complaints and issues raised as part of
00:19:57 staff engagement and stress workshops carried out in late 2015, where staff felt that they
00:20:04 were isolated from the rest of the brigade. They didn't feel valued as an organisation
00:20:09 or within the organisation. And I think it probably stems back to the location of control.
00:20:15 It's in Martin. It is. But before, if you go back, they used, if I give you a very brief
00:20:21 history, there used to be a number of controls around London, I think Wembley, Croydon,
00:20:27 Lewisham, if I remember rightly. And then that became one control at Lambeth. And all of those
00:20:33 occasions, control was at the same premises as a fire station. When it was Lambeth, it was the
00:20:39 original headquarters. So there's always been that mix of control staff with operational staff
00:20:45 up to the point they left Lambeth. And they left Lambeth and they moved to the Isle of Dogs.
00:20:50 And when was that? Are we talking 90s or the 80s or more recently?
00:20:55 I think early noughties probably, that they moved to a place called Greenwich View Place,
00:21:00 which was on the Isle of Dogs. I think they were there for around about 10 years. And then they
00:21:04 moved to Merton, I can't tell you exactly, maybe 2011, something like that. So they had become
00:21:11 separated from any other staff within the organisation. I think that's probably where that
00:21:17 stems back to. So geography essentially? Yeah, initially, yes.
00:21:24 How did you monitor matters and topics that were discussed at the Brigade Control Management
00:21:29 Meeting? Presumably you'd read the minutes. Yes, absolutely. And as I say, through the time I was
00:21:40 there in 2015 when I was based at Merton, sorry I beg your pardon, 2016 when I was based at Merton,
00:21:45 and going in 2017, the majority of those meetings I believe were vision related around some of
00:21:55 those issues to vision. So in terms of monitoring that, I was absolutely monitoring it on a day-to-day
00:22:03 basis of what was happening with vision. And any other matters that were recurring topics of
00:22:08 discussion with Mr Hayward, for example? Not that I can recall. In terms of your management of Mr
00:22:15 Hayward, did you set him targets? No, I don't believe I formally set him targets, but informally
00:22:29 he would certainly be tasked with working with CAPTA and ICT bridge engineers, they were based at
00:22:36 Merton, to try and get the fixes into the vision system. How did you assess his performance,
00:22:44 absent any formal targets at least? It was very difficult in 2016 to manage performance because
00:22:52 we'd moved to the new controller mobilising system, which was a fantastic system, it was a GPS based
00:23:01 system, so performance of the system did bring significant benefits to Londoners, in that on
00:23:07 average a fire engine was reaching a call in around about 10 seconds quicker than it had been under
00:23:13 ProCAD. So in true performance it was doing well. The consequences if you like for control staff was
00:23:23 extremely difficult for control staff, which can't be understated. And given the weight you've
00:23:29 attached that, can you give the panel an idea of the full extent of the difficulty of the consequences
00:23:34 that would be experienced by control staff? So I know there were control staff leaving the room in
00:23:41 tears because the system failed, for want of a better word. What the system did, and I witnessed it
00:23:48 first hand five or six times in 2017, was as calls were coming in the system would start slowing down
00:23:54 and it would slow down and slow down to a point that it stopped working and then control had to go
00:23:59 to their secondary mobilising system, which was basically pen and paper, because the computers had
00:24:05 all stopped working and it took sometimes a few minutes to come back up, sometimes a few hours,
00:24:12 which was extremely stressful for control staff. And it was down to Joanne Smith, Scott Hayward
00:24:20 myself and others to work with CAPTA who built the system to just get the fixes in place to prevent
00:24:28 these, well they had to try and identify why it was failing because it wasn't an easy thing to work out.
00:24:33 And were those problems resolved? Yes, but it took a very, very long time. Well into 2017 and there's
00:24:42 probably still some faults with the system even today, I don't know that, but certainly during
00:24:48 2016 and 2017 there were multiple faults. Thank you. Now if we can go to Mr Hayward's second witness
00:24:58 statement, LFB 0086213 forward slash seven and paragraph 38 which is at the bottom of the page.
00:25:10 Mr Hayward states that in turn he delegated responsibility for training to SOMs, I'll call them SOMs,
00:25:21 Lindsay Turner between 2009 and 2012, Vic Bagnell between 2012 and 2015 and Joanne Smith between 2015
00:25:31 and 19. Were you aware of that further extent of delegation? Yes, I didn't know about Lindsay Turner
00:25:39 and Vic Bagnell's roles, but my understanding was that Joanne Smith had the remit for overseeing
00:25:44 training. And you'd satisfied yourself that that further delegation was appropriate and effective?
00:25:50 Yes, Joanne was a very, very professional and the most experienced control officer.
00:25:54 How did you satisfy yourself that delegation was appropriate and effective?
00:25:59 Joanne, I knew that she was the most experienced control officer that LFB had and from speaking to
00:26:06 staff and I spoke to many, many staff during the time I was doing the review, everyone had very,
00:26:11 very good things to say about Joanne. I was very happy that I thought that was appropriate that Scott
00:26:16 had given her that role. And you saw no reason to change it for any reasons? No.
00:26:20 Notwithstanding that delegation, presumably you accept that as AC operational response you were
00:26:27 ultimately responsible for the provision of effective training to brigade control staff though?
00:26:32 Yes. Now can I look at further responsibilities to do with control and if we could go to paragraph 16
00:26:40 of your first witness statement which can be found at LFB 0032823 forward slash four.
00:26:47 Now in paragraph 16 there you outline helpfully your responsibilities as AC operational response
00:26:56 and you explain that you had overall responsibility for brigade control. Would that responsibility
00:27:01 also include the operational support team described as OST? Yes.
00:27:06 And so the responsibility for training brigade control also fell within your portfolio? Yes.
00:27:12 And in addition to brigade control and OST you were responsible for, as we've discussed,
00:27:19 the Resource Management and Logistics Centre. What was that first of all?
00:27:23 The Resource Management Centre was originally based at Stratford Fire Station and it was moved
00:27:31 a few years before I started at Merton. It was moved to Merton mainly to save money.
00:27:38 And they sorted out the SBM, I think the inquiries heard about the SBM, which is the standby module,
00:27:44 which looked at all of the fire stations across London, the number of staff they would need with all
00:27:50 the different skills and if there was any shortages at any fire station it was the RMC's responsibility
00:27:56 to move a firefighter from one station to another to be able to put those fire stations on the run,
00:28:01 make them all available. That was the RMC's responsibility.
00:28:04 We touched on this earlier that you were responsible for the National Coordination Centre.
00:28:09 We see in the fourth bullet point there. Yes.
00:28:11 What was the National Coordination Centre?
00:28:13 So I think following 9-11 attacks the UK government put measures in place to increase the resilience
00:28:23 for things like terrorist attack across England and Wales.
00:28:28 And there were a number of appliances that were purchased and resourced by UK government.
00:28:34 Things like instant response units which had mass decontamination equipment on extra water boughs,
00:28:44 high volume pumping appliances, that kind of thing.
00:28:47 Understood.
00:28:48 And it was the National Coordination Centre's role to deploy and move around the country
00:28:54 those type of resources for specific events, terrorist attacks, mass flooding events, that kind of thing.
00:29:00 Thank you. Can I now turn to day-to-day involvement with control?
00:29:04 And we see at paragraph 17 of your first witness statement, which is just over the page,
00:29:11 that you say in the fourth line, and I quote,
00:29:15 you had free and unrestricted access to brigade control and that you would, and I quote,
00:29:20 meet and speak with staff at all levels on an almost daily basis, close quote.
00:29:26 Did you have any day-to-day operational involvement with control?
00:29:31 Well, I was an operational officer, so I would still be deployed to instance,
00:29:39 commensurate with my role, and when attending incidents or when being mobilised,
00:29:44 I would certainly have to engage with control to find out details of the incident.
00:29:48 And, you know, when I got to the incident, when I leave the incident, I would have to engage with control then, yes.
00:29:54 Would you listen to calls received by CROs, for example?
00:29:58 We didn't refer to them as CROs, but CROs, yes.
00:30:03 Certainly in the time I was undertaking my review, I would certainly sit down with the CROs, AOMs, OMs,
00:30:08 and listen to calls by using a headset plugged into their terminal, yes.
00:30:14 And would you monitor them using, I think it's called call coach, is that right?
00:30:18 I was aware of call coach, but I never used that myself. I was never trained on that.
00:30:22 I was never trained on any of the equipment that the control officers used.
00:30:25 Do you know whether Mr Haywood, for example, used call coach to monitor the calls received by CROs?
00:30:31 I don't know that. I know Joanne Smith certainly did. I don't know that Scott did.
00:30:35 Did you have any role in the performance management of the CROs or the officers of any other rank who received calls?
00:30:43 No direct responsibility for that, no.
00:30:50 Did you ever directly manage Joanne Smith?
00:30:53 No.
00:30:54 That was left to Mr Haywood, presumably?
00:30:56 Yes.
00:30:57 And would you directly manage any other of the senior middle ranking staff, if I can call them that?
00:31:03 No.
00:31:06 Can I now turn to a separate topic, which is something you adverted to earlier on, which is the Lacknell House Board.
00:31:12 Now following the fire at Lacknell House in July 2009, the LFB set up the Lacknell House Board in October 2009.
00:31:21 Now the purpose of the board was to oversee all aspects of the Lacknell investigation and related issues,
00:31:28 so as to better understand the LFB's response to that fire.
00:31:33 In broad terms, is that a fair summary?
00:31:35 Yes.
00:31:36 And it was also there to ensure that appropriate action was taken in a timely manner to deal with the issues that had been identified.
00:31:44 Again, is that a fair summary?
00:31:46 Yes.
00:31:50 And the identified actions were contained in an action plan that was appended to the minutes of the Lacknell Board meeting of 15 September 2010, is that right?
00:32:01 I believe so. I wouldn't have been aware of it at 2010.
00:32:06 If we can just go to it, just so you can see what I'm talking about. It can be found at LFB 0055192 forward slash seven.
00:32:23 The document between pages seven to ten is what I will refer to as the action plan.
00:32:31 And as I understand it, at paragraphs 69 and 70 of your first witness statement, you say that you were assigned work on particular actions, is that right?
00:32:39 I was assigned one particular action, yes.
00:32:42 And that action had nothing to do with control, is that right?
00:32:46 That's correct.
00:32:49 Now, if I can now turn to having set out the broad parameters of the Lacknell Board's remit, can I now look at your involvement in addressing various actions and recommendations?
00:33:00 Now, first of all, we have a letter sent on the 4th of April, or rather an email, between Dave Brown and AC Richard Chandler.
00:33:10 And we can find that at LFB 0028942.
00:33:19 And we can see roughly two thirds of the way down this page, below the heading Brigade Control, there's the first bullet point.
00:33:27 And in that, Mr Brown directs Mr Chandler to, quotes, go through every point on the Lacknell action plan and pull them together into spreadsheet and satisfy yourself that everything has been completed, close quotes.
00:33:43 First of all, did you ever see a copy of any resulting spreadsheet?
00:33:48 No, I didn't.
00:33:50 Were you aware that this exercise had taken place or was required to be carried out?
00:33:56 No, I wasn't aware.
00:33:59 Did Mr Brown ever discuss with you the findings that Mr Chandler reached as part of his review of the Lacknell Board action plan?
00:34:08 No.
00:34:11 Now, on assuming your role as AC operational response in March 2016, did you know that some of the Lacknell Board actions did in fact relate to the operations of Brigade Control?
00:34:22 Yes, I was aware of that.
00:34:25 Did you satisfy yourself that the actions which concerned control had been properly, fully and effectively addressed, or did you assume that they had been fully, effectively and properly addressed?
00:34:38 I guess I must have assumed because I took up my position in 2016 and the Lacknell incident had been seven years before and I wasn't going in there to look back at things that had happened in the past, so I think I must have assumed.
00:34:51 And it was simply because the passing of time, you'd assumed that they'd done everything that they were required to do?
00:34:58 Yes, I guess so.
00:35:00 I can take it from your earlier answer that you hadn't read when you assumed your post as AC operational response, the Lindridge reviews from 2013?
00:35:16 Excuse me, I didn't know there had been a Dave Lindridge review.
00:35:20 And no one referred to it in any conversation?
00:35:22 No.
00:35:23 Could I take you to an email dated the 28th of June 2013?
00:35:28 It was sent from AC Richard Chandler to Dave Brown and we can find that at LFB, trouble 060701.
00:35:41 As you can see, it was sent by Richard Chandler at 1429 on the 28th of June 2013.
00:35:54 And if we could deamplify and see at the top of the page, it was forwarded or sent by Mr Chandler to Scott Hayward directly, very swiftly thereafter and there was damage at the same time for information.
00:36:10 Now, the email from Chandler to Brown set out a number of comments on the Lacknell audit, presuming that's a reference to the Lindridge review of 2013.
00:36:22 And the email sets out various actions and the status of those actions and it also appears to include AC Chandler's comments on the status of each action.
00:36:32 Am I right to assume that you have not seen this before?
00:36:36 That's correct.
00:36:38 Notwithstanding that, can we look at item 16, which is on page two, roughly halfway down that page.
00:36:49 And it had the heading control general review of training.
00:36:55 And then we have fifth line down, recommended action.
00:36:59 It says this and I quote, a fundamental review of control training should be undertaken in 2015-16.
00:37:07 Training for control should be brought under the training contract currently in place with Babcock.
00:37:13 Explore the options for independent external peer review or audit of control training.
00:37:20 Now, did you or Dave Brown see your review that you later carried out as quotes a fundamental review of control training as contemplated by AC Chandler here?
00:37:32 No, I don't think it's the same thing.
00:37:36 Were you aware of whether any fundamental review was carried out as contemplated by AC Chandler?
00:37:44 Not a fundamental review of control training.
00:37:47 No, I don't believe there was one to my knowledge.
00:37:51 Now, throughout your time as AC operational response, Scott Hayward was the principal operations manager of the POM.
00:37:58 He also attended the Lacknell House Board between 2009 and 2012.
00:38:04 Did Mr. Hayward ever discuss with you any of the control specific matters that have been considered by the Lacknell Board?
00:38:11 No.
00:38:13 Dave Brown had also been a member of the Lacknell Board.
00:38:17 Did he discuss with you any of the control specific issues that have been identified by the Lacknell Board?
00:38:23 No, I don't believe so.
00:38:26 I now want to come to a separate topic, which is the one again you've highlighted in your earlier answers, and that's the 2016 review of brigade control.
00:38:35 And first of all, can I look at the background to that review, which you've touched on earlier, but I'd like to get some further detail.
00:38:42 Now, if we can go back, apologies for jumping around to your first witness statement, which can be found at LFB 0032823 forward slash four.
00:38:56 And if we could look at paragraph 13, the top third of the page, and here you say that you were asked to conduct the 2016 review of control alongside your role as area DAC.
00:39:11 Now, you touched on this earlier, but what's the point that is the area DAC, you were relatively speaking, an external pair of eyes to give an independent review of what was going on in brigade control?
00:39:24 That may be the case. I don't believe I was told why they decided to pick me.
00:39:31 He didn't say, listen, you're an effective outsider. You can give this a degree of external scrutiny that requires or anything along those lines.
00:39:39 No, he didn't say that. No.
00:39:43 Sorry, it may be because I was the DAC for Southwest area and the control at Merton forward within the geography of the Southwest area.
00:39:52 So again, geography.
00:39:53 It may be that.
00:39:54 But it wasn't anything in the narrow sense that you had no day to day responsibility for control.
00:39:59 And therefore none of the area DACs would have had any responsibility or any history with control.
00:40:05 Did Mr. Brown explain to you what had prompted the review?
00:40:09 Yes.
00:40:10 And what was it?
00:40:12 So I was aware that between, I think, September and November 2015, some senior officers have been into control to conduct staff engagement sessions and stress workshops, not just to control.
00:40:29 These were being undertaken throughout that year all across the organization in different teams.
00:40:35 But the ones that control have been, let's shall we say, problematic and that staff were making complaints and raising various issues.
00:40:44 It should also be said that, unfortunately, it coincided with the rollout of vision in the November of that year.
00:40:52 And I would think probably much of the many of the issues were probably because control were feeling quite stressed about the rollout that had happened in November.
00:41:00 And so it had nothing to do with AC Chandler's suggestion from 2013?
00:41:05 No.
00:41:06 Now, when you became the AC operational response in March 2016 and so responsible for brigade control, you were effectively reviewing your own department when carrying out the review.
00:41:18 Is that a fair observation to make?
00:41:20 I didn't see it that way.
00:41:21 I was a fresh pair of eyes, like you've said, and I saw it as exactly that when I went in there.
00:41:26 I had free rein of the control.
00:41:28 And it was for me to look at some of the issues that have been raised by staff and identify solutions to fix them.
00:41:36 Can we look at the terms of reference?
00:41:38 And you touch on this in paragraph 13 of your first witness statement, where you explain in the first sentence that your review was originally titled, quotes, cultural review of brigade control, close quotes, was later changed to review of brigade control.
00:41:56 What was the reasoning for the name change?
00:41:59 Dave Brown decided to change the name. I'm not entirely sure why.
00:42:05 But you clearly didn't like the word cultural.
00:42:07 I couldn't possibly comment.
00:42:10 Did the name change indicate or suggest a change in focus of your review?
00:42:16 Maybe. Although the name change, I still saw it really as a cultural review, given the issues that had been raised in the months previously.
00:42:24 So it didn't cause you to alter the approach you were minded to take?
00:42:28 No.
00:42:35 Was the review or was it communicated to you that there were problems in control that were attributable to the particular culture of control?
00:42:50 It would certainly seem that looking at the, I'd seen a summary of the issues, if you like, that staff were raising with the officers that had gone in there to carry out those workshops and meetings with staff.
00:43:07 So I'd seen copies of what staff were raising. So seeing those.
00:43:14 Sorry, can you just repeat the question?
00:43:15 Yes, of course. Was it communicated to you that there were problems in control that were attributable to the particular culture of control?
00:43:24 As I say, yes, I suppose would be the answer to that.
00:43:27 Now you've helpfully exhibited the terms of reference for your review, which we can find at LFB Trouble Zero 32827.
00:43:42 First of all, did Mr Brown approve the terms of reference before they were ultimately approved at a meeting on the 8th of February 2016?
00:43:50 Yes.
00:43:51 And they were approved at a JCC meeting. Can you help us? What is the JCC?
00:43:56 It's a joint committee for control. It was the meeting between the managers of control and the RVs, the responsible bodies, which were predominantly GMB, Unison and FBU joined those meetings in, I think, 2017, 18, something like that.
00:44:15 And am I right in understanding that Mr Heywood also agreed with, approved, whatever's the right word, these terms of reference as well?
00:44:23 I believe Scott Heywood was shown the terms of reference, but it was really drawn up by me and approved by Dave Brown.
00:44:29 And basically shown to Mr Heywood for his information rather than...
00:44:32 I believe so, yes.
00:44:33 It's always tempting to get the answer out. If you could let me finish the question first. The reason is it allows the transcriber to note down my question, your answer.
00:44:43 I apologise.
00:44:44 It's an irrepressible tendency to get the answer out. Now, you refer in your statement to collating the issues. Those issues are the ones that had been identified as part of this exercise you referred to, to see what staff were worried about or complaining about.
00:45:04 Yes.
00:45:06 And they were raised at engagement sessions and stress workshops that had been held with control staff.
00:45:11 Yes.
00:45:12 And the focus of these terms of reference was solely shaped by the results and the conclusions from those sessions. Is that a fair reading?
00:45:23 They weren't informed by anything else.
00:45:26 I don't believe so.
00:45:28 Unless Dave Brown wanted to add in anything that hadn't come out from those sessions, but he wanted to, you know, have a review of, I'm not entirely sure.
00:45:40 We see on this page the subheading, the second one, within scope. And then there are six, I think, bullet points set out underneath that. And then there's a paragraph which reads as follows.
00:45:54 And I quote, the areas listed above are contractual and the brigade already has agreed policies and procedures in place that cover these.
00:46:04 The review will identify if these are being followed correctly.
00:46:08 The areas listed below, whilst not strictly terms and conditions of service, will be analyzed and examined by the review team.
00:46:17 Was there any substantive difference between your approach to the areas identified as contractual as opposed to those areas which had been identified as not strictly part of terms and conditions of service?
00:46:31 No.
00:46:34 The third bullet point, which was in the second list of bullet points, part of the not strictly part of the terms and conditions and service, was, and I quote, familiarization, training and maintenance of skills.
00:46:49 And that can be seen there.
00:46:51 Why was familiarization, training and maintenance of skills not completed as part of the terms and conditions of service?
00:47:04 I'm not completely sure.
00:47:10 I put differently, it seemed that training was inherently or ought to be inherently part of terms and conditions of service.
00:47:17 And yet the way it's set out here gives the impression that training and maintenance skills was not part of terms and conditions of service.
00:47:26 Is that a fair reading?
00:47:27 That is fair. And I, looking at it now, there's every reason that that should sit in the list of bullet points within scope above, yes.
00:47:37 Did the fact that training and maintenance skills was in the not strictly part of terms and conditions of service section affect the way you approached your consideration of training and maintenance of skills?
00:47:52 No.
00:47:55 Would that topic have been governed, at least in part, by policy note 164 on control training?
00:48:06 I'm not familiar with the policy note 164, if I'm honest.
00:48:10 If we can just, there are so many policies, I don't blame you for not being familiar with them, with the numbers shouted out.
00:48:17 If we can go to LFB, trouble 084054.
00:48:25 And there we go, PN164.
00:48:30 Owner, head of service delivery and mobilizing, responsible work team mobilizing.
00:48:35 And as you can see from the contents page, it was to do with trainee control training, then continuation and refresher training.
00:48:41 Have you seen that before?
00:48:43 No, if I'm honest, I don't think I have.
00:48:46 And that is something that would have been the responsibility in practical terms of Mr. Heywood, is that right?
00:48:53 Yes.
00:48:54 I mean, the fact is dated 1994 would be of concern to me anyway, and it would have been at the time I started in 2016.
00:49:03 There were a number of documents that control used that dated back a long time, and I know the inquiries heard about 1093 and some others.
00:49:12 Within my review, I wanted to make sure that suitable and sufficient, meaningful training and familiarization training was taking place.
00:49:20 That was my aim.
00:49:21 I don't want to miss it. If we go to page six, I don't want to mislead you into thinking this was the only version.
00:49:25 There's a 2015 version as well.
00:49:27 And there we have it there.
00:49:32 But again, the point is you weren't familiar with the existence or the content of this policy.
00:49:37 I wasn't, no.
00:49:39 When now if we could go back just so we have it on the screen to the terms of reference that we were looking at before, which is LFB, trouble zero, three to eight to seven.
00:49:53 Thank you.
00:49:54 Now, when you were drafting these terms, presumably you did not have regard because you weren't aware of them.
00:50:02 The Kelly report from 2010 or the Lindridge reviews of 2013.
00:50:06 Is that right?
00:50:07 As I said, I wasn't aware of those previous reports.
00:50:10 No.
00:50:11 And when you circulated these terms of reference, no one said, hang on a second, Tom, have you had a look at the Kelly report or the Lindridge reports?
00:50:21 No one said that.
00:50:22 No.
00:50:23 Now, can we look at the process of information gathering and the drafting process of your review?
00:50:32 And again, apologies for jumping around, but can we go back to your first witness statement, which can be found at LFB, trouble zero, three to eight, two, three, forward slash five.
00:50:45 And we can see in paragraph 20 in the bottom half of that page, you set out the six control specific policies that you examined for the purposes of your review.
00:50:56 So, let's look at the five elements.
00:50:57 First of all, PN573, control staff overtime policy.
00:51:02 Secondly, PN330, mutual exchange of duty by control staff.
00:51:08 Third, PN164, training, control staff new entrant.
00:51:14 PN148, wearing of uniform.
00:51:18 PN089, meal relieves and messing arrangements.
00:51:23 And PN048, leave for control room staff.
00:51:28 Now, we looked at PN164 just now.
00:51:32 You said that it was a policy you examined for the purposes of your review.
00:51:38 On reflection, did you examine 164 for the purposes of your review?
00:51:44 Not in any significant way, just because of the lack of training or any other training other than on the new mobilizing system that was taking place during that time in 2016.
00:52:04 Were these, was this sextet of policies, were they the only policies you examined for the purposes of your review?
00:52:12 No, the reason these policies were added here was because to counter some of the issues that have been raised by staff, the detail of the proper way of doing things, if you like, would be in these policies.
00:52:28 And there were issues raised over, for instance, the way overtime was issued.
00:52:33 So that's why referring to PN573 was added here.
00:52:37 And that would be the same for why PN164 was added, because issues have been raised about training.
00:52:43 Did you review PN539, which concerned emergency call management?
00:52:51 Would you like to see it?
00:52:52 I'm sure I did, but I don't recall any detail, if I'm honest.
00:52:57 Given that you don't recall any detail and it's not referred to in your statement, how sure in reality are you that you did review PN539?
00:53:08 So I can't be sure.
00:53:11 Did you review PN790, which concerned fire survival guidance calls?
00:53:16 Again, I can't be sure.
00:53:20 If it's not referred to here, can the panel take it that it's unlikely that you referred to PN790 for the purposes of your review?
00:53:30 No, I think I probably did, but I just cannot be certain that I did.
00:53:36 Apologies, this is probably going over all ground, but I think just for the sake of clarity, is it right to take it that you didn't review any previous literature,
00:53:47 reports or review that were concerned with control for the purposes of your review?
00:53:54 Sorry, can you repeat that question?
00:53:55 You didn't go back and look at any previous reviews of control when carrying out your own review, is that right?
00:54:01 That's correct, I didn't.
00:54:03 Mr George, just help me with this.
00:54:05 Looking at the list of policies that you have included here and your explanation as to the reasons for putting them in,
00:54:14 would it be right to get the impression that your review was concerned primarily with what I might call compendiously working conditions?
00:54:24 All these are things in which you've had feedback from staff about the way their work was organised and so on.
00:54:31 Was that the main focus of your inquiry?
00:54:34 That would be a fair summary, sir. It was predominantly to look at the procedures, processes and in particular the behaviours that existed within control.
00:54:45 That's what my review was focused on.
00:54:47 Thank you very much.
00:54:49 Were you provided with any briefing notes from, say, Mr Heywood or Ms Smith about the issues that fell within the scope of your review?
00:54:57 I don't believe so.
00:55:01 Did you review significant operational incidents involving observations or recommendations that affected brigade control as part of the review?
00:55:11 I don't believe I saw any, no.
00:55:15 And the reason would be your answer to the Chairman that primarily you were concerned with compendiously described as working conditions rather than anything else?
00:55:25 Yes, that's correct.
00:55:28 I mean, I should say that I needed to assist Scott and the management team in dealing with vision.
00:55:37 That became a huge focus and part of my role.
00:55:41 But at the point I went in there, as I've explained, it was looking at the processes and behaviours that existed in there, yes.
00:55:50 Put bluntly, and we can come on to this in due course,
00:55:53 did the issues surrounding vision crowd out consideration of other issues that were affecting control simply because they were so complete and were causing such difficulties for control staff?
00:56:06 Yes.
00:56:10 And the practical consequence was there was very little time left over for other matters such as training.
00:56:15 Is that a fair observation to make?
00:56:17 Yes, that's fair.
00:56:19 We touched on briefly PN 593 and PN 790.
00:56:24 Could we look, whilst we're just on the topic, at PN 539, which as I say dealt with emergency call management,
00:56:31 and that can be found at LFB at quadruple 0, 0737 forward slash 1.
00:56:43 There we go.
00:56:44 That's the front page.
00:56:46 And if we go to page 16 within this document, which is the policies appendix 3.
00:56:53 And as you can see, it is concerned with fire survival guidance.
00:57:00 And if we can go back, apologies, to page 1,
00:57:06 we can see there that the owner is said to be the head of operational response.
00:57:13 Now, does that mean that between March 2016 and March 2017, you were the owner of this policy?
00:57:20 If the owner was still head of operational response within those dates, yes, it would have been.
00:57:26 Do you remember reviewing this policy at all during your year in tenure?
00:57:34 I can't recall specifically.
00:57:36 We did have many conversations with Joanne around improvements that she and I would like to make to call management,
00:57:44 but whether specifically they were centered around this policy, I don't recall.
00:57:49 Can you help us?
00:57:50 What are the core responsibilities of a policy owner within the LFB's policy arrangements?
00:57:57 It's to ensure that the information that's within that policy is true and correct,
00:58:04 that it is exactly what the organization wanted to achieve is within there,
00:58:10 and that it was reviewed as current every three years.
00:58:14 Thank you. And could we go to page 22 in this document?
00:58:22 And we can see in the table at the top of the page,
00:58:26 we can see the reference to the equality impact assessment in abbreviated terms
00:58:34 and a date given of the 17th of September 2008, another anniversary.
00:58:41 Was it your responsibility to ensure that an equality impact assessment had been carried out
00:58:46 to confirm that the policy as amended did not discriminate against anyone and promoted equality?
00:58:52 Yes, it would have been if I was the head in charge overseer of this policy at the time, yes.
00:58:59 And below that we see a table which is entitled the audit trail,
00:59:06 and we can see set out there a number of amendments that were made.
00:59:12 Now on our reading, it appears that there was no updated equality impact assessment.
00:59:19 First of all, do you agree that that's a correct reading of that table?
00:59:27 Yes, it would appear so, yes.
00:59:29 If that's so, is the review of an updated EIA something which you ought to have done during your year in post?
00:59:38 Yes, and I'm surprised it wasn't done. It wasn't, if I can just explain, it wasn't just left to the head of service.
00:59:45 There was a team within brigade control that would be the keepers, if you like, of all brigade policies,
00:59:52 and they would assist the owners of policies with any changes that needed, if they felt there needed to be changes.
00:59:59 They would remind you that the three-year point was coming up, so you would be reminded of that.
01:00:06 And if, as owner, if I had been reminded of that point beforehand, it would be something I would have done.
01:00:13 So which is why I'm surprised it's not there.
01:00:16 Does the absence of an updated EIA indicate that during your year in post, you did not formally review this particular policy?
01:00:27 That may well be correct. I mean, if I can just add, equalities impact assessments were relatively new to the brigade,
01:00:38 and all policies certainly had them, but that hadn't been the case for that long.
01:00:43 At some time, certainly not before 2010, it wouldn't have been the case.
01:00:48 I can't remember exactly what date we started making sure they were there.
01:00:53 Nonetheless, do you have any recollection of formally reviewing this policy with or without the assistance of Joanne Smith?
01:01:01 No, I don't.
01:01:03 Could we turn back to page 16? And again, it's the Appendix 3 on fire survival guidance that we touched on earlier.
01:01:13 Now, you can take it from me that Appendix 3 does not specifically refer to a person's mobility.
01:01:21 And in fact, there's nothing in PN 539 that guides a CRO to ask questions about a person's disability or impairment.
01:01:32 Are you able to assist the panel as to why that particular matter is not covered either in the policy or in this appendix?
01:01:41 I'm afraid I can't.
01:01:42 Is the absence of any reference to mobility broadly described something that you would expect to have been picked up in an equality impact assessment?
01:01:51 Yes, I would.
01:01:56 You can also take it from me that there is no guidance in Appendix 3 in relation to callers whose first language is not English.
01:02:05 Again, is that an omission in this appendix that you'd expect to be picked up as part of the equality impact assessment process?
01:02:13 Yes, I would.
01:02:18 Could I now turn to PN 790, which is the fire survival guidance policy, which can be found at LFB quadruple zero 1257.
01:02:26 Just looking at the top and policy ownership, on my reading you're not listed as the policy owner,
01:02:34 but given the documents clear connection with the work of brigade control, did you review this during your time as AC operator?
01:02:44 Yes, I did.
01:02:45 I think that's correct.
01:03:11 Thank you for that. I now want to move on to a separate issue, which is the staff meetings, the workshops, and what I'll going to describe to you is your list of issues.
01:03:24 Now, as part of the report, I think I'm right in saying that staff provided responses to a survey and attended one-to-one meetings. Is that right?
01:03:34 Yes.
01:03:35 And did you conduct those meetings or did other members of your team conduct those meetings?
01:03:41 No, I conducted those meetings.
01:03:43 Now, if we can go back to your first witness statement, which is LFB trouble zero 32823 forward slash four, and in particular paragraph 14.
01:03:58 Now, in paragraph 14 you say that you, quotes, collated the issues raised at the workshop sessions into a document which you shared with the director of operations.
01:04:10 Now, just pausing there, director of operations was Dave Brown at this time. Is that right?
01:04:14 Yes.
01:04:16 You go on to say this. This formed the basis of the scope of my review. When you say this formed the basis of the review, do you mean staff feedback in its most raw state, or is it the list of issues which you exhibited to your first statement, which we'll come on to next?
01:04:36 I think they're one of the same. The staff, I'd seen the issues raised by staff that were collated by the officers that have been into control to carry out those staff sessions.
01:04:46 Those officers had, when they knew I was going to carry out the review, those officers contacted me directly. So I knew the issues that had been raised and I collated those and put it into one document. So I think it's one of the same.
01:04:59 Now, if we can go to that document which is at LFB, trouble zero, 32831. And that is the collation you're referring to there.
01:05:14 Yes, correct.
01:05:15 If I call it a list of issues, I hope I'm not doing it to service, but it seems to be a handy abbreviation.
01:05:20 I agree.
01:05:22 Now, if we can stay on the first page of the list of issues, and it's really the second paragraph, you say this.
01:05:31 It should be noted that this information is from a staff viewpoint only.
01:05:36 It must be acknowledged that senior managers within control have not had an opportunity to respond to issues that have been raised.
01:05:44 First of all, had you not sought the views of Scott Haywood or any of the SOMs on the content of this list of issues?
01:05:53 Not at this time, no.
01:05:55 Why not?
01:05:56 Because at this time I was being, I hadn't started in control, so I'd been given the role of doing this while I was an area DAC.
01:06:07 So I was collating the information. I hadn't been down to meet any staff at the moment at all.
01:06:13 So not just the senior managers. I hadn't met any of the control room officers either.
01:06:17 Can you remember now when you first consulted Scott Haywood about these matters?
01:06:26 I can't remember exactly, but yes, he was certainly, the issues were certainly shared with Scott Haywood, yes.
01:06:34 Did Mr Brown contribute to or comment upon the drafting of this list of issues at all?
01:06:41 Yes, I believe he did.
01:06:46 Can you remember now how substantive his comments were?
01:06:51 I think it was more just the layout and the grammar punctuation, styling of it more than any other substance.
01:07:00 Thank you.
01:07:01 Could I now turn to look at a few of the items within the list of issues?
01:07:06 And the first one I'd like to look at is 3A, which can be found at the foot of page 2.
01:07:14 You see there in the bottom third of the page, under the emboldened headline, or heading rather, establishment, level of staffing, and it says this.
01:07:25 A. There is a constant shortfall in staff numbers. On one shift, levels were down to nine staff, should have had 17.
01:07:34 The POM was paid to advise him of the shortfall, and he said to cancel training if it got busy.
01:07:41 The training watch went home at 1600 hours, so concern was raised about what to do between 1600 and 20200 hours.
01:07:51 Now, when you wrote constant there, what did you mean?
01:07:56 So this is, I think, a direct lift of what I believe was one member of staff that had said this to the officers that went to Merton to carry out the staff engagement workshops.
01:08:08 So I hadn't been able to corroborate whether this was correct or not.
01:08:12 This was what one member of staff was raising, in I think their words. I think it was a direct lift.
01:08:17 And so the frequency was something, it was the raw feedback from a member of staff?
01:08:22 This was raw information from staff, and I saw it as my role as part of the review to see if this type of comment was correct. Yes.
01:08:30 Were you given a staff assessment as to what was the cause of these constant shortfalls?
01:08:39 I don't think at this time. That certainly became apparent when I started and based myself at Merton, yes.
01:08:45 At this stage, did you have an informed feel as to how frequently training had been cancelled as a result of shortfall?
01:08:53 No.
01:08:57 At this stage, was cancellation of training the only consequence of shortfall? If not, what were the others?
01:09:06 At this stage, I don't think I knew.
01:09:08 Once you'd identified this list of issues and got a feel for the parameters of the review, did you discuss the constant shortfall point in particular with Mr Heywood, first of all?
01:09:26 Yes, I certainly would have done.
01:09:29 And can you give us the gist of what his response was to the nature and extent of the problem, first of all, and next its cause?
01:09:38 I think the information Scott gave me was that for a number of years, the establishment within control had been below minimum numbers.
01:09:52 And I think a lot of that had been down to the fact that control were under the threat of being outsourced a few years before.
01:10:00 And I was aware of that in my other role. It was well known in the brigade.
01:10:07 So Scott could not recruit staff for a number of years while there was the chance that control was going to be outsourced.
01:10:14 And I think that's where the shortfall had started from there.
01:10:19 Was the prohibition on recruitment a self-imposed restriction or was it a result of an instruction from higher up in the LFB?
01:10:29 It would have been an instruction from higher up.
01:10:37 Did you discuss with Mr Heywood whether it was, bluntly, acceptable to cancel training sessions in this way?
01:10:46 I wasn't aware that training had been cancelled in that way.
01:10:52 Even though it had been at least flagged up as a prospect, little a in this?
01:10:57 Certainly someone was raising it, that it had been, but I hadn't had a chance at that stage to discover whether that was true or not.
01:11:08 Could we turn over the page and again look at the foot of page three and it's really the issue of training?
01:11:16 And what it says is this.
01:11:18 A. Request for training not vision related have been turned down without explanation.
01:11:25 B. Staff suggesting new recruits are only getting four weeks training instead of the nine weeks they should be getting.
01:11:34 There is a suggestion that when the recruits start on the watches, they do not know enough,
01:11:40 which in turn puts existing staff under even more pressure.
01:11:45 At this stage, did you know what type of training was being asked for but turned down?
01:11:51 Not at this stage that I produced this document, no.
01:11:55 Later did you discover what type of training was being turned down?
01:11:58 Yes.
01:11:59 What was it?
01:12:01 In the main it was training requested by staff who were looking to progress their careers
01:12:07 and looking for a CRO to progress to AOM, Assistant Ops Manager.
01:12:13 So far as you are aware, it wasn't training to do with the management of fire survival guidance calls?
01:12:22 Certainly not specifically FSG.
01:12:25 I think there were some staff raising issues just about the lack of training and development in general.
01:12:31 But certainly not specifically FSG.
01:12:35 Did you later discover why new recruits were only receiving four weeks training, i.e. less than half of what had been prescribed?
01:12:44 They absolutely weren't.
01:12:45 There was no truth in that statement that I could uncover at all.
01:12:51 It was nine weeks. It had always been nine weeks.
01:12:54 So I couldn't quite get to where that comment came from.
01:12:59 I didn't have the names of individuals who had made these comments to the staff carrying out the survey.
01:13:05 So I couldn't go back to an individual and ask why they put four weeks.
01:13:08 What documents did you review for the purpose of coming to your conclusion that there was nothing in the criticism?
01:13:15 Of the four weeks training?
01:13:16 Yes.
01:13:17 I went to witness the new entrance training.
01:13:21 I spoke to the staff within OST who were the trainers for the new entrance training.
01:13:27 And I saw the syllabus for the nine weeks.
01:13:30 And I'd spoken to staff that had recently completed the nine weeks training, so relatively new staff that were now out on the control floor.
01:13:42 When you presented Mr. Brown with your draft, did he discuss with you the similarity between the substance of the issues that affected control,
01:13:56 which had been identified by the Lacknall board and the issues that at least the raw feedback from staff were at first blush identifying?
01:14:04 No.
01:14:05 Taking a step back, when you reviewed the feedback, at any stage did you have cause for concern that CROs did not feel adequately trained or prepared for the job they're asked to do?
01:14:24 No, I didn't feel that.
01:14:25 Although, as I say, with the rollout of the new control and mobilizing system, vision, most staff felt they were unprepared for using vision.
01:14:38 As part of your review, did you identify any concerns on the part of CROs about their preparedness for handling FSG calls?
01:14:47 No.
01:14:48 Thank you.
01:14:49 So it's quarter past 11.
01:14:51 Subject to your approval, that would be a convenient place.
01:14:53 Would it? Good.
01:14:54 Well, Mr. George, as you probably know, we have a break during the morning and this looks like a good time to take it, so we'll stop there and we'll resume, please, at half past 11.
01:15:04 And please don't talk to anyone about your evidence or anything to do with it when you're out of the room.
01:15:09 Thank you very much.
01:15:10 Would you like to go to the usher, then, please?
01:15:21 Thank you, Mr. Clear, half past 11.
01:15:23 Thanks, sir.
01:15:51 Thank you.
01:16:21 Thank you.
01:16:51 Thank you.
01:17:21 Thank you.
01:17:51 Thank you.
01:18:21 Thank you.
01:18:51 Thank you.
01:19:21 Thank you.
01:19:51 Thank you.
01:20:21 Thank you.
01:20:51 Thank you.
01:21:21 Thank you.
01:21:51 Thank you.
01:22:21 Thank you.
01:22:51 Thank you.
01:23:21 Thank you.
01:23:51 Thank you.
01:24:21 Thank you.
01:24:51 Thank you.
01:25:21 Thank you.
01:25:51 Thank you.
01:26:21 Thank you.
01:26:51 Thank you.
01:27:21 Thank you.
01:27:51 Thank you.
01:28:21 Thank you.
01:28:51 Thank you.
01:29:21 Thank you.
01:29:51 Thank you.
01:30:21 Would you ask Mr. George to come back in, please?
01:30:46 All right, Mr. George, ready to carry on?
01:30:54 Yes, thank you, sir.
01:30:55 Thank you.
01:30:56 Yes, Mr. Coneer.
01:30:57 Thanks, sir.
01:30:58 Mr. George, can we now turn to discuss Mr. Brown's involvement in your review?
01:31:01 And for that purpose, can we first go to LFB, trouble zero, 83873?
01:31:06 As you can see, this is a chain of email correspondence.
01:31:15 Can we go to the second email on this page, which is an email that you sent on the 1st
01:31:21 of July, 2016, at 1931 hours, when you emailed your draft report to Dave Brown?
01:31:28 Now, looking at the email at the head of the chain, we can see that on the 5th of July,
01:31:34 at 1334, Mr. Brown commented on your draft report, and those comments can be found at
01:31:40 pages 3 through to 29 of this change.
01:31:45 Before we go into looking at some of that detail, what was your general take on Mr.
01:31:52 Brown's comments that he provided on your draft report?
01:31:56 I think Mr. Brown had a very particular way of writing reports.
01:32:02 So, in general, the comments were around structure and layout, maybe some punctuation grammar
01:32:09 changes, but predominantly on structure and the layout of the report, I think.
01:32:13 Now, the emails anticipate that you discussed the draft and his comments with Mr. Brown.
01:32:21 What was the gist of those discussions that you had?
01:32:25 In terms of the report, as I've said, he gave me some changes he'd like to see in it,
01:32:32 which I didn't disagree with, I think, and made those changes over a period of a couple of weeks.
01:32:37 In relation to the recommendations, which can be found between pages 13 and 21,
01:32:47 and we'll come onto them in due course, but before we get into the detail,
01:32:51 what was his general take on the practicability and the utility of the recommendation you'd set out?
01:32:58 I think he agreed with what I'd written in the report.
01:33:01 I think some of the areas he were probably surprised to him that they were what I'd witnessed in control,
01:33:08 but he agreed with all of the recommendations that I made, and certainly between the first draft
01:33:15 and what was published in the middle of July, he didn't ask me to remove any recommendations that I'd made.
01:33:21 Can you remember now what particular points surprised Mr. Brown?
01:33:27 I can't, I'm afraid.
01:33:29 Now, can we turn to the draft report?
01:33:31 And as anticipated by certain elements of your list of issues, training was a significant feature.
01:33:38 Now, again, one thing you were generally aware of before we look at these things was that
01:33:49 there were failures relating to training had been picked up by the Lacknell Board.
01:33:53 Was that something that resonated with you at this time once you put pen to paper for your draft report?
01:33:58 No, the Lacknell Board and the Lacknell incident were not on my mind when I was carrying out the review or constructing the report.
01:34:06 And when you were having these discussions with Mr. Brown, did he draw out any similarities
01:34:11 between the problems that had been identified by the Lacknell Board and what you'd identified as part of your review?
01:34:16 No.
01:34:19 Once you'd read the draft or part of this discussion process, did Mr. Brown ask you whether the Lacknell actions concerning control,
01:34:27 in your view, had they been effectively implemented?
01:34:31 He didn't talk about the Lacknell actions to me in regards to control at all.
01:34:36 Other than Dave Brown, who else commented on your draft report?
01:34:43 In terms of my first draft to when it was published, no one. It was between me and Dave Brown.
01:34:49 So no colleagues were asked from outside control, for example, for a fresh pair of eyes to review matters?
01:34:55 Sorry, I apologise, because the review itself, I was using a number of staff from control to assist with the review.
01:35:03 But I can't recall if I shared the first draft with them or whether they saw it from the time of the final publication, if you like.
01:35:13 Looking back now, do you think the fact that circulation was limited to you and Mr. Brown or you and your team sourced from control,
01:35:21 do you think that that was an undue restriction on the range of people looking at it in the sense you denied yourself
01:35:28 an objective disinterested review from those in the LFB but not concerned with control?
01:35:33 No, I saw it from the time of publication of it, if you like, that others would have their chance to have a say.
01:35:40 Certainly staff in the control room all saw a copy of the final report.
01:35:47 But I didn't see it needed to be circulated for a wider comment while it was being put together.
01:35:57 No.
01:35:58 Because the point was, as you saw it, this was going to kick-start a debate and discussion about what was going on in control.
01:36:04 That's correct.
01:36:05 Can I now look at the involvement of Mr. Hayward himself?
01:36:08 And for this purpose, can we go to LFB, trouble 0, 83, double 8, 4, forward slash, 4.
01:36:20 And if we can look at paragraph 18, I think this flows from the answer you previously gave.
01:36:25 You identify the eight volunteers that made up your review team, is that right?
01:36:30 That's correct.
01:36:31 Now, Mr. Hayward isn't one of them. Why not?
01:36:35 He was a strategic adviser to the review team along with Chris Moore, who was the lead representative body from GMB, I think.
01:36:48 Now, Mr. Hayward says he was a strategic adviser as well. What did that involve exactly?
01:36:55 If I'm honest, at the time of carrying out the review, I felt it more appropriate that Scott Hayward was not involved.
01:37:04 But Dave Brown felt he should be, and therefore we gave him the title of strategic adviser.
01:37:12 And that role would be for me to ask Scott anything from his perspective for anything I was as part of that review.
01:37:22 Did you find yourself calling upon Mr. Hayward as a strategic adviser for the purposes of drafting your report?
01:37:28 No, not for the purposes of constructing the report.
01:37:32 But as I said, I met with Scott every day on matters relating to control.
01:37:37 And why did you not want to include him and why did Mr. Brown want him included as part of this review team?
01:37:44 I think I felt it would have greater gravity in terms of I was truly independent, a fresh pair of eyes coming into control.
01:37:53 And I think Dave Brown felt it would be a bit unfair to not include Scott in any way, shape or form.
01:38:01 Did you discuss the substance of your draft report when it was in a meaningful state with Mr. Hayward at all?
01:38:09 Scott certainly saw the final report from the 15th or 16th of July.
01:38:14 I can't recall if I shared him the first copy of the draft, if I'm honest.
01:38:19 During the drafting process and discussions with the review team, did anyone raise with you FSG training at all?
01:38:26 Not specifically, no.
01:38:31 During part of your day-to-day discussions with Mr. Hayward and following publication of the report,
01:38:37 did he draw out with you any of the similarities between the problems that have been previously identified,
01:38:44 whether by the Latner Board or by station manager Kelly, with you in any form of discussion?
01:38:49 No.
01:38:50 Now, in paragraphs 11 to 17 of your second witness statement, we don't need to go to it,
01:38:59 but the reference is LFB-8083884-4-3.
01:39:05 You explained the contribution of control staff in the form of feedback forms.
01:39:10 And did you discuss the matters raised in the feedback forms or the points set out in the terms of reference
01:39:17 with control staff except those in the working group?
01:39:22 No, the feedback forms I kept confidential, so no one else saw those apart from me and the individual that was contributing.
01:39:30 But the issues that were raised were collated and they were shared, yes.
01:39:35 Did you discuss training with Joanne Smith at any stage?
01:39:39 Yes.
01:39:40 During the drafting process?
01:39:41 Did you discuss training with any other members of OST during the...
01:39:44 Yes, I would have done, yes.
01:39:46 Can you remember now what particular training related matters you discussed with Joanne Smith?
01:39:51 Not specifically, but she was responsible for overseeing control training.
01:39:57 So any matters relating to training would have been either through Scott or Joanne.
01:40:02 And can we take it from your previous answers that FSG training didn't form part of those discussions?
01:40:08 It did, but if I can just explain, I had a number of correspondence with Christine Sharp,
01:40:16 who was overseeing some FSG training in 2016.
01:40:21 In fact, I think that my first email from Christine was within two days of starting my new role,
01:40:27 explaining what FSG training was going to be taking place that year.
01:40:31 And this is the command unit, the joint command unit training.
01:40:34 We'll come on to that in due course.
01:40:36 But my point, I think the point I'm making is I didn't have any overall concerns that there was no FSG training taking place,
01:40:42 because within 48 hours of landing at control, I was being given a schedule of the FSG training that was planned to take place.
01:40:49 Now, when you're carrying out the review, presumably you weren't aware of the fact that the specific issues identified after LACNOR had not been completed.
01:41:02 So you weren't aware of first of all, FSG training can take no contribution from fire safety officers,
01:41:08 as was required by the fire service circular 1093. Were you aware of that?
01:41:13 I don't believe I was, no.
01:41:15 Refresher FSG training was found by the LACNOR House Assurance Review of August 2018 not to have been completed consistently.
01:41:23 Were you aware of that?
01:41:24 No.
01:41:25 Refresher training had no practical role play element. It was only a four hour session, not a full day's session.
01:41:31 Were you aware of that?
01:41:32 No.
01:41:33 Were you aware that AC Brown and AC Steve Churek had decided that FSOs need not be involved in the delivery of refresher training to control offices?
01:41:44 I did not know that.
01:41:45 Can we look at an internal email from Scott Heywood to Vic Bagnall on the 7th of February 2013, which can be found at LFB 0000 39935?
01:41:57 This email has now become familiar, or however I read it out again, and it says this.
01:42:12 Morning Vic, I've just had my arse kicked about the length of the full FSG training.
01:42:18 In the report, we say it is a full day, and yet we have just carried out the training in four hours with no role play.
01:42:25 Dave was very unhappy and made it very clear to me. It makes us look unprofessional in court.
01:42:31 I appreciate that you've just picked this up, but we need tighter control of the trainers and not let them freelance as they have appeared to have done on this occasion.
01:42:41 Can we discuss it at our next meeting?
01:42:43 Now, did Dave Brown raise with you the fact that control had not been providing a full day's training despite the LFB telling the coroner that's what was being done?
01:42:54 No, I think at some point, whether it was Dave Brown or Scott, did inform me that the agreed FSG training would be alternating years.
01:43:07 But other than that, I didn't know of anything that had been agreed in the past, no.
01:43:13 Are you able to give the panel some assistance as to when you were given that indication that FSG training would be provided on an alternating basis?
01:43:23 It would have been in 2016 when I was carrying out the review, I think.
01:43:28 And can you remember whether it's more likely to have been Dave Brown or Scott Heywood who gave you that information?
01:43:37 It's more likely to have been Scott Heywood, or sorry, or Joanne Smith.
01:43:41 Because they presumably were responsible for providing that training?
01:43:45 I guess so.
01:43:46 And was that information given to you as a result of a request from you or was it something they volunteered unprompted?
01:43:55 I think it would have been as part of a discussion, a wider discussion.
01:44:01 Now, your report was published on 19 July 2016.
01:44:07 Following publication, did you have a dedicated meeting with Scott Heywood to discuss its contents and in particular its recommendations?
01:44:15 Straight after the publication of the review, I was still based at Merton, so I was having regular meetings, daily meetings with Scott anyway.
01:44:23 So no, I don't think there was a regular meeting solely to discuss it.
01:44:28 So there was no dedicated meeting to discuss this report?
01:44:31 No.
01:44:32 Was there, did you get a sense though from the meetings and the contact you had with him as to what his view was on your conclusions and crucially your recommendations?
01:44:41 Yes.
01:44:42 And overall, can you give the gist of Mr Heywood's response to your conclusions, first of all?
01:44:49 I think he agreed with the vast majority of what was in the report.
01:44:54 I think the one area where he, let's say, disagreed or was around the engagement of staff from the senior management team, which was one of the areas that I'd identified.
01:45:10 And you thought it was insufficient in round?
01:45:13 I think he thought he was liaising with members of control more so than I'd identified.
01:45:23 In relation to your recommendations, did he, did you necessarily part way on any of those?
01:45:29 No, we didn't part way on anything, no.
01:45:31 Can I look at now key performance indicators?
01:45:34 And at page five of your report, which we can find at LFB-0032826-5.
01:45:49 We can see in paragraph 22, which is at the bottom of that page, you refer there to several key performance indicators relating to control.
01:45:59 And then you list three particular categories, namely, is it LI15LI?
01:46:06 I think LI stands for local indicator.
01:46:08 Local indicator 15I, which is average time to answer an emergency call.
01:46:13 Local indicator 15R2, percentage of emergency calls answered within seven seconds.
01:46:21 And local indicator 15R3, average time to deal with an emergency call.
01:46:28 Now, am I right in understanding that those indicators reflect the KPIs that can be found in the London Safety Plan?
01:46:37 Yes, that's correct.
01:46:39 To whom was performance against these three criteria reported?
01:46:43 I mean, these local indicators.
01:46:46 Well, I reported to Dave Brown and these indicators I would have discussed, or our performance against these targets, I discussed with Dave Brown.
01:46:56 Now, to the LII, each of these local indicators relates to the speed and duration of answering and dealing with calls.
01:47:06 Is that LII view consistent with your understanding of them?
01:47:10 Yes.
01:47:12 Were any other KPIs set?
01:47:14 I don't believe so.
01:47:16 Were any targets set that governed the quality of information given during the course of a call?
01:47:22 No.
01:47:23 Were any targets set in relation to training?
01:47:33 I don't recall for control, certainly in the operational arena there were targets, local targets for how much time firefighters should spend on training.
01:47:45 But I don't recall there being a set target for control staff.
01:47:49 Can you recall now why there was no target in relation to the quality of information in calls and why there was no target in relation to training?
01:47:59 In terms of setting a target for the quality of call handling, it was a difficult thing to put together.
01:48:09 But calls were routinely quality assured by watches, operational managers and senior operational managers, so there was an element of quality control.
01:48:23 In terms of why a target set for training time for control, I don't believe there was, there may have been.
01:48:33 But no, I'm not sure why that wasn't done.
01:48:38 Looked at slightly differently Mr George, would it be right to say that no one suggested that there ought to be an indicator in relation to quality of information in calls and training?
01:48:48 That's correct.
01:48:50 Looking at these indicators, they appear to deal with essentially transactional matters, speed, volume of call handling and not their quality.
01:49:01 Why was there this focus on the transactional element rather than quality, i.e. substance?
01:49:09 I think at that time the governance around the brigade was by LFIPA, London Fire and Emergency Planning Authority.
01:49:18 And the information was put to the authority and there were four committees from the authority that looked at the numbers, the quantity.
01:49:32 And these particular indicators were certainly fed into the information that was passed to LFIPA members.
01:49:40 And essentially because these were reflective of what the London Safety Plan required, that dictated matters essentially?
01:49:47 Yes, it was very much a quantity focused performance management focused approach at that time.
01:49:56 Did you have any reservations about that quantity or quantitative approach as opposed to the absence of any qualitative assessments?
01:50:06 Yes, I was very much throughout my career, certainly when I was the area DAC and when I progressed to the director role, I would very much focus on the quality of what we did.
01:50:21 Now I'm mindful that you haven't seen this, but could we look at Station Manager Kelly's 2010 audit?
01:50:30 And that can be found at LFB, trouble 0, double 5, double 2, 0, forward slash 10.
01:50:41 And if we could look at paragraphs 74 and 75 please.
01:50:46 And they say as follows, 74, development of a formal quality management plan would provide a robust framework to effectively manage all aspects of brigade control training.
01:50:58 75, the call coach system appears to be an effective tool for managing staff performance in terms of their response to emergency calls.
01:51:08 This system also could provide the basis for performance measurement on training courses where a clear measure of ability is required.
01:51:17 Now to the best of your knowledge, was call coach used to produce a measurable performance indicator about the effectiveness of performance training within control?
01:51:28 Not as far as I know, but when I started in control, call coach couldn't be used because it wasn't compatible with vision.
01:51:35 It had been used with ProCAD is my understanding, the previous mobilizing system.
01:51:40 And I know from conversations I had with Joanne, she was very keen to get something similar to call coach working with the vision system so she could continue that looking at that quality element.
01:51:52 Absent the two systems working together, was any stopgap introduced to ensure that there was performance monitoring of the effectiveness of training?
01:52:03 Yes, the staff within OST, the SOMs and the OMS would review calls taken, but it was fairly ad hoc.
01:52:13 And were Joanne Smith's concerns motivated by the fact that there were no reliable or no consistently reliable benchmarks against which to judge and assess the effectiveness of training?
01:52:28 I think that would be fair.
01:52:32 Now following the Kelly audit, Scott Hayward provided Dave Brown with a two page update in January 2013.
01:52:41 And if we could go to that, which is LFB 00106102.
01:52:51 I'll just let you scan the content.
01:52:59 Have you seen that document before?
01:53:01 No, I haven't.
01:53:03 Could we go to the foot of page two of the document, and item nine in particular?
01:53:10 You'll see there the text in black says this.
01:53:13 Review the call coach performance criteria and implement appropriate elements of these criteria to any subsequent role play assessment process.
01:53:23 And below that in red text it says this.
01:53:26 Control have been carrying out call sampling on staff since 2010 with a few interruptions to that process due to events such as the Olympics.
01:53:36 Calls are randomly picked for AOMs and CROs to ensure that call handling conforms with the call handling standard agreed by all staff.
01:53:46 FSG calls are reviewed using the system, using this system if there is a learning point highlighted from the instance during the call handling process.
01:53:56 Mindful of your previous answer about the inconsistency of call coach with vision, did you receive any data about performance as assessed historically using call coach?
01:54:10 No.
01:54:13 Looking at Scott Hayward's response, it appears as if this sampling was undertaken on a random and unsystematic basis.
01:54:23 Are you able to say whether that was in fact the case or was there a more structured review carried out?
01:54:29 I think it was random for the general day to day 999 calls, but for I believe all fire survival guidance calls and all calls that unfortunately led to a fatality, they were certainly all reviewed.
01:54:46 Thank you.
01:54:48 I'm now going to, it's been a somewhat long run up for which I apologise Mr George, I'm now going to turn to you the recommendations you made as a result of your review.
01:54:56 Just by way of a preliminary matter, can I ask you about STARS, which I think stands for Staff Attendance Recording System.
01:55:06 Yes it does.
01:55:07 And in a nutshell, STARS is the LFB system for recording personal information relating to staff, including leave and absence and those type of matters.
01:55:17 Yes it does, but it's more than that. It has other systems linked to it. So the STEP system, the system for training, evaluation and performance is linked to STARS as well.
01:55:28 And STARS can therefore, the information contained on it can relate to and have an impact on training. Is that a fair general observation?
01:55:36 Absolutely, the training and release team that is used for releasing operational staff, for instance, they would use the information on STARS to be added to know when an individual is available to undertake training or a course for instance, yes.
01:55:52 And so if people weren't able to interrogate and manipulate the information in STARS effectively, that may have an adverse impact on allocation of time and personnel to training.
01:56:03 Yes, it certainly would, yes.
01:56:04 Could we turn to paragraph 46 of your review, first of all, which can be found at LFB 0032826 forward slash 11.
01:56:17 And really, it's the paragraphs that we're coming on to, those that deal with lack of development and training, Mr George.
01:56:25 Now, if we can start off by looking at paragraph 46, which is under the heading development in role, and that paragraph says this.
01:56:34 It is recognized in the last few months of 2015 and first few months of 2016, a considerable proportion of the SOMS and POMS time has been taken up with the implementation of the new control and mobilizing system.
01:56:49 This has understandably led to some meetings with staff, including PRDS reviews.
01:56:55 Stopping there, what are PRDS reviews?
01:56:58 They are performance review and development.
01:57:01 It is the performance review and development system.
01:57:04 Thank you.
01:57:05 They are basically staff appraisals.
01:57:07 Thank you.
01:57:08 Not taking place as frequently or as thoroughly as is normally expected.
01:57:13 Some staff have commented that PRDS objectives are often not added until late in the year and that some objectives are not realistic.
01:57:23 Managers have been instructed to ensure the PRDS process is correctly followed throughout 2016-17, including setting realistic and achievable objectives and holding review meetings.
01:57:36 It should be noted that the PRDS process is currently under review with significant changes likely from April 2017.
01:57:46 The new mobilizing system you referred to there, that's vision, isn't it?
01:57:51 No, this is different.
01:57:53 The last sentence of that paragraph is referring to the brigade as a whole, updating the PRDS system.
01:58:02 I'm sorry, the reference in question was the implementation of the new control and mobilizing system referred to in the third line of paragraph 46.
01:58:11 Is that vision?
01:58:12 I beg your pardon, yes, that's vision.
01:58:14 Thank you.
01:58:16 Now, am I right that your review did not examine vision itself, but you did look at issues that flowed from its implementation?
01:58:25 Is that a fair overall summary?
01:58:27 Yes.
01:58:28 Could I take you to Mr. Heywood's first witness statement and the table he's produced there, which can be found at LFB 0055191 forward slash 26.
01:58:39 And we see there a table in the top half of that page, which shows, as its title suggests, the numbers of staff who received FSG training in the calendar years 2011 to 2017.
01:58:59 I'll just let you briefly read that so you can see the thrust of the information contained there.
01:59:09 Now, we can see that in 2015, no FSG training was undertaken.
01:59:19 And so that topic would appear to have been wholly overlooked.
01:59:23 Is that right on the basis of the information set out here?
01:59:26 Yes.
01:59:27 In 2016, 38 of the 83 staff received training representing 46% of control at that time.
01:59:37 Again, is that right?
01:59:39 Well, that's certainly what this table says.
01:59:41 I don't believe this is accurate.
01:59:44 I don't recognise the 83 staff, for instance.
01:59:47 And certainly in that year, I witnessed FSG training with the command units taking place.
01:59:53 So, yes, it's correct that this is what the table says, but I'm not concurring that this is accurate.
02:00:00 So those taking it from that, those are not figures you recognise from the time?
02:00:06 That's correct.
02:00:10 Now, mindful of what you've just said, could we go to paragraph 80 of Mr Heywood's first witness statement,
02:00:15 which can be found at LFB 0055191 forward slash 30.
02:00:22 Now, what Mr Heywood says at paragraph 80 is this.
02:00:33 Between 2012 and 2017, we have provided training for control staff on the NCC.
02:00:40 Can you help us? That's the National Coordination Centre, presumably.
02:00:43 That's correct.
02:00:44 Vision. The RMC. What was that?
02:00:48 That's the Resource Management Centre.
02:00:50 And the SBN.
02:00:51 That's a standby module.
02:00:53 Control staff were also detached to carry out the functions of the NCC, RMC and SBN.
02:01:01 The SBN in particular needed a minimum permanent contingent of four staff to operate
02:01:08 and maintain skills across all control staff, some of which were provided by control.
02:01:14 Responding to one of these changes at any one time would have been challenging.
02:01:19 But in late 2015, 2016, in particular, these changes, together with the significant difficulties presented by the implementation of vision,
02:01:29 meant that a number of these work streams all came together at the same time.
02:01:33 The training requirements, new functions and new system drew all of our spare capacity between 2014 and 2017.
02:01:43 And the last sentence, the key one I want to emphasise to you.
02:01:46 This meant that there was reduced capacity available for other important training, in particular, FSG refresher training.
02:01:55 First of all, did you know about the problems caused by the implementation of vision in 2015 and 2016 insofar as they impacted on training?
02:02:06 Yes.
02:02:08 Did anyone raise with you an adverse impact on FSG training in particular?
02:02:17 No.
02:02:19 Did you, as a result of carrying out your own consideration, identify any adverse impact on FSG training as a result of the implementation of vision?
02:02:32 No.
02:02:34 I, as I said, during 2016, I witnessed first-hand FSG training taking place alongside the command units.
02:02:43 What steps, what practical steps did you take to ensure that the adverse impact of vision and its implementation on training was mitigated?
02:02:56 The priority at that time was fixing vision, which it took up a vast majority of time for certainly the SOMS, the POM and myself, and Dave Brown to an extent as well.
02:03:14 Could we go back to your report on paragraph 48, which confirmed LFB-0032826-11?
02:03:29 Again, to remind you, this is the section of report dealing with training essentially.
02:03:37 Paragraph 47 says this.
02:04:07 This is not often done, and staff are seldom instructed to do so by their managers.
02:04:13 48. A lack of regular training and development has been raised as an issue by the vast majority of the staff that were spoken to or who responded to the survey.
02:04:23 This includes preparation for assessment centres and training in role post-promotion.
02:04:28 Some staff commented that they frequently felt bored and that whilst they started their role full of enthusiasm, as time progressed, enthusiasm dwindled.
02:04:38 Introducing a comprehensive suite of training and development opportunities into control is deemed to be a priority.
02:04:46 Would it be fair to say that you found that training was unplanned, poorly recorded by both officers and managers, and that these failings were widely acknowledged within control at the time?
02:04:58 Yes. If I can add some context.
02:05:01 Please do.
02:05:02 I've come from the world of operations where I've been an operational officer for almost 30 years at this point.
02:05:08 And certainly in the last decade, before I moved into control, the training on fire stations was the systems had advanced with STARS and then STEP.
02:05:22 So a watch officer, a watch manager on a station could quite clearly see the training that had been undertaken by their firefighters and junior officers.
02:05:33 They could plan that training in advance.
02:05:35 And it was very simple that once that training had taken place, the officer could just simply click on the individuals that had taken part in the training and it would immediately update the individual's training record.
02:05:47 Sadly, that was not the case in control.
02:05:50 When I started in there in 2016, it was almost like going back in time 10 years.
02:05:55 The systems hadn't kept up.
02:05:57 The systems for control hadn't kept up with the rest of the organisation.
02:06:01 And I could therefore see why some of the staff were saying they felt isolated from the rest of the brigade through some of those systems issues.
02:06:13 And I was surprised that previous managers had not made sure that those systems had been adapted for control.
02:06:21 And I think, stop me if I'm going on too long, but I think the reason was when STARS and STEP and other systems were built, they were aimed at the large majority of the workforce, which was 5,000 plus firefighters, not really specifically aimed at the 100 or so control officers.
02:06:40 And it was changes to the systems that needed to happen to make it a useful tool, an essential tool for control to use.
02:06:48 I don't want to put words.
02:06:50 Sorry to interrupt.
02:06:52 We've discussed on a number of occasions with you and with others this distinction between control and operational side.
02:06:58 But I'm getting the clear impression that the two were not integrated in the systems, in the management or anything.
02:07:08 Is that correct?
02:07:10 That was certainly correct at that time, sir.
02:07:13 Yes, as I've explained, the systems were across the whole brigade, but they were very clunky, if you like, and they didn't work very well for control.
02:07:22 So for an operations manager to plan training in advance for control, it was very difficult to do.
02:07:28 At a station, the watch manager could plan for the next shift, which position on a fire engine the firefighter was going to be.
02:07:36 That couldn't be done in control.
02:07:38 The operations manager could not plan the shift before which position the control officer was wanting to sit.
02:07:44 And that's what operations managers wanted to do that.
02:07:46 So they were operating with whiteboards, with spreadsheets on their own personal computers, with bits of paper, with their watch rotors and who was going to be taking annual leave,
02:08:01 when would all be paper based or individual Excel spreadsheets, not using the systems that should have been there to assist them.
02:08:09 Do you know why, when, for example, STARS and STEPS were introduced, why the control room staff were not taken into it straight away?
02:08:21 No, I don't know. They should have been.
02:08:24 And that would be a question for the individual that was overall responsible for control at that time to have ensured that that was the case.
02:08:35 Thank you very much.
02:08:38 Thank you.
02:08:39 Thanks. Essentially, I don't want to put this too crudely and I don't want to put words in your mouth, but the essential reason why systems did not keep pace at control with other elements of the LFB was essentially a failure on the part of the relevant managers to ensure the system did keep up to date.
02:08:57 Someone should have made sure that the systems that were operating well at fire stations were also operating well for control.
02:09:07 And is another aspect of that, this sense that control was a breed apart, an island unto itself, put less pompously, a separate distinct element of the organisation?
02:09:20 That's certainly what the majority of control staff felt and I could understand why.
02:09:26 Is it more than that? You didn't so much understand, you accepted those concerns as being legitimate. Is that a fair way of putting it?
02:09:33 Control staff had legitimate concerns, yes.
02:09:35 Thank you. Your findings as you've set out here and punditantly expressed in paragraphs 47 and 48 are not confined to particular types of training.
02:09:46 Was there any particular type of training or development mentioned by staff or identified by your investigation that gave a special cause for concern?
02:09:57 No, in general terms I think the greatest issue staff were raising were those that were seeking promotion or had recently been promoted.
02:10:05 They were looking for some additional development that they weren't getting.
02:10:10 Were you able to unearth quite why planning was ad hoc and not planned in a suitably robust way?
02:10:20 I think I've touched on it. Yes, each of the six watches, so six operational managers, OMs, and they each planned the training and recorded who needed training and when for the watch members.
02:10:34 And some I think had it paper based. Some were using Excel spreadsheets that they saved on their own computers.
02:10:41 There wasn't really possible for them to use the systems, for instance STEP, which station staff were using.
02:10:50 And again, the failure to ensure that there were consistently and accurately completed records is essentially a managerial failure to ensure that supervisors were doing what they had to do and do it in a way that could be interrogated to ensure that staff were being properly trained.
02:11:06 Yes, I mean it's an onus on the individuals to update their individual training records, but that at the time they would have to complete the training and then manually go into the system to update it.
02:11:17 And there was also a process that the OST would I think monthly inform the information management team who owned some of those systems to make sure that the records got updated.
02:11:29 But they were not, it was not a robust system.
02:11:32 Thank you.
02:11:34 The next aspect I'd like to come on to is recommendation 49C, which was OM to ensure an appropriate robust annual watch training plan is in place for their watch.
02:11:46 Now, before I come on to the substance of this, could I take you to volume one of the Fire Service Manual, which can be found at INQ00014945 forward slash 133.
02:12:08 Before I ask you questions about this and you'll see on the far right hand side I'll be directing questions towards the section entitled Watch Refresher Training.
02:12:18 Can you assist the panel as to what the Fire Service Manual is?
02:12:23 I believe this was a set of training manuals that replaced the old Fire Service Drawbooks.
02:12:31 And was it a manual to which you had need to refer to regularly or was it rarely looked at by you simply because of the position you held within the brigade?
02:12:41 I think every fire station had a copy of the Fire Service Manuals.
02:12:47 If you're asking how often would they be looked at regularly, probably not.
02:12:52 Thank you.
02:12:53 Looking at this particular paragraph on the right hand column halfway down the page, we see under the heading Watch Refresher Training this.
02:13:04 In addition to the basic core skills training, all control personnel should undergo continuous on watch refresher training.
02:13:12 This training will be carried out on a systematic basis, both scheduled and monitored.
02:13:18 The subject matter will depend upon local circumstances with emphasis being placed on little used procedures.
02:13:29 First of all, and apologies if this is an unfair question, Mr George, were you aware of that requirement?
02:13:35 No.
02:13:37 Would you agree with me, however, that the requirement clearly expects training needs of control personnel to be properly planned and monitored?
02:13:46 Yes.
02:13:47 If we can go back to your report now, which can be found at LFB 0032826 forward slash 12.
02:14:04 And if we could look at 49C, which is the very top of the page, you say this.
02:14:10 Each OM is to ensure that an appropriate, robust annual watch training plan is in place for their watch.
02:14:18 Agreed by their SOM and available to all watch members and managers.
02:14:23 All training must be recorded on an individual's ITR, Individual Training Record.
02:14:29 The POM SOMS should work with colleagues from the Brigades Information Management Team to introduce an IT solution to this.
02:14:39 Similar to training diaries used by station staff.
02:14:43 Now, does it follow that during your review you identified that there was a lack of watch training plans in place?
02:14:50 Certainly robust training plans, yes.
02:14:53 How widespread was the deficiency or the absence of robust training plans?
02:15:00 It was certainly a deficiency.
02:15:03 And was it your view that it, sorry just following up, was it a deficiency that you found more times than you were comfortable with, if I can put it like that?
02:15:12 Yes, of the six watches there was no consistency that I could see.
02:15:17 And was it your view that it was the primary responsibility of operations managers to ensure that their watch was properly retrained and in accordance with the requirements of PN 164?
02:15:29 Yes.
02:15:31 What records did you review for the purposes of your consideration of this point?
02:15:40 I can't recall exactly.
02:15:42 I think I did ask in formal and informal meetings with the different operational managers, the systems they were using.
02:15:50 You've touched upon this already, but can you help the panel as to what arrangements you'd identified during the course of carrying out this review?
02:15:58 Arrangements that were in place for the provision of structured training for watches.
02:16:03 Sorry, can you just rephrase that?
02:16:05 Yes, of course. What arrangements were in place to structure training for watches, put more simply?
02:16:10 I think the ops managers knew what training they needed to be ensuring their watches were doing.
02:16:18 And I think there was an attempt by them to make sure that that happened.
02:16:22 I think unfortunately at that time that I was there in 2016 and into 2017, it just wasn't possible for them to get to that in any structured and robust way.
02:16:34 I think there was other training taking place other than vision.
02:16:37 As I've said, I witnessed the FSD training with command units.
02:16:41 I did also at times witness staff undertaking, whether that was individual led or whether they'd been prompted by their ops managers to undertake training.
02:16:50 And that would be CBT type training on their workstations.
02:16:55 And I saw OST sitting with individuals from control going through certain training as well.
02:17:01 So I knew there was other training other than vision taking place.
02:17:05 I think there was probably more training taking place than what was being recorded on individuals ITRs.
02:17:11 It's just the whole system was, it was a poor system. It just needed to be made more robust.
02:17:18 And what were the primary problems that flowed from the absence of a robust system for watch training recording?
02:17:24 There was an ease to, training could fall by the wayside without it being flagged in any particular way.
02:17:33 Whereas what I witnessed on a fire station, if you went past a time where the frequency of when a firefighter should have received some training,
02:17:41 it would immediately start flagging up to anyone that was looking at the system.
02:17:46 So you wouldn't be able to ignore it.
02:17:48 Given the findings in relation to watch training plans, does it follow from that that there was no formal process for control wide training and a planning for control wide training?
02:18:00 I think OST did have some processes in place for the training that OST gave, but I'm not sure how again, how robust that was.
02:18:08 And so you have no sense on the substance or the adequacy of the arrangements for brigade control wide training then?
02:18:15 I didn't get that sense.
02:18:19 Whose responsibility was it to produce and implement the training plan?
02:18:24 I saw it as the responsibility of the operation, the ops manager with final sign off by the senior ops manager.
02:18:33 Now, we may not need to go to it, but Mr. Hayward says in his second witness statement,
02:18:38 and the reference is paragraph 37 at LFB 00862 on three forward slash seven,
02:18:46 that OST was responsible for establishing and maintaining the recurring training plan as directed by the SOM.
02:18:53 After I assumed head of service in 2016, I was accountable for ensuring that training was delivered.
02:18:59 Prior to this, an assistant commissioner would have had responsibility for ensuring training was delivered.
02:19:04 This would have sat with AC Chandler and therefore AC Tom George before 2016.
02:19:10 Do you view that or accept that as correct?
02:19:13 I accept that.
02:19:16 So in practical terms, was the creation of the training plan effectively delegated to members of OST?
02:19:23 Yes.
02:19:28 I'm talking in practice.
02:19:29 I suppose so, yes.
02:19:32 Before you carried out your review, what arrangement did you identify that in turn identified training needs?
02:19:42 Before I carried out my review, I was going solely on the issues that staff had raised.
02:19:49 Again, with the proviso that I know you say you haven't seen this report,
02:19:54 but if we can go back to Station Manager Kelly's audit from 2010, which can be found at LFB 0055220 and go forward slash seven.
02:20:09 And if we see it paragraph 47, which is in the bottom half of that page, SM Kelly said this.
02:20:16 It appears that adequate long-term planning of the regularly delivered elements of the Brigade Control Training Department curriculum is not being carried out.
02:20:26 Then, if we go further down the page of paragraph 50, we find his recommendations.
02:20:32 The first one of which is this.
02:20:34 Implement adequate training, planning and recording systems.
02:20:39 Now, if you can hold that in your mind.
02:20:41 If we now turn to a separate document, which is a minute from a Brigade Control Management Meeting in September 2012, which can be found at LFB 00113402 forward slash six.
02:20:55 Now, again, Brigade Control Management Meeting minute.
02:20:57 We see item five, which is headed AC Chandler update.
02:21:03 The minutes record this under the heading Training.
02:21:07 Ops managers discussed the issues of training for control, but did not reach a conclusion on the matter.
02:21:13 One, AC Chandler update.
02:21:16 One, AC Chandler pointed out that there is no robust defense if anything happens in control.
02:21:23 He also went on to say training needs assessment for all staff to be built into the PRDS.
02:21:31 Now, on the basis of this document, at least, it seems that AC Chandler identified that a training needs analysis was required for control.
02:21:40 Now, in the basis of this document, at least, it seems that AC Chandler identified that a training needs analysis was required for control.
02:21:45 required for control room staff. When you wrote your report, is it right that you were
02:21:51 not aware that you were not the first person to identify this problem?
02:21:56 I was not aware of that. At that time, I became aware of some of the areas such as this much
02:22:05 later when I was Deputy Commissioner and Director of Operations and the Grenfell Tower and Investigation
02:22:13 Review team within the LFB raised some of these issues that were going back to 2009,
02:22:19 2010 that control should or shouldn't have done or things that hadn't been done that
02:22:25 have been agreed and I was made aware of it much later, probably 2018.
02:22:31 When you carrying out your review, did you identify any arrangement or document which
02:22:37 set out the process to address training needs?
02:22:41 No.
02:22:50 Given that you had identified an absence of training plans, did you ask Scott Haywood
02:22:55 for an explanation for that state of affairs?
02:23:01 I may have, I think at that time, even if there had been a training plan of what the
02:23:08 ops managers intended to do, everything was consumed by vision and the training that
02:23:16 was needed to train staff on the workarounds so they could use the system properly.
02:23:25 So what I mean by that is staff could possibly leave having done three days, three shifts
02:23:32 on duty and then within the three days they were off before they came in, a change would
02:23:36 have happened, something made by Capita to try and fix a particular problem and there
02:23:40 were hundreds.
02:23:43 And then you need to get to the control, that individual from control as quickly as possible
02:23:47 to inform them and train them on the workaround so that they could continue functioning properly.
02:23:53 Given that all consuming nature of vision and the problems that its implementation flowed,
02:23:59 is it likely that you didn't ask for Haywood for an explanation as to why there were no
02:24:04 or no robust training plans?
02:24:06 They will be why, yeah.
02:24:08 Can you remember whether you asked Joanne Smith for example for an explanation as to
02:24:12 the absence of training plans?
02:24:14 It would be the same response as I've just given.
02:24:22 Again, I'm mindful of the answer you gave earlier on that you weren't aware of the
02:24:27 Alfipa GPAC audit but for the sake of completeness I'd like to take you to it.
02:24:33 It was a report, a summary of an audit dated 9th of March 2015 which in broad terms highlighted
02:24:43 the risks of poor record keeping at control, particularly in relation to training and particularly
02:24:51 FSG training.
02:24:53 If we go to LFB trouble 0, double 4, 640.
02:25:03 That's the document I suspect it's in a formula that, a format rather that is all
02:25:08 too familiar.
02:25:10 Having seen this front page, can you remember seeing it at all at any time, particularly
02:25:16 during the time you carried out your review?
02:25:18 No, I've seen papers that go to GPAC in the past but I don't recall seeing this one.
02:25:24 Could you help us, what was the function of GPAC at the time?
02:25:28 It was one of four committees of Alfipa, the London Fire and Emergency Planning Authority.
02:25:34 The GPAC members changed over time and it was for the LFB directors and commissioner
02:25:43 usually to present information to the GPAC committee on how the LFB had been performing,
02:25:49 I think they met every quarter.
02:25:51 And would GPAC at least have the power to review and scrutinise the control during your
02:25:57 time as AC operational response?
02:25:59 They would certainly scrutinise the information being presented to them, yes.
02:26:03 Could I take you to page 25 within this document?
02:26:07 Now we have here a table under the heading summary of reports issued in quarter two 2014-15.
02:26:23 And then if we can look at the individual column headings reading from left to right,
02:26:27 and we see audit title and systems in the far left hand side, areas of effective control,
02:26:35 then risk recommendation and category, then responsibility and agreed action, and finally
02:26:41 on the far right hand side the target date.
02:26:45 Now staying on page 25, we can see in the left hand column that audit title and systems
02:26:51 description has been given as brigade control.
02:26:55 And if we could look for present purposes on the third column from the left, headed
02:27:00 risk recommendation and category.
02:27:04 And if we can look slightly further down the page, so we see the heading you see there
02:27:09 in the middle, rating-medium.
02:27:14 What it says there is this.
02:27:16 Failure to effectively monitor the receipt of FSG training could result in staff receiving
02:27:22 insufficient levels of this mandatory training.
02:27:26 This could result in reputational damage in the event of a serious incident involving
02:27:31 persons trapped being dealt with by staff who had not received the required level of
02:27:36 training.
02:27:37 And then if we can go into page, further down on page 26, also under the heading rating
02:27:43 medium, it says this again.
02:27:46 Failure to ensure that training records are accurately maintained could result in training
02:27:50 levels being inappropriately reported and all staff not receiving the required training
02:27:57 potentially leading to an inappropriate response to an incident.
02:28:03 Now, GPAC identified problems with training records as presenting a medium risk to Alfeba.
02:28:12 Would you accept that on any view that is a significant failing that has potential for
02:28:17 significant failing that's been identified?
02:28:19 Yes, I would.
02:28:22 I'm not sure who drafted this particular document.
02:28:25 I wouldn't have thought it would have been GPAC members that came to that conclusion.
02:28:29 I would have thought it would be LFB officers that presented this information to the committee.
02:28:35 And I would assume then that they would have sanctioned it, yes.
02:28:40 Now, whether it was LFB or GPAC, did Dave Brown discuss the substance of this audit
02:28:48 with you at any time?
02:28:50 No.
02:28:52 When you were first commissioned to carry out your review, did you think to ask for
02:29:00 any previous report review studies which had considered the effectiveness of control broadly
02:29:07 and the provision of training in particular?
02:29:09 No, I don't think I did that.
02:29:12 At the time I was given the task of reviewing control, as I've explained.
02:29:16 It was a cultural review and solely commissioned because of the issues that have been raised by staff.
02:29:25 And Dave Brown never said to you, listen, we've had a Kelly review, we've had the
02:29:30 Latinal Board and we've got a GPAC audit which cover control issues, you need to be aware
02:29:34 of them.
02:29:35 He said nothing along those lines at all.
02:29:37 That's correct.
02:29:39 Did Mr Heywood ever refer to or cite the information set out in this GPAC audit when you were discussing training?
02:29:49 No, and I don't know if Scott Heywood was aware of this GPAC audit.
02:29:54 Would it have been put bluntly and crudely above his pay grade to have seen documents such as this?
02:29:59 It may well be the case.
02:30:01 So we now know that the lack of planning and record keeping that you had identified may well have been a chronic and systemic problem.
02:30:15 Would you accept that?
02:30:16 I would.
02:30:17 Could we look now to implementation more generally and could we go to, for that purpose, paragraph 29 of your first witness statement
02:30:28 which can be found at LFB trouble zero three two eight two three forward slash seven.
02:30:40 Now you see in paragraph 29 there and in the second line you said this, that you ensured actions from your review were being
02:30:49 worked on and I discussed progress and issues with POM.
02:30:53 Is that a fair reading of what you said out there?
02:30:55 Yes.
02:30:56 Did you continue to monitor the remedial actions and their implementation after you became director of operations?
02:31:03 Yes, I did.
02:31:04 Ultimately, was it your responsibility to ensure that these remedial actions were not only implemented but implemented effectively?
02:31:11 Yes.
02:31:13 Did you essentially leave Scott Heywood to get on with it and then check in with him on progress from time to time?
02:31:20 You could put it like that.
02:31:23 Joanne Smith was leading on some of the actions as well but it was Scott I spoke to to get the updates on where we were with each action.
02:31:31 And were or was progress on implementation of the remedial actions the first point in your one to ones with Scott Heywood?
02:31:42 Yes, it was a regular, it was a diarized action if you like on our one to one meetings, yes.
02:31:50 And was that the primary mechanism whereby you held Mr Heywood to account in terms of the effective implementation of your recommendations?
02:31:58 I suppose it was the formal way we did but I would speak to Scott a lot more than just at our meetings.
02:32:06 So on particular issues, Scott may phone me or call into my office to discuss particular actions, yes.
02:32:12 And how would you press him on the information that he was giving to you?
02:32:17 Would you accept it at face value or would you press him on, for example, what the factual basis was for the points he was putting to you?
02:32:25 No, I would challenge him if I felt the challenge was needed.
02:32:28 And on what issues did you feel that you had to press him when you were having these discussions?
02:32:32 I think there were some issues where Scott was having, should we say, challenging conversations with the members of the unions who were pushing back on some issues.
02:32:45 For instance, one of my recommendations was to reduce the number and the regimented approach to the breaks the control staff took.
02:32:56 So on a 12 hour shift, staff had four hours of breaks.
02:33:00 It was very, very structured, exactly what time almost to the minute that staff would leave for a break.
02:33:05 And I felt one, the break was too much, four hours, and two, it was too strict and I wanted to see some more flexibility.
02:33:14 So on that particular issue, Scott, I think, was having problems with the unions on that.
02:33:18 And so I would challenge him on that as an example.
02:33:21 And what interest did Dave Brown take in the effective implementation of your recommendations?
02:33:30 So Dave Brown certainly agreed with each of the recommendations I had made.
02:33:35 I think I did give him throughout the second half, latter half of 2016, updates on how we were getting on.
02:33:42 But it wasn't, I don't think it was a monthly update.
02:33:46 I think it was more informal than that.
02:33:50 Given the identified lack of planned training within control that you'd concluded existed,
02:33:59 what steps did you take to ensure that an effective process was put in place to provide planned training?
02:34:06 I think I'd suggested to Scott that he liaise with colleagues within the Information Management Department and IT
02:34:15 to make those changes to the systems so that the systems of control reflected more that I'd already spoken about that was in place at fire stations.
02:34:24 Should a suggestion be read as instruction?
02:34:27 Yeah.
02:34:29 Was Joanne Smith involved in that work?
02:34:32 I'm sure she would have been. She was the lead for training, so she would have been, yes.
02:34:38 You say you're sure she would have been. To your knowledge, was she?
02:34:43 She would have specified probably to Scott. I'm sure the three of us probably had discussions on what was needed.
02:34:50 But it was probably Scott that had the conversations with the other heads of service.
02:34:54 But you can't speak directly to that?
02:34:56 No.
02:34:59 Now, if we can go back to your second witness statement, which can be found at LFB-000-83-884-4-6.
02:35:13 And if we could look at paragraph 29B, B for Bravo, and the third bullet point in particular, you say there, this, paragraph 49C.
02:35:24 Following the 2016 report, operations managers, OEM, were required to develop annual watch training plans agreed by their senior operations manager, SOM.
02:35:36 These were made available to all watch members and managers.
02:35:39 It is my understanding that a watch training plan for each of the six watches, to the best of my knowledge,
02:35:46 the records of training undertaken in relation to the plans were paper-based until around December 2018, when an IT-based solution was introduced, similar to station diaries.
02:35:56 When you say it is my understanding, what is the basis of that understanding?
02:36:03 Because at the time, December 2018, I was the director of operations.
02:36:08 And I think shortly before that, I understood that the systems I was looking to see change still hadn't been changed, which was a particular frustration to me.
02:36:19 And I think it was at that time I tasked my staff officer, who was a group manager, Rob Davies, to go down and meet with Scott,
02:36:29 meet with the head of IT and maybe information management, say bang some heads together, to make the change that I wanted to see happen.
02:36:40 And that change came about with the assistance of Rob Davies, I think.
02:36:45 And so it had been on the basis of debriefing from Rob Davies?
02:36:49 Yeah, Rob had been previously a borough commander, so he knew exactly how the systems worked on stations.
02:36:56 And as I say, I was frustrated that it was taking as long as it had to bring in the changes that I wanted to see.
02:37:04 And therefore I lent Scott the support of Rob Davies, who between them managed to get it done.
02:37:11 Can we look at Appendix 2 of your report, which sets out the assignment of actions to individuals?
02:37:18 And that can be found at page LFB, trouble zero, 32826, forward slash 31.
02:37:32 And if we could amplify reference 49, that appears to show that the actions arising from paragraph 49 of your report are assigned to JS.
02:37:45 Is that Joe Smith?
02:37:47 Yes, it is.
02:37:48 Now, was the failure that you've adverted to, timiously, to implement your recommendation with respect to training plans essentially the responsibility of Joe Smith, therefore?
02:38:01 No, I don't think that particular action to bring in the changes to the systems, that certainly wouldn't be the responsibility of Joe Smith.
02:38:14 This was in the context of the report, that reference 49, there was a whole load of suggestions I was making, training and development areas that I would like to see brought in, and Joanne Smith was responsible for those.
02:38:30 Did Dave Brown ever ask you to provide him with a training plan for control?
02:38:36 No.
02:38:38 Were you aware of him asking Scott Heywood to provide him with a training plan?
02:38:44 I don't believe so.
02:38:46 You understood that watch training plans had been put in place before you changed roles and well before the Grenfell Tower fire. Is that a fair summary?
02:38:56 Yes, but they would have probably been paper based, they wouldn't have been on the step system.
02:39:02 Did you ever physically see the training plan for control?
02:39:06 I can't recall that.
02:39:10 You essentially relied upon Rob Davies' debrief that the recommendation had been implemented?
02:39:16 Rob Davies certainly told me that the IT system changes had been implemented. Rob wouldn't have told me that the control training plan was in place, that would have been Scott.
02:39:29 Did Rob Davies give you his assessment as to why implementation of this recommendation had not been executed as swiftly and as effectively as you directed?
02:39:44 No, I think he didn't. I think the watch training plans had been put into place much sooner than Rob got involved, but Rob was purely used to get the IT system changes done, so it was more robust.
02:40:02 Assistant Commissioner Jonathan Smith wrote a briefing note entitled Control, Overview and Control Improvement Plan and that was dated the 22nd of July 2019. It was addressed to you and Andy Rowe I think, is that right?
02:40:16 Yes.
02:40:17 Could we go to that document which is LFB Trouble 0 84097?
02:40:23 There you go, as we can see it post-dates the fire by two years or so, but can we go to page 3, in particular the final paragraph on that page, which is under the heading Training Assurance and Professional Development.
02:40:43 AC Smith wrote this.
02:41:13 Substantive Training Plan. Are you able to explain why training was described as ad hoc and lacking in structure and outside of any substantive training plan in 2019 if the watch training plans had been developed following your review?
02:41:30 No, I can't explain that and I was shocked and angry when I read this, but I wasn't surprised when I read this and if I can just add some context to that. So this was just a few months before I retired.
02:41:44 I think in the latter half of 2018, it may have been early 19, the Brigade's Grenfell Tower and Investigation Review Team, I remember a meeting with them where they shared some of the issues that have clearly been highlighted in things that the Brigade had said that they would do that clearly weren't done.
02:42:04 I think probably from the Kelly report and the Lindridge report probably, and I was very shocked and angry at that time that those issues were still outstanding.
02:42:13 And at that point, I made a decision that things needed to change in terms of the leadership at control and I made the poem redundant. And at that point, I felt we needed to increase the senior officer at control.
02:42:33 And I spoke with Commissioner Danny Cotton at the time. We were going through a round of, we needed an additional assistant commissioner and the successful candidate was Jonathan Smith who had come in from Hertfordshire.
02:42:47 And I spoke to Commissioner Cotton and requested to her that we place Jonathan Smith at control. It would be a fresh pair of eyes. It would provide that greater link from control to the operational staff.
02:43:02 And as I say, I think it was early 19, or maybe late 18, Scott Hayward left the organisation and Jonathan Smith started. And the brief I gave Jonathan was, I think, to carry out this review along with Andy Rowe as well and Commissioner Cotton as well so that we could actually get a fresh look at what the actual issues were still down there yet.
02:43:28 Thank you. I hope that helps in terms of the context around how this report came about. It does. Thank you. Can I now look at and go back into the substance of your review and again paragraph 49, but subparagraph A, which was the structure and shift pattern changed to allow training to take place.
02:43:47 Now if we go back to LFB trouble 0 3 to 8 2 6 forward slash 11.
02:43:59 And if we could look at paragraph 49 please.
02:44:04 That says this one reason for a lack of regular maintenance of skills training has been the difficulty in getting the watch together away from the control room to undertake team based training sessions.
02:44:16 When the shift change in 2011, it was proposed that such training would be carried out on the short shift.
02:44:23 However, this is really been achieved for a number of reasons, including a shortage of stuff, high sickness levels and the inflexibility of breaks.
02:44:32 A number of things need to change to allow suitable sufficient and regular training and development to take place, including a ensuring that any overall staffing structure change and change the system of breaks allows and encourages staff training to take place.
02:44:51 I'm mindful of what you set out there. We can just go back and report paragraph 39, which is on page nine.
02:45:00 You wrote this.
02:45:02 When the current shift was introduced, the agreement was that training would take place when the short shifts overlap due to staff shortages, the times of the early short shift were amended to provide adequate cover.
02:45:16 This in turn significantly reduced the time set aside for training. Therefore, the current shift pattern does not allow sufficient time for an OM or AOM to deliver regular meaningful training to their watch outside of the main control room.
02:45:31 A time period similar to strategic resource on a fire station is needed to achieve this reverting the start time of the early short shift from 0800 hours to 10,000 hours in accordance with the original agreement will allow four hours every day when the early and late short shifts overlap 1200 to 1600 hours.
02:45:53 And this time must be set aside predominantly for maintenance of skills training.
02:45:59 When you wrote your report, what training provided to our staff were on watch.
02:46:06 Yes.
02:46:08 So they could be recalled to the control room at any time during the course of that training.
02:46:13 Yes.
02:46:15 Given the shortages of stuff and the high sickness levels that you referred to in paragraph 49, presumably there were times when some stuff could not attend training, so as to ensure that control room was fully and appropriately staffed.
02:46:31 Yes, I think the short shift as it says there was the best possible time for staff to leave the control room and actually sit in the training room.
02:46:42 There was a training room at Merton to undertake training where they weren't likely to get called in for an incident.
02:46:49 Unfortunately, due to the shortage of staff, predominantly the short shift staff were used to fill the gaps on the duty watch.
02:46:58 So, speaking of various ways of resolving the dilemma that you found, did you consider whether staff could be trained in say smaller groups or running more training sessions so as to ensure the greatest possible number of staff received the training they required?
02:47:13 I didn't consider that specifically.
02:47:16 There was training taking place and there was a system of control.
02:47:21 So even if staff were in the training room, if there were a high number of calls suddenly coming in, there was an alarm that sounded at Merton which would call all available control officers back to the main room.
02:47:33 And in my time at Merton that alarm went off a few times.
02:47:36 So it's everyone rather than just an individual member of the watch?
02:47:40 There were two different alarms is my understanding.
02:47:43 One was all control staff on that particular watch.
02:47:49 So that would pull staff back from their breaks.
02:47:52 And there was another alarm if things got, let's say even worse, that would call all control officers in the entire building back into the control room.
02:48:00 So if all the CROs have been called back during the course of a training session, for example, how would the balance of that training session be provided to the members of staff who'd been called back to duty?
02:48:11 Often it was only for a peak for multiple calls, predominantly multiple calls coming in to an incident, not multiple fire survival calls, multiple 999 calls.
02:48:22 So it would normally be over very quickly.
02:48:25 So for an example, over the years, particularly with the more and more people that have a mobile phone, the number of 999 calls to one incident has increased dramatically.
02:48:37 So if you had a car fire on a motorway 20 years ago, you might get one call for it.
02:48:41 Now it's not uncommon to get 50 calls for it.
02:48:44 So all coming in at once.
02:48:46 In those situations, it was not uncommon for the alarm to sound, all available control officers to report to the room and then just take 999 calls as quickly as possible.
02:48:54 So on that basis, looking at the short shift itself, control room officers who'd been called back to duty, then released, they wouldn't have lost the full four hours where there was no for that.
02:49:06 Correct.
02:49:08 When you refer Paragraph 49 to the shortage of staff as being a reason for training not being undertaken, did you consider proposing an increase in staffing resource at control in order to deal with that problem?
02:49:22 Yes.
02:49:23 And through 2016, there was two, I think, new entrance training courses while I was there.
02:49:31 And then over the time in 2017, 2018, I can't recall exactly how many more, but probably at least five or six, probably new entrance courses.
02:49:43 And each of those courses would have up to six candidates on them.
02:49:48 Effectively, had you sought a lifting of the prohibition on recruitment of new control staff then?
02:49:54 Absolutely.
02:49:55 And apologies for being unnecessarily formalistic or loyally about this.
02:50:00 Did you have to put in a submission asking for that and to whom was that submission addressed?
02:50:05 At the time that I was Assistant Commissioner reporting to Dave Brown, yes, he and I discussed.
02:50:12 At the time that the National Coordination Centre left London for Merseyside, I believe six control room officers were part of the establishment at LFB to deal with the NCC.
02:50:26 And when the NCC left, we didn't make any staff redundant.
02:50:30 We had positions so that we, I think we moved the establishment so that those six positions were now part of the recognised establishment at control.
02:50:39 And then during my time as director, I did make some further establishment changes.
02:50:47 I certainly increased the number of supervisors and AOMs by one per watch.
02:50:52 And I believe I increased the number of CROs by one per watch as well, I believe.
02:50:57 Did you experience any resistance to the increase in resource, staff resource at control?
02:51:04 The only resistance would have been budgetary because we were, as an organisation, put under an awful lot of pressure to reduce the overall budget every year.
02:51:16 And it was a difficult thing for each head of service to look at their budgets to make recommendations for how they would reduce.
02:51:24 There was a target set given to each head of service to reduce their overall budget.
02:51:29 I think that had been a problem, including for control, that the head of service for control had been put under pressure, understandably, by the director responsible for how they would reduce their budgets that year.
02:51:41 And I think that had led to some staff reductions in the years previously.
02:51:46 As director myself, I liaise closely with Sue Budden, who was the director of contractual services, effectively the accountant for the firm, if you like.
02:51:57 And between us and the commissioner, we agreed with an increase in establishment.
02:52:04 So I think your question was, was I challenged on it only in financial terms, possibly by the director of contractual services and possibly LFIPA members?
02:52:16 Was the resistance you experienced no more than that which you'd expect from those who had overall responsibility for managing the budget?
02:52:25 No, I think certainly Sue Budden, Commissioner Cotton, and the governance of LFIPA changed.
02:52:34 LFIPA ceased to exist. And we had a deputy mayor for fire and operational resilience, which was Fiona Twycross.
02:52:40 And predominantly my dealings with her and I think Fiona and Sue and Commissioner Cotton each saw that what I was saying about maintaining and increasing the establishment of control was a benefit.
02:52:53 Thank you.
02:52:54 Going back to the practical arrangements, if a staff member was recalled to work as a result of an upsurging 999 course, for example, what arrangements were in place to ensure that if a training session was undergoing, the staff member received the training that they were due to complete on that day?
02:53:13 It would be an assumption, but my assumption was that if it was OST that were delivering the training, that OST would recall that particular member of control back in later date to complete the training.
02:53:25 But you're unaware of the specific processes and procedures that were applied by OST to achieve that aim?
02:53:30 That would be correct.
02:53:31 Thank you.
02:53:35 This may be a level of detail you can't now fairly recall, but how frequently did you find that staff were in fact being called back to the control room during training sessions?
02:53:47 I couldn't say whether it was during a training session.
02:53:51 I can say that during 2016 when I was predominantly based at Merton, I heard that alarm go off maybe five or six times.
02:54:01 It wasn't a common occurrence.
02:54:03 And usually when it did, I would be wanting to know why it had gone off for my own operational reasons as well to see if there was a significant incident taking place in London.
02:54:11 So it's five or six times during a year?
02:54:14 It would be less than a year because I was based at Merton from the April to the mainly to the end of December.
02:54:20 After that, I moved and most of my time was spent at headquarters preparing for the changeover in my role.
02:54:28 Looking at paragraph 39 there, you referred to the need for strategic resource to allow for the delivery of meaningful training.
02:54:37 Can you help us? What do you mean more precisely by the phrase strategic resource?
02:54:41 So strategic resource was used in the operational arena.
02:54:44 So there would be a number of fire engines that were allowed to be taken off of immediate availability so they could undertake activities that were difficult to do while there was potential to be called away.
02:54:59 So, for instance, large scale training exercises, it may be that they were on a housing estate undertaking lots of home fire safety visits.
02:55:08 So that was commonplace on fire stations. It was not in existence at control.
02:55:13 Thank you. In her statement to the Metropolitan Police, Debbie Rill, who was a CRO, states, probably easy if I take you to it, Met Trouble 080520 forward slash 14.
02:55:38 And if we could see in the fourth paragraph on that page, she says this.
02:55:56 Trying to train control room staff is always difficult because we are always on duty, unlike our operational colleagues who come off the run.
02:56:04 We tend to get a bit of training here and there, but not any dedicated time as such, although it is getting better now.
02:56:10 We need a whole day set aside every few months for training where we can train as a watch.
02:56:16 On the basis of your experience and understanding, Mr George, was Miss Rill correct when she said that control staff were always on duty, unlike our operational colleagues who come off the run?
02:56:29 Yes, in the main she's correct.
02:56:31 Thank you.
02:56:33 Did you consider whether it's possible to create protected ring fence time for training?
02:56:39 Yeah, I saw the overlap time of the early short shift and the late short shift as a four hour period where that could be dedicated primarily for training.
02:56:49 Where they were off the run, to use her phrase.
02:56:51 That's correct. But to get to that point, we needed to ensure that the establishment was correct so that those staff on the short shifts weren't filling in the gaps.
02:56:59 Thank you. Could I just finish one question before the lunch break?
02:57:04 Could we go back to the fire service manual, which was published in 1998, which can be found at INQ 0014945 forward slash 129.
02:57:24 As you can see from the top right corner, this is appendix one and it concerns control staff training, competence and promotion.
02:57:32 If we could look at the right hand column and the second paragraph there, it says this.
02:57:38 Training for control personnel has always been hindered by the small numbers of staff available and the need to maintain cover in the control centre.
02:57:46 Training is usually watch related and carried out at the normal place of work.
02:57:51 This ensures the maximum number of personnel available.
02:57:54 For these reasons, Brigade should consider the provision of a training officer and or watch training days away from control.
02:58:01 Did you find any evidence when you were carrying out your review that control had considered watch training days, for example, away from the London Operations Centre?
02:58:11 I wasn't aware that that had ever been considered, no.
02:58:15 Did you see any consideration of providing a training officer or such like?
02:58:20 No, we had some very professional control officers within the OST.
02:58:25 I think the establishment there was four AOMs and I increased that to six for a period of time and they undertook a large percentage of the training there.
02:58:38 I think London as well was in a, LFB was in a favourable position in terms of numbers of control officers.
02:58:45 I've visited several control rooms around the country and in many fire rescue services there may only be two or three control officers operating through a 24-7 period.
02:58:58 London obviously, due to the complexity of the number of calls, had significantly more.
02:59:04 But there were certainly quite periods where training could be undertaken on a watch.
02:59:10 Thank you. So we are a minute before one.
02:59:14 Yes.
02:59:15 The next section will take longer than one minute.
02:59:17 Of course.
02:59:18 So this is an appropriate place.
02:59:19 Of course, yes, I think it is. Thank you.
02:59:21 Well now, Mr George, it's time we had a break for lunch, so we'll stop there.
02:59:25 We'll resume, please, at two o'clock.
02:59:27 And as I said to you before, please don't discuss your evidence or anything to do with it with anyone over the break.
02:59:33 Thank you, sir.
02:59:34 Would you like to give the hour show?
02:59:35 Yes.
02:59:45 Thank you very much. Two o'clock then, please.
02:59:47 Thanks, sir.