London Fire Brigade Evidence - Wednesday 1st December 2021 (1/2)

Full transcript

00:00:26 good morning everyone welcome to today's hearing today we're going to continue hearing evidence from the london fire commissioner so would you ask mr rowe to come in please

00:00:47 good morning commissioner good morning we're ready to carry on here i am thank you thank you very much mr chairman good morning to you good morning to members of the panel uh commissioner good morning to you good morning i'd now like to ask you about

00:00:59 morning i'd now like to ask you about the fire at shepherd's court that happened in august 2016. we heard extensive evidence from assistant commissioner dan daly in relation to that fire and he confirmed

00:01:10 relation to that fire and he confirmed that the fire started in a flat on the seventh floor of that purpose-built block and spread via the panels that were under the windows on the outside of the building because those panels comprised combustible polystyrene insulation now

00:01:24 combustible polystyrene insulation now that's a very brief summary is there anything i've got wrong in what i've just said i don't believe so i mean i i have read the post-incident report for shepherd's court i wasn't

00:01:35 court i wasn't in attendance at the incident so i probably don't have the same grasp of the detail that dan daley would have but yes i think that that's a useful summation of the the findings of that

00:01:46 summation of the the findings of that post incident thank you thank you well we'll come to the operational aspect of the incident later on in your evidence but for the moment i just want to focus if i can on the combustible cladding that was present on the building can we go please to rbk triple zero two

00:01:59 can we go please to rbk triple zero two six eight eight eight

00:02:06 this is a letter date of the 6th of april 2017 uh written by uh ac dan dailey to laura johnson director of housing at rbkc

00:02:17 johnson director of housing at rbkc it was one of a number of letters sent to directors of housing and the like across london is the letter familiar to you i have read this letter yes right you didn't

00:02:28 read this letter yes right you didn't see it at the time i didn't see it at the time but i've read it as part of my preparation for the inquiry thank you let's um let's look at some of the key passages if you stick with the first page and look at the second paragraph there you see it says this

00:02:40 there you see it says this my predecessor assistant commissioner steve chirik wrote to housing providers in march 2009 about a variety of matters relating to fire safety in residential housing blocks

00:02:51 blocks one of those matters was a replacement double glazing and the associated replacement of spandrel and filler panels on the external faces of blocks of flats with floors above 18 meters in height in the case of this fire we

00:03:03 height in the case of this fire we believe such panels were a contributory factor to the external fire spread we have seen a number of cases where it appears on the basis of the information available to us that the level of fire

00:03:14 available to us that the level of fire protection to the external face of the building did not comply with the requirements of part b of the building regulations insofar as they seek to limit the speed at which a fire can travel and spread over the external face

00:03:26 travel and spread over the external face of a building or may contribute to a fire

00:03:31 fire testing of panels has found that the combustibility of the composition of the panels at shepherd's court did not meet the levels expected for conformity with the building regulations on testing it was found that panels may deform or

00:03:43 was found that panels may deform or delaminate exposing any combustible core or constituent material resulting in the panel becoming involved in the fire and allowing the fire to spread and enter flats other than the flat of origin of

00:03:55 flats other than the flat of origin of the fire

00:03:57 the fire our first commissioner would you agree that the shepherds caught fire involved in fact precisely the same issue that presented itself at lachenal house and then presented itself

00:04:08 then presented itself later that year at grenfell tower yes very similar because it both in the case of the lack of house fire and the shepherds caught fire uh the use of spanderal panel in-field panels was an

00:04:20 spanderal panel in-field panels was an issue and the spread of fire in the context of those panels was an issue

00:04:24 issue yes i think more obviously at shepherd's call

00:04:28 call exactly thank you yes and and the core point here being the commonality between the fact that they were non-compliant and combustible facade panels yes

00:04:39 apologies yes yes now leaving aside the the question of degree extent of external first bread that resulted by reason of those panels

00:04:50 reason of those panels and also ignore the fact that grenfell was fully clad rather than having simply scandal squares of facade do you agree with me that the point being made here was was that the fire had spread as a result of the use of

00:05:02 had spread as a result of the use of non-compliant construction materials on the exterior of a residential high-rise block same issue at latino and same issue later that year at grenfell that's the point i'm seeking too in in the

00:05:13 the point i'm seeking too in in the context of shepherd's court yes absolutely the the external fire spread was a significant significant contributing factor in the context of lachen whilst the external infill panels

00:05:24 lachen whilst the external infill panels were certainly a contributory factor i think as we discussed yesterday the very serious failures of internal compartmentation were as much to blame for the the very rapid and

00:05:36 to blame for the the very rapid and unexpected fire spread at lacanal but there is a commonality across both fires but to a greater extent at shepherd's court yes and does it would you agree that it would follow from there that the more paneling you've got

00:05:48 there that the more paneling you've got the greater the risk of extensive external fire spread yes particularly if that that the scope of that paneling the extent of that panning was co-joined and continuous

00:05:59 panning was co-joined and continuous yes and therefore i think you would agree the greater the risk of fires breaking back into compartments should non-compliant material have been used in the construction of the assad

00:06:10 used in the construction of the assad yes because inevitably there were more points of intersection via window frames or other joints in the building to the interior of the building yes can

00:06:21 to the interior of the building yes can we please then go back to the module six uh written opening submission at nfb double zero one two three two six three

00:06:34 uh and if we look together please at page two paragraph six you see uh there

00:06:41 uh there um the paragraph begins by the time of the fire at shepherd's court in august 2016 the lfb were aware of the dangers of certain types of modern external wall systems such as rain screen cladding but the extent and

00:06:54 rain screen cladding but the extent and wider impact of those systems which was seen in the grenfell tower fire was not fully understood now i just want to ask you about the second part of that sentence there can you explain what

00:07:05 you explain what is meant by the statement that the extent and why the impact of certain external wall systems was not fully understood i think what that means is that the building industry

00:07:17 building industry had moved more quickly than the london fireside's use of modern methods of construction a variety of materials in facades whether it was actually wooden cladding or whether it was manufactured composite materials

00:07:29 was manufactured composite materials aluminium you know clad composites so that we i think we were beginning to understand that modern methods of construction and the kind of innovative use of materials was outstripping our

00:07:40 use of materials was outstripping our ability to always not even just understand but even know what people were using and that we were coming across some very odd examples of exterior fire spread so for example the

00:07:51 exterior fire spread so for example the mandarin

00:07:53 mandarin court hotel was a 20 pump fire where an external living wall um spread fire from the basically the ground floor to the top floor of the hotel because because of the

00:08:05 hotel because because of the plastic mesh that sat behind the living wall now this was not something we'd seen

00:08:11 seen before and you know now we were suddenly seeing living walls on a scale adorning the size of commercial and indeed even residential buildings so there's something about the pace at which the

00:08:22 something about the pace at which the building industry was moving compared to our complete understanding of how people might be using all sorts of facade materials connecting them together and using them in combination with other

00:08:33 with other um elements of a of construction to finish a building so i think it's about our ability to keep pace with the building industry right just just on that um let's help me

00:08:44 right just just on that um let's help me the mandarin court hotel am i right in thinking pro-stated the grenfell tower fire yes it did something like 2018 wasn't it i think it was something like that yes do you know from your knowledge now what the of the fire safety

00:08:57 now what the of the fire safety department within the lfb at the time knew of the method of construction which you've just described so plaster over mesh and its uh and its combustibility i

00:09:08 mesh and its uh and its combustibility i i couldn't tell you what they knew exactly at that point i would be surprised if colleagues in fire safety engineering our fire engineering experts didn't have some awareness of uh

00:09:20 of uh construction of that nature because i think they're very well trained professionals who work very hard to kind of try and keep abreast of all the different developments in the construction industry but i can't speak to the detail

00:09:32 industry but i can't speak to the detail of it because i don't know right from the time you became commissioner in january 2020 have you done anything to have a look at the fire safety department even as a silo

00:09:43 even as a silo and and ask it whether it was keeping up with modern methods of construction such as the example you've just given us yes so myself the deputy commissioner richard mills paul jennings who is our

00:09:54 richard mills paul jennings who is our current assistant commissioner for fire safety have regular conversation about how the built environment is developing i have a monthly catch up actually specifically to deal with emerging issues in fire safety so

00:10:06 with emerging issues in fire safety so myself and the depth sit with the ac outside of any formal board structures fire safety is an agenda item in the cross-cutting

00:10:17 agenda item in the cross-cutting operational um kind of

00:10:21 kind of corporate board so so we come back to it again and again it's how it's how i know about the the battery issue because although that's really quite niche batteries on a scooter as we discussed

00:10:32 batteries on a scooter as we discussed yesterday is something that's filtered up and through and was brought to my attention in one of the monthly updates so we keep on coming back to it but it is a challenge because the building industry is doing things that you know i think are to be admired

00:10:44 that you know i think are to be admired for their innovation but at times do need to be challenged for their their kind of um prioritization of fire safety so for example in croydon and forgive me i don't know the exact detail it's either

00:10:56 don't know the exact detail it's either under construction has had the planning approved or is in construction i'm waiting for an update well

00:11:03 well we're building the tallest ever building constructed with shipping containers and the question my fire engineers have is is the frame that sits beneath those shipping containers able

00:11:15 shipping containers able to withstand the corrosive effects of a very high temperature fire for example but you know to be fair to my fire engineers they had never come across up until that point the possibility of

00:11:26 up until that point the possibility of building up 44-storey tower out of shipping containers so i think london is right to be proud of the innovation that its construction industry demonstrates but that does come

00:11:37 industry demonstrates but that does come with a challenge and therefore we need the construction industry to place fire safety as much as a priority as they do for example as health and safety in construction and think about it in

00:11:49 in construction and think about it in terms of the value of space and what what they provide inside buildings to keep their residents safe coming back to grenfell um is what you mean here in the passage that i've just read to you

00:12:00 read to you that until grenfell the brigade didn't anticipate that a fire could spread across the entirety of a combustible facade of a building as opposed to being

00:12:11 facade of a building as opposed to being confined to a more isolated part of the facade no i don't i don't think it is saying that because it would be disingenuous to do so knowing that one part of the brigade in fire safety had seen international fires where it was

00:12:22 seen international fires where it was clear that a a fire could spread across the entire facade of a building so i i think we knew it could spread across the entire facade of the building but what our experience even

00:12:33 but what our experience even though was you know i'm afraid contained within fire safety had told us was that you didn't tend to get very significant internal breach of compartmentation combined with that so if you look at the

00:12:44 combined with that so if you look at the international examples of rapid external facade spread they're not often combined with very considerable failure of internal compartmentation

00:12:56 compartmentation but you know i think we all have to acknowledge that that knowledge that you could see an entire facade consumed by fire was not shared across all the bits of the organization it should have been so you don't you don't use shepard's

00:13:07 so you don't you don't use shepard's court uh to say to as it were to defend the brigade by saying well that was only a partial power of the partial exterior the brigade knew enough to know didn't it at

00:13:18 brigade knew enough to know didn't it at the time that there was a real risk that a fully clad building could result in a a whole building fire i think one part of the brigade did yes certainly at that point in time yes thank you now i'd like to show you the tall building slideshow

00:13:31 to show you the tall building slideshow that the chairman referred to yesterday during your evidence now there are two versions of this in fact but if we look at lfb triple zero three two nine one six

00:13:44 um this is the version that we looked at at phase one although it still retains the date 13th of july 2016. it's which was its original date it was updated after the shepherds caught fire

00:13:55 after the shepherds caught fire in early october 2016. uh if you um recall your evidence in phase one day 48 i think you were taken to this and i think at that stage you

00:14:06 to this and i think at that stage you said you hadn't seen it before um looking back on it now is that is that the case yes i i'd not at the point i stood in the first phase of this inquiry i had not seen that presentation i have since

00:14:18 not seen that presentation i have since because again i've considered it as part of my preparation for this phase of the inquiry yes now when you were asked about it and just for

00:14:27 just for those who want to look it's it's the phase 1 transcript day 48 of page 173 lines 8 to 24. and i'm going to summarize what you said there but um you were asked about this

00:14:38 there but um you were asked about this and you said that you didn't understand at the time of the grenfell tower fire the new construction materials and methods were being used with limited understanding of their fire behavior and performance and that your base

00:14:49 performance and that your base assumption was that buildings were constructed in accordance with the building regulations which would include principles that the facade would not contribute to the fire spread itself

00:15:00 spread itself does it remain your evidence as to the state of your own personal understanding as at the date of the grenfell tower fire

00:15:07 fire yeah yes because my general understanding at that point in time was that whilst i knew because i said it yesterday my own professional interest that we had seen you know extensive facade fires abroad

00:15:20 you know extensive facade fires abroad you know

00:15:21 you know i wasn't considering it in the context of the uk at that point because we simply hadn't experienced it in quite that way that total failure of a facade i was fully aware that we might

00:15:32 facade i was fully aware that we might face external fire spread because i'd understood the lessons from lac and indeed you know i know dan daley really well and and he talked to me about shepard's call but

00:15:41 but i have to say and it is still a shock to me that the scale of the failure of the british regulatory system in this regard i was still in a place like many offices where we i just don't think we anticipated failure on that scale in the

00:15:54 anticipated failure on that scale in the british built environment so rightly or wrongly but that that's that's the my honest kind of position at that point yes just to see if i've got that evidence correctly

00:16:05 see if i've got that evidence correctly then does it follow that your understanding at the time of the grenfell tower fire was that the risk of fire spread via an external facade system applied to certain buildings

00:16:16 certain buildings overseas at risk but but not in england no i think it was more nuanced than that i think what what i'm saying is that the totality of failure we saw for example in dubai was something that i thought

00:16:27 in dubai was something that i thought was perhaps more relevant to another regulatory system but i was absolutely alive to the possibility of some form of external fire spread um

00:16:37 um in the uk because i've experienced the aftermath of lachenau and had spoken to dan about shepard's court so it wasn't a complete

00:16:45 complete um you know blind sightedness on the possibility of some form of external fire spread i'm talking about the total failure of kind of a modern method of construction in in the context of

00:16:56 of construction in in the context of facades again let me try and i don't want to put words in your mouth but does it come to this you looked at those overseas fires particularly in middle east and europe and said the extent of that facade fire couldn't happen here

00:17:07 that facade fire couldn't happen here because of our regulatory regime i don't think it was even as concrete as that i just don't think i well

00:17:14 well i mean i suppose if the way i would have put that in my own head is i'm not sure that could happen here because i i had enough faith in the the building regulatory system that i

00:17:25 the building regulatory system that i thought it wouldn't

00:17:29 you know because i think we you know i think again up to the point of grenfell i would have anticipated partial failure of that regulatory system absolutely because that's the nature of emergency

00:17:40 because that's the nature of emergency services you invariably pick up the pieces after some failure of a regulatory system but the uk you know to its credit has a long history of actually designing and then implementing fairly robust

00:17:52 implementing fairly robust and rational regulatory systems you know and emergency services exist within that context

00:17:58 context i think grenfell you know continues to me to be a a an article of public shame really for the united kingdom that a regulatory system failed so completely

00:18:10 so completely so i think we all anticipated where elements of a regulatory system might not quite work you know could fail because of human error or because someone had missed one part of it but to

00:18:22 someone had missed one part of it but to face what was an almost complete failure of everything from design to inspection to competent construction and frankly um you know good moral decision making is

00:18:35 you know good moral decision making is still really shocking i suppose that that's why i wouldn't have thought it would perhaps manifest itself in such a total way

00:18:46 um i was planning to take you through this slideshow piece by piece and i will do that uh if i need to but but let me see if i can take this more briefly are you

00:18:57 if i can take this more briefly are you very familiar with the contents of this of this uh slideshow i wouldn't say very familiar mr miller i've looked at it a couple of times in terms in terms of preparing for the inquiry very good well let's just look at it then um if we turn to page 15

00:19:12 uh it says this at the very top fire started on seventh floor in two bedroom flat with rapid spread of the fire along the facade and then if we go to page 16

00:19:23 go to page 16 uh post fire questions you can see um in the second bullet point that did the facade construction contributed to the fire spread to the upper floors and then there's an arrow

00:19:35 upper floors and then there's an arrow preliminary testing was carried out and witnessed by the fire engineering group to determine the behavior of the facade and if further actions were required and then um the presentation sets out in some detail the results of two series of

00:19:47 some detail the results of two series of tests

00:19:48 tests that were carried out uh in the weeks after the fire on samples of panels taken from the scene and if we can scroll through pages 17 18

00:19:59 and if we can scroll through pages 17 18 and 19

00:20:00 and 19 you'll see those there those are the tests 17 18 we go to 18 and then 19. there they are and if you stay on 19 and look at the photograph

00:20:12 look at the photograph there that's taken during the second series of tests and the text on the left hand side says second series of tests conducted on the panel without the metal fascia significant sustained flaming

00:20:24 fascia significant sustained flaming occurring following the removal of the ignition source test 3 was stopped after 5 minutes 54 seconds as the testing facilities were overcome by the size of the fire this series of tests revealed that the

00:20:36 this series of tests revealed that the insulation contributed to the combustion when the metal fascia was removed next slide 20 conclusion of the test these tests the tests demonstrated that once the

00:20:48 the tests demonstrated that once the metal fascia was removed the insulation was contributing to the combustion process therefore the facade may have contributed to the fire spread and then next page 21

00:20:59 and then next page 21 general conclusion and i think we did look at this at your phase one evidence uh but note the bold in the original text and it says this as a general principle in bold the external

00:21:11 a general principle in bold the external envelope of the end of the building should not contribute to the fire spread along the facade new construction material and method of construction are being used in facades and with a limited understanding of

00:21:22 and with a limited understanding of their fire behavior stroke performance there is a need to understand what products are being used in the facade system and their fire behavior and if they are used appropriately and

00:21:33 and if they are used appropriately and meet the relevant guidance these could affect the way fires develop and spread in a building now we know that this same presentation also includes various different items of technical information from the from the

00:21:45 technical information from the from the regulatory guidance and i can just give you a quick example of that if you go to page five

00:21:54 in the same document back at page five external fire spread what are the issues on the right hand side and you can see that the top left of the text is a diagram

00:22:06 of the text is a diagram and

00:22:07 and in the red box rapid fire spread it says cladding system contributes can you just see that cladding system contributes to flame spread resulting in risk of multiple simultaneous secondary

00:22:19 risk of multiple simultaneous secondary fires

00:22:21 fires and then underneath that there is a diagram or image taken in fact from the 2013

00:22:27 2013 edition third edition of bre-135 uh br135 uh

00:22:36 i'm going to assume that you weren't familiar with that technical data or perhaps you were not awesome no no uh and then you can see if you go to the uh next slide

00:22:48 sorry to say on this i'm so sorry that it'll work on both sides but go back to page five

00:22:52 page five that was too quick on the left hand side of the diagram you can see a large orange arrow and some text next to it which says if the external cladding contributes to the flame spread there is a risk of

00:23:03 flame spread there is a risk of secondary fire spread to all levels you see that i do and then on the right hand side the same escape of fire from the window to the facade but on that side in the top right

00:23:14 facade but on that side in the top right hand corner of the diagram in the red box it says restricted fire spread cladding system does not contribute to flame spread risk of secondary fire is limited

00:23:25 and then in the next slide at six you've got the same arrow which is the um

00:23:32 vertical mechanisms of external fire spread and there are the factors set out combustible materials in the facade system

00:23:40 system cavities

00:23:41 cavities part of system as a result of construction defects created by delamination note flames and cavities can extend five to ten times original length regardless

00:23:52 to ten times original length regardless of materials present so that

00:23:55 so that tells us and we can read it that that the risk

00:23:59 the risk uh exists the combustible materials might be used in a facade system and also the risk that cavities um exist

00:24:07 um exist whether intentionally or by a result of a defect yes absolutely yes there's then some technical materials set out on pages 7 8 and 9

00:24:19 pages 7 8 and 9 and 10

00:24:21 and 10 which is essentially approved document b technical guidance note 18 which i need to trouble you with the second edition from june 2015 and and br 1 br 135

00:24:33 and br 1 br 135 and

00:24:35 and i don't need to take you to that because you're not familiar with the technical material but would you agree on what i've shown you that this presentation demonstrates a detailed and pretty sophisticated level of technical

00:24:46 sophisticated level of technical understanding of the risks of facade fires in the built environment at least on the part of lfb's fire safety department yes i would and i think and again it speaks to the points i made yesterday

00:24:59 speaks to the points i made yesterday that um

00:25:00 that um you know one of the things we we should have done better was to ensure that that knowledge was shared with all the other relevant parts of the organization i think that is clear and indisputable yes and and do you agree that that would

00:25:13 yes and and do you agree that that would also show that the nfb was aware at least within the first safety department particularly as a result of the actual tests done on the facade panels from shepard's court

00:25:24 shepard's court that uh

00:25:28 that uh external fire spread through the mechanism of a burning facade system was something that could happen here yes i think i think it would be hard not to draw that conclusion particularly in

00:25:39 to draw that conclusion particularly in the context of the effects of delamination and the spread you know inside a cavity of flames

00:25:46 of flames of a far greater size and that in essence perhaps this is too subtle a reading of the slide but slide shape but in essence the regulatory regime

00:25:57 the regulatory regime in england did not obviate or did not always obviate the risks giving rise to the mechanisms of external fire spread demonstrated by this slideshow

00:26:09 this slideshow no i i would agree with that so i think that

00:26:12 that it was clear that if those methods of construction were likely to be encountered in the built environment and we had recognized that risk

00:26:20 risk inside our own fire safety department there has to be a question about the regulatory system that would perhaps allow that to occur when i talk about a regulatory system i think we have to

00:26:32 regulatory system i think we have to think about it both in terms of base principle but the process that that regulatory system frames from design through inspection to construction and the signing off of construction and in particular i mean

00:26:44 construction and in particular i mean i've had an interest obviously since the fire in how the industry and those that regulate the building industry test things in composite because it's

00:26:55 test things in composite because it's not enough to just test things in individual isolation to test a panel you know you've you've got to almost build a wall with all the elements behind it to really understand how a building might

00:27:07 really understand how a building might operate in in its total nature

00:27:13 yes and i think you might be referring to perhaps unwittingly to bs8414 parts one and two i'm not sure i've got the detail of the british standard i'm sorry but but do you accept this this this

00:27:24 but but do you accept this this this point is a serious point that the extent of white the wider impact of the type of external wall system was fully understood before the grenfell tower fire as demonstrated by this this slideshow i think within our fire

00:27:35 slideshow i think within our fire engineering department and in fire safety there was without a doubt a growing understanding that composite wall panels however they were used whether as infill or in extension across a whole facade

00:27:46 or in extension across a whole facade presented at the the very real danger of external fire spread is obvious from this presentation and and are you able to explain looking back on it now from the position you occupy as commissioner

00:27:58 you occupy as commissioner how it came about that that detailed technical information and the knowledge of those risks as shown by this document remained

00:28:08 remained siloed within the fire safety department and were never disseminated to frontline firefighters i would break it into three factors and then this is obviously my perspective i wasn't there at the time i

00:28:20 perspective i wasn't there at the time i can't speak to the decision making at my level then but i would break it down into culture the the pressure of what people in what is a relatively small fire engineering department for the environment you know

00:28:31 department for the environment you know fantastic people world-class engineers actually

00:28:34 actually you know but the scale of what they were having to deal with on a day day-to-day basis in terms of the volume and complexity of consultations and then back to governance again so not having the governance that supported

00:28:46 the governance that supported senior leaders to effectively put them in a place where they had to work across the boundaries of departments and directorates so so partly this thing about everyone

00:28:57 so so partly this thing about everyone having their head down working really hard a culture of kind of focusing on your area of business that had grown over many years the governance that would have better supported people to break out of their

00:29:09 supported people to break out of their department or directorate to share information because they were mandated to and then actually if i think about fire safety in particular the very real pressures

00:29:17 pressures that whilst we have the largest fire engineering team in the uk and rightly so you know if i think about just a high-rise environment alone there are 12 000 high-rises in

00:29:29 high-rises in the uk

00:29:30 the uk i've just had the update from the building risk review this morning over the course of the pandemic we have inspected eight and a half thousand of those high rises in london we have eight

00:29:41 those high rises in london we have eight and a half thousand of the twelve thousand residential high rises in the uk in london that is disproportionate compared to anywhere else in the uk manchester the next largest connection

00:29:52 manchester the next largest connection you know which equates to about a third of the population of london has only 500 residential high rises that is 100 less than westminster which has 600 high rises as a borough alone so

00:30:05 600 high rises as a borough alone so that fire engineering department is dealing with a moving landscape a built environment that is on an exponential scale beyond anything else experienced in the uk and actually pretty much worldwide it's only the

00:30:17 pretty much worldwide it's only the other global cities that stand in comparison so i have some sympathy for the fact that they would have known this would have focused on it and then would have relied on someone at a more senior level to pass the information across through good governance which i'm afraid

00:30:29 through good governance which i'm afraid was not in place at that time

00:30:35 yes let me come back to that answer in due course um but let's let's proceed let me show you something um which uh is andy jack's witness

00:30:46 which uh is andy jack's witness statement

00:30:47 statement uh which he provided to the inquiry and it's is easier i think if i go to it um it's nfb

00:30:54 it's nfb double zero one two zero three zero eight

00:30:58 eight and there are two passages i just want to show you the first is on page four

00:31:06 and you're i'm sure you're familiar with who andy jack is i i am indeed yes and uh he says at page four in paragraph 14

00:31:17 14 he says in the second line the adequacy of the adb in respect of b41 that's um external fire spread was a live issue for the investigation of

00:31:28 live issue for the investigation of offenses in respect of latino house and during the preparation for and the hearing of the lachnal house inquest certainly following the latino inquest and the rule 43 recommendations made by the coroner on 28 march 2013 it was a

00:31:42 the coroner on 28 march 2013 it was a commonly held view at the lfb that the guidance to b41 was insufficiently clear

00:31:51 and then if you go to page seven please and let's look together at paragraph 24 at the foot of that page and this is under the heading the misinterpretation of b4 in the residential construction industry and

00:32:03 residential construction industry and practice

00:32:05 practice at the time of the email exchange between myself and colleagues on the fire safety and fire engineering teams and this i think is is 2012. uh

00:32:16 uh it was a commonly held view at the lfb that there was widespread misunderstanding by building controlled bodies and industry stakeholders of the scope of b41 as it applied to the regulations

00:32:27 b41 as it applied to the regulations governing spread of fire over the surface of a building and that this misunderstanding was fostered by a lack of clarity within the guidance this is evident from the letters of the then commissioner ron dobson to the dclg

00:32:39 then commissioner ron dobson to the dclg on the 11th of december 2012 and the 26th of september 2013. uh now that's what he said my question is were you aware at the time or were

00:32:50 is were you aware at the time or were are you aware now that it was a widespread view at the time

00:32:55 time that

00:32:56 that b4

00:32:57 b4 external fire spread within adb was

00:33:02 was unclear or generally misunderstood i think you have to view this from the perspective of andy jacks so andy jacks is a preeminent fire safety expert he's an excellent officer who offers i think

00:33:14 an excellent officer who offers i think real value to the national landscape and understanding of fire safety but he is very focused on fire safety i think when he talks about widespread understanding my reading of this document would be that he's talking

00:33:25 document would be that he's talking about the fire safety department he's talking about colleagues in fire safety and he's talking perhaps singularly of the commissioner who obviously may have been briefed on that matter i certainly did not have that

00:33:37 i certainly did not have that understanding at that point in time and i would i would suggest that the majority of other operational officers did not share that understanding of approved document b to answer the second part of your question am i aware now yes i'm very

00:33:49 question am i aware now yes i'm very aware of approved document b and i find it to be somewhat impenetrable and i think

00:33:54 think that as part of the outflow of this inquiry i would hope that we you know along with the legislation that is going to come to pass through government we improve

00:34:02 improve on the guidance that is available to the building industry in regard to fire safety generally

00:34:08 yes now uh

00:34:11 uh i think

00:34:12 i think thus far

00:34:14 thus far you would agree with this i think that it was very much on the lfb's corporate radar if i can put it that way that

00:34:22 that the assumption that materials on the outside of a high-rise building did not pose a fire risk by virtue of our regulatory regime was an unsafe assumption

00:34:33 assumption sorry could you repeat that question differently the lfb knew as a corporate entity that they could not assume that materials on the outside of high-rise buildings didn't pose a fire risk

00:34:45 buildings didn't pose a fire risk because they complied with the regulatory regime it's clear from the letters uh from people of dan daley seniority that the letters from the commissioner to to various parties and obviously the

00:34:56 to to various parties and obviously the understanding held in fire safety that that was the case yes

00:35:03 and i and do i take it that you would agree that at least in some form that critical information should have been placed into the minds of first responders watch managers crew managers attending a fire absolutely yes

00:35:16 managers attending a fire absolutely yes yes um now just i just want to show you something that's a little bit later in time early june 2017 a matter of weeks only before the grenfell tower fire itself lfb triple zero two four two

00:35:27 itself lfb triple zero two four two seven one

00:35:35 this is a presentation dated june 2017 created by kevin hughes who has some qualifications after his name who i think at the time

00:35:47 name who i think at the time was a dac

00:35:49 was a dac from what we can see it was drafted a little earlier in 2017 but it was it's dated to june that year and it's entitled firefighting in tall buildings and it's a set of conference notes as

00:36:00 and it's a set of conference notes as you can see from the first line of the text

00:36:05 if i take you to slide eight you can see where we start with a particular building this is another interesting incident

00:36:16 this is another interesting incident says the text the picture shows the fire service tackling a small flight a small fire on the 10th floor and you can just see

00:36:23 see two firefighters i think on the balcony there if you go to page nine uh there's a bit more detail fire on tenth floor the red arrow here we see a close-up of the building

00:36:34 here we see a close-up of the building the top of the penthouse flat on the tenth floor what is really interesting about this is the fire actually started at the ground floor and progressed from the ground floor to 10 floors up all behind the cladding in a very short

00:36:45 behind the cladding in a very short space of time and then slide 10 please

00:36:50 point of ignition at street level this slide shows the point of ignition at the ground floor the fire was started by careless disposal of smoking material and then if you go to slide 11

00:37:03 how the fire traveled the cause and there's some red arrows there

00:37:07 there the slide shows how the fire traveled from street level to the 10th floor flammable building facades are a common challenge for the nfb and we'll need to scroll down thank you they cause

00:37:18 scroll down thank you they cause unexpected fire spread sometimes unseen until it breaks out again in a different location and they often lead to fire breaking out on several floors these type of fires can really challenge the fire strategy of a tall building in

00:37:30 fire strategy of a tall building in residential buildings the fire is not contained confined to the flat of origin and our state put limited evacuation strategy is compromised large-scale evacuations in residential

00:37:41 large-scale evacuations in residential buildings especially those with single staircases cause a problem in terms of staircase capacity and obstruction to firefighters and then there's something about commercial buildings we can skip

00:37:52 about commercial buildings we can skip over that and then in the penultimate paragraph

00:37:55 paragraph the reason for highlighting this is to raise awareness of the problem i believe that the codes and fire engineering principles we use to design fire safety into buildings are excellent but

00:38:05 but facade fires and on controlled spread of fire across the outside of tall buildings is a significant threat to the effectiveness of many of the systems of the many systems within the building

00:38:16 the many systems within the building this is a vulnerability that we can design out of buildings by ensuring the limited combustibility of facades and where any doubt exists at the design or specification stage we should be seeking independent testing of facade materials

00:38:28 independent testing of facade materials to provide assurance that they are of limited combustibility now um

00:38:35 now um one can summarize it this way do you accept that here as of june 2017 a week or two before the grenfell tower of fire the lfb as a corporate entity knew

00:38:47 fire the lfb as a corporate entity knew first but flammable or combustible building facades were a common challenge for the lfb i think this presentation is an example

00:38:58 i think this presentation is an example of two things firstly i'm not sure it's a particularly good presentation because i think the example that's been given there is actually actually speaks to the failure of compartmentation and

00:39:09 to the failure of compartmentation and avoid behind a facade because it starts behind a facade and then it comes out much later and actually we did have experience of that over many years you know i've been at a 15 pump fire in

00:39:20 know i've been at a 15 pump fire in hounslow years and years before where a poorly constructed timber framed building a you know a fire had started in one corner near a car park and ended up diagonally you know almost 20 meters

00:39:31 up diagonally you know almost 20 meters away at another corner of a building leading to partial collapse we've known about the danger of unexpected fire traveling voids for years and indeed instructed people on it so in that sense the example itself is slightly erroneous

00:39:42 the example itself is slightly erroneous because i don't believe it was the facade that was actually the primary causation here it was the the poor

00:39:49 the poor application of fire breaks behind the facade that would have would have created the conditions kevin hughes has described there the second part of it and i think this does point to a real issue for nfp by the way so i'm not

00:40:00 issue for nfp by the way so i'm not seeking to mitigate this presentation is that you have an example of an officer there a senior level working within a fire safety department going to a conference to present on behalf of lfb i'm not sure how excited

00:40:12 behalf of lfb i'm not sure how excited the people who led him at the time were on that presentation so that's someone speaking on behalf of the london fire brigade perhaps without having had the oversight

00:40:22 oversight to to have that point of view either challenged or clarified or considered in the round and i think it speaks to his issue of joining things up again about one part of the organization

00:40:33 about one part of the organization knowing what the other organized part of the organization is doing because it you know again it is it it speaks to that to me as much as anything this presentation well uh

00:40:44 well uh i'm just really going on the words on the slide

00:40:47 the slide do you accept that flammable building facades were a common challenge for the lfb

00:40:52 lfb um

00:40:53 um not in our experience in terms of volume no not not up to that point we certainly again it would be completely wrong in the context of this inquiry to pretend it wasn't

00:41:02 it wasn't known as an issue for the london fire brigade it's clear from the letters that ron dobson had sent that dan daly had sent the

00:41:09 sent the knowledge contained within the specialist fire engineering department that we knew about the risk but in terms of actually having experienced fires where there was you know significant involvement of flammable cladding i

00:41:21 involvement of flammable cladding i think our experience was fairly limited it wasn't

00:41:24 it wasn't um

00:41:25 um in the wider knowledge as the major contributory factor in terms of risk at a high rise fire even at that point it's it's it still wasn't

00:41:34 wasn't so i think the use of the word common is erroneous because again i don't believe the knowledge that people like kevin hughes had who to his credit is a very experienced fire safety um inspecting officer and specialist i

00:41:46 um inspecting officer and specialist i do not believe that knowledge was shared so when they talk of common understanding i'm afraid people like andy jackson and kevin are perhaps talking about the common understanding within that section of professionals within the

00:41:57 section of professionals within the london fire brigade and again that knowledge wasn't what wasn't perhaps shared effectively because it would not have been the common experience or understanding of most operational crews and offices well

00:42:08 most operational crews and offices well that i understand yeah and that's what i'm really seeking to understand why that was but going on what we see on the slide do you accept

00:42:17 accept looking at the third and fourth paragraphs down

00:42:21 down that

00:42:23 that i'm summarizing a flammable building facade can really challenge the first strategy of a tall building

00:42:31 building absolutely yes and then in residential buildings the fire is not always confined to the flat of origin and the state put strategy may well be compromised absolutely because again whilst we hadn't

00:42:43 whilst we hadn't trained firefighters and officers effectively to understand how they might reverse that strategy we had of course referenced it in our own high-rise policy for a number of years you know we had been part of the formulation of the

00:42:55 had been part of the formulation of the national generic risk assessment that was clear that that was a possibility there's a possibility that was known in the london fire brigade yes yes uh and as he says facade fires an

00:43:06 and as he says facade fires an uncontrolled spread of fire across the outside of tall buildings was a significant threat to the effectiveness of the many systems within the building yes it couldn't dispute yes

00:43:18 the building yes it couldn't dispute yes and again is the reason why as of june 2017 that knowledge was not in the heads of your watch managers or above any of whom could be called upon at an incident at a high rise in london at any time but sat siloed in a

00:43:29 london at any time but sat siloed in a coterie of fire survi of fire safety officers

00:43:33 officers yes because and the shame of it is that this would be a useful presentation to give to watch officers and and operational officers i think i think that is the point is that we we knew

00:43:44 that is the point is that we we knew this we were giving it to a conference of people who also had a right to be interested and deserve to have that knowledge shared with them but we had not given this presentation simply to our own

00:43:55 own wider operational staff and leaving aside whoever was responsible for the undertaking a massive accusation of our residential high-rise building

00:44:06 high-rise building was always on the cards it had always been considered as a possibility but we had not trained people to

00:44:14 people to undertake it it was recognized it was recognized within the gra it was referenced um

00:44:20 um you know briefly within our own policies so that that recognition was there but i think perhaps we had always avoided tackling that as a training issue because of the very real difficulties in

00:44:32 difficulties in training to that possibility because it is challenging we're training to that now so if i think about what we're doing now that is what we are doing now we are training firefighters to carry out mass emergency

00:44:43 firefighters to carry out mass emergency evacuation you know the transition from evacuation to mass rescue and i have to say we found it enormously challenging is of note to me that the the governmental uh working

00:44:54 that the the governmental uh working party drawn together to consider this very issue has sat for a number of years since the fire without producing any guidance for either the national fire and rescue service nor nor other parties who might be

00:45:05 nor other parties who might be interested we've we've had to do this on our own in partnership with nfcc you know we've had to consider how we might reasonably train firefighters to carry out what is an enormously difficult process at the point you're

00:45:17 difficult process at the point you're confronted with it because obviously we are doing it in buildings that are simply not designed for that purpose doesn't mean we shouldn't do it we must do it and we are doing it but it's extraordinarily difficult

00:45:31 just on that then can you just just break that up a little bit first of all on training generally is babcock still um the contracted uh outsourcee

00:45:42 contracted uh outsourcee it is yes so backcock is still our outsourced training provider for those elements of centrally delivered training but i'll just make the point that and i think there is a great focus on the contractor but the reality is that

00:45:53 the contractor but the reality is that 90 both in terms of volume and syllabus of training is delivered by junior officers to their watches on our fire station so whilst i have a real interest obviously in the performance of our

00:46:05 obviously in the performance of our contractor and the training outcomes we see

00:46:08 see i have as great an interest in the support we give our junior officers and the syllabus we provide for them and the materials we provide for them on fire stations because that is where the bulk of the training actually lies which is

00:46:21 of the training actually lies which is not the responsibility of the contractor as a separate or perhaps parallel point let me just explore this with you you'll have heard or have seen some of the evidence earlier in this module about the way in which training gets conceived

00:46:34 the way in which training gets conceived of

00:46:35 of perhaps as a response to a trend identified in the diot process and then go through the operational news process and then

00:46:43 and then turns into a tea cap and various things that happen that process of which we've heard so much was in place up to 2017 what is the process now by

00:46:54 up to 2017 what is the process now by which

00:46:55 which training such as training firefighters to instigate a mass evacuation is now um designed um and delivered i think

00:47:05 i think rather than rather than sort of focus on the nominicatus i think it would probably still be called the training commissioning uh um an application process so the tcap process

00:47:15 process but it's about the nature of the bureaucracy that surrounds that so where we've got to now is a manifestly rationalized process so slim down

00:47:24 down so that we put commissioning officers much closer to the contractor or actually step into a space where we co-create because we recognize that it's much easier for a fire and rescue

00:47:35 it's much easier for a fire and rescue service to maintain contemporary experience of a very rapidly developing risk environment than it is for a third-party contractor and therefore we've got a responsibility as an

00:47:46 we've got a responsibility as an intelligent client to bring that knowledge to bear in the commissioning of training so we've rationalized the process we've slimmed it down i think it needs to be improved further i think it needs to become

00:47:57 i think it needs to become you know agile further still but that's a shared responsibility between us and the contractor

00:48:07 and what sort of time frame now um

00:48:10 um would you be looking at between identifying the need for for training on a particular activity and rolling it out to station-based staff i wouldn't have a fixed period of time because i think it's dependent on your assessment of

00:48:22 it's dependent on your assessment of risk if we discovered a risk that um you know was so paramount that we needed to do something quickly and effectively we would prioritize on that basis but i suppose the reality of

00:48:33 basis but i suppose the reality of training 5 000 staff with their availability in the context of the ships means that it normally takes about a year your prime example of that would be what we've done around high-rise actually we recognized the point took

00:48:45 actually we recognized the point took over in january 2020 that we simply had to bring into operation vastly altered operational policies in respect to fire survival guidance evacuation and high-rise firefighting which had to be

00:48:57 high-rise firefighting which had to be seen together so couldn't be seen as individual policies must be seen together understood together used together it took us a year to commission and deliver in totality

00:49:08 to commission and deliver in totality uh the training to all five thousand of our operational staff and we're now into the second round of validation and test by exercise of that process and we will have to evolve it again because of the research we are

00:49:20 of the research we are leading on around firefighting in the high-rise environment i'll have to change again we'll have to go back around the round again so i think when we want to we can flex that contract very quickly for example if if i think

00:49:32 very quickly for example if if i think about a separate a separate occurrence around training one of the rightly critical findings the causes of concern that came out of our 2019 inspection

00:49:43 out of our 2019 inspection was the volume and um quality of our our incident command training we went back to the contractor and changed the syllabus within a matter

00:49:54 and changed the syllabus within a matter of weeks

00:49:56 of weeks and have delivered a completely different approach to revalidation again over the same time period over the course of a year we got toward our operational leaders

00:50:05 leaders and either validated them or gave them a different form of acquisition training if they were stepping into that role so i think the contract the contract can be made to work for us on the basis of risk but it requires

00:50:17 the basis of risk but it requires you know a robust relationship with a contractor it requires us to take our responsibilities seriously as the intelligent client as the person commissioning the training

00:50:28 commissioning the training but my personal focus is not really on the mechanism by which we get to the outcome it is the outcome itself i think you can reasonably consider in-sourced and outsourced solutions to training in fact

00:50:40 outsourced solutions to training in fact we deliver on a hybrid model in a number of places now and the contractor is entirely comfortable with that as a we it's about getting the right outcome for firefighters so the people of london get the right outcome

00:50:54 and are you able to explain why it took an incident like grenfell tower for the brigade

00:51:00 brigade so radically to revamp its training processes

00:51:04 processes i'm afraid i can't because i wasn't at that level of decision making or relationship with the contractor i can only speak to my own relationship which is professional courteous and robust i meet with the ceo

00:51:16 meet with the ceo of babcock fairly regularly we have quarterly meetings at director and commissioner level with our our you know relevant other parties within babcock and to be fair it is at times a challenging relationship as it

00:51:27 times a challenging relationship as it should be you know we challenge each other back and forth as to each other's responsibilities and what we expect to see as a quality of outcome now what i'm really driving at is something different um which is there were eight years between lachenal

00:51:39 there were eight years between lachenal and grenfell and some recommendations which came from the coroner at lachen which resulted in training for example incident command uh which we've heard a lot of evidence about are you able to tell us from your

00:51:51 about are you able to tell us from your perspective as commissioner now why it took grenfell to revamp say radically your training program and that that radical revamping wasn't done when it became obvious that training was safe

00:52:02 it became obvious that training was safe was not being rolled out quickly in the light of the latino recommendations again i'm not sure i could i from my position now looking back and we have looked at obviously our training with some rigor and continue to

00:52:14 training with some rigor and continue to you know we we're just going coming to the end of another review of all our training

00:52:18 training processes

00:52:20 processes um

00:52:21 um it's hard to pinpoint again a single factor i think there was a challenge in the transition from a very large in-sourced training model to a very large outsourced training model that just the transition process i remember

00:52:32 just the transition process i remember it

00:52:32 it being challenging um i think there will have been something around how the organization culturally accepted the move to an outsourced training model you know perhaps elements of resistance

00:52:43 perhaps elements of resistance potentially within it you know an ideological basis to to resist that that there is likely to have been the challenge actually of just starting something new and then working to evolve it because i can see

00:52:54 working to evolve it because i can see that

00:52:55 that you know

00:52:56 you know even prior to me taking over as commissioner the the development of training in partnership with babcock had got better from a starting point so there had been attempts to evolve it

00:53:08 attempts to evolve it but to be frank grenfell was and rightly so was enormous shock to the london fire brigade you know it painted a stark picture so i think

00:53:19 a stark picture so i think recognizing it as the catalyst for change is appropriate because it should have acted as a catalyst for change it was the most terrible reminder as i said yesterday for any institution

00:53:30 for any institution that that should have been there in place supporting the breed you know the residents of of that block

00:53:37 block that we needed to make change and this brings me to one of the questions i started yesterday with which was why wasn't lachenall the catalyst for change given that there were six deaths and it was a defining

00:53:50 were six deaths and it was a defining moment

00:53:51 moment in the brigade's history i think that it was a catalyst for change i think we saw a great energy immediately after the fire to bring change i saw the same energy immediately after 7-7 which was

00:54:03 energy immediately after 7-7 which was equally traumatic for the brigade you know and equally difficult in terms of some of the things we'd expose firefighters to and what we we saw it do to communities in london generally again

00:54:14 to communities in london generally again there was a great energy after 7 7 to learn the lessons i think what i come back to is the same point i made yesterday

00:54:20 yesterday and it's the thing i think i have the greatest responsibility to try and change

00:54:24 change and embed now is the ability to sustain the lessons and the change generation needs to keep on coming back to it and really i'm picking you know in the in in the kind of total

00:54:35 you know in the in in the kind of total nature of it what those lessons mean so i think i think la canal was a catalyst for change i think that 77 was a catalyst for change i think 911 was a catalyst for change

00:54:46 change but

00:54:48 but in each of those cases it was about then sustaining the lessons that that generation of officers had learned and bring it bringing it forward and i think that's where we you know i would i would

00:54:59 that's where we you know i would i would suggest our greatest vulnerability was exposed

00:55:03 exposed let's then turn to lachenal and i want to examine with you how the brigade in fact implemented the latino coroner's recommendations from 2013 onwards

00:55:14 onwards and let's start with incident command training we've already touched briefly on the recommendations in the context of the lack of house study uh i'd like to take you to the recommendations uh let's look at the

00:55:26 recommendations uh let's look at the coroner's letter lfb triple zero three two one five eight this is the letter to the lfb of the 28th of march 2013 addressed to the then commissioner ron

00:55:37 addressed to the then commissioner ron dobson

00:55:40 dobson and if we go please to page three we can see the seven recommendations relating to incident command at the top of the page

00:55:48 page and

00:55:49 and she says it is also recommended that the consideration be given to training of ics and potential ics to enhance their performance in relation to the following and there are seven

00:56:00 and there are seven bullet points set out there the third bullet point says to anticipate that a fire might behave in a manner inconsistent with the compartmentation principle

00:56:12 compartmentation principle now first would you agree that this recommendation was one can presume born out of the rapid unexpected and widespread failure of compartmentation at lachnal

00:56:23 compartmentation at lachnal yes yes

00:56:26 and that that recommendation essentially went to the need to prepare commands to face the risk of building failure yes now certainly the understanding of i had taken from the fire itself yes

00:56:38 had taken from the fire itself yes now we've heard a lot of evidence so far about in the internal processes and systems that were put in place by the brigade after the inquest to address this and other recommendations and now our understanding and please

00:56:51 and now our understanding and please correct us if this is wrong is that you are not personally involved in any of those internal processes is that right no the the only intersection i had with um any of the post lacanal

00:57:03 um any of the post lacanal um kind of desire to improve was the um use of an exercise that we had set up anyway in southwark and then became clearly an opportunity to test a revised

00:57:15 clearly an opportunity to test a revised high-rise firefighting policy at the time so that that was my only real knowledge and involvement with any part of that process and that was only as an exercise

00:57:27 process and that was only as an exercise facilitator so the person who had ensured we had enough fire engines there that we had a suitable venue for it that i joined all the different parts of the kind of machine up to enable that exercise to happen on the

00:57:39 enable that exercise to happen on the day was that the haygate challenge of the 16th of june 2011 yeah right

00:57:45 right because that's before the inquest itself well there you are i think that probably demonstrates you that i'm not connecting the time up in the right way so that is that is my only involvement actually in in that right well with that in mind i'm

00:57:57 in that right well with that in mind i'm not going to ask you about any of those processes but what i would do want to explore with you is the training that ultimately emerged specifically in response to these seven recommendations

00:58:08 response to these seven recommendations on uh incident command namely

00:58:13 namely in a very focused way the the package called whole croft house are you familiar commissioner with the whole croft house package um not not in intimate detail but i

00:58:24 um not not in intimate detail but i recognized the title i would no doubt i've read it as part of the preparation for the inquiry again right well let's see how we go can we go to bab6011 please

00:58:40 now here is the first page of the training guide for the whole craft house cde or command decision exercise this is undated i should tell you but this is the um

00:58:52 this is the um uh training guide for crew and watch manager

00:58:55 manager um just looking at the document on your screen are you familiar with it do you think

00:58:59 think uh i'm not sure to be frank i mean it i recognize obviously i recognize the branding of it and i've read so many documents now that

00:59:06 that um our training materials provided to our offices and crews but i think as we move through it i may become more familiar with it right i think i probably recognize it from the detail of the

00:59:17 recognize it from the detail of the package itself right okay well we understand that it wasn't finalized until august 2016 by which time you were a dac

00:59:25 a dac do i take it from what you've just told us that notwithstanding that you have no recollection of undertaking the whole craft house exercise yourself i don't think so no right well we've looked at the detailed content of this package with other

00:59:37 content of this package with other witnesses before you in this module including former commissioner danny cotton so i'm not going to go through it with you but i'd like to look at um some put some headline points to you and see if you can respond

00:59:49 if you can respond um

00:59:50 um this exercise first do you know involved only very limited compartmentation failure in that the fire was said to have spread from the corridor on the fourth floor to a single flat on the

01:00:01 fourth floor to a single flat on the fourth floor no i wasn't aware of that i mean i could show it to you in the document of page 76 if we just go to that you weren't aware of that you say no

01:00:10 no uh and there it is on the in the first box there as an inject

01:00:17 it didn't involve any external fire spread whether it was a result of non-compliant panels or otherwise and that is absent from the entire document

01:00:27 document it referred only in passing to the need to consider full or partial evacuation with no guidance as to how it should be carried out or at what point i can show you that if we go first to

01:00:38 i can show you that if we go first to page six

01:00:44 uh

01:00:47 you can see uh there

01:00:50 uh there uh in the last paragraph under 1.4 the um

01:00:58 the incident increases in complexity to involve persons reported far survival calls significant fire growth and mass evacuation compounded by the hazards and risks associated with remedial building works

01:01:09 works this will create significant challenges for cm and wm delegates and then page 69 we see how the package actually addresses that issue particularly mass evacuation and at 69

01:01:22 and at 69 under the heading collective evidence of performance trainer assessment holdcraft has inject number seven and then the third sorry fourth red box down consider partial or evacuation of

01:01:33 down consider partial or evacuation of block

01:01:34 block that's it

01:01:36 that's it and uh only one fsg call on page 12. and just to remind you lacking all had five now on the assumption that what i have described to you in this package is fair and accurate on

01:01:48 this package is fair and accurate on that assumption would you agree that that exercise scenario amidst critical features of the lack of house incident not least one rapid and widespread

01:01:59 not least one rapid and widespread failure of complementation two extensive fire and smoke spread and three

01:02:05 three an appropriate number of fsg calls yes but then i i think my question in return would be at what point in the in the learning cycle of a watch officer

01:02:17 in the learning cycle of a watch officer is this

01:02:18 is this exercise carried out because i think when you've got new officers you've also got to build their knowledge and exposure to stress over time so if this was

01:02:29 was one of the earlier exercises they were exposed to where you're starting to build their confidence starting to get them to think about some of the decisions they might have to make although i would like to see more guidance obviously about what partial or

01:02:40 guidance obviously about what partial or full evacuation might even mean then it might be appropriate but you would expect it to be followed reasonably knowing the lessons from lacking with something more complex

01:02:51 lacking with something more complex delivering a greater level of pressure with more guidance around how you might deal with multiple points of failure and the challenges the very real challenges of evacuating

01:03:02 of evacuating um you know in the context of emergency or block

01:03:06 or block well we haven't seen any other package that would have created the bedrock uh training about how to go about or when to go about a partial or full evacuation of a block or

01:03:19 evacuation of a block or how to

01:03:20 how to identify sudden impending

01:03:24 impending fire growth i'm not sure it existed and the reason i know that is because obviously i have as commissioner gone back you know not personally to unpick every single detail of training i wouldn't be able to do that in my role i don't think

01:03:36 able to do that in my role i don't think you'd reasonably expect that but we have set people about the task of obviously completely revising our training syllabus and we do now train in a very different way face-to-face

01:03:47 different way face-to-face incident commanders to take exactly those decisions with the guidance as to how they might carry out that enormously difficult task and then and now we put them into a simulated environment we're in the process of running a series

01:03:59 we're in the process of running a series of very challenging 12-pump exercises for every single firefighter and officer in london to to take those decisions not in the environment of a decision-making exercise in a classroom

01:04:10 decision-making exercise in a classroom but inside a tower blog with you know with a simulated incident underway evacuating people from from the block so i think i think the fact that we've

01:04:22 so i think i think the fact that we've gone back and i can see that we haven't got that depth of training and we've bought into operation a completely different

01:04:28 different syllabus around high-rise firefighting which we will need to continue to build on you know we we anticipate uh you know if we secure the investment and we get the right balance of resources in place that we will need to

01:04:40 resources in place that we will need to deliver

01:04:41 deliver a repeated kind of cycle of what we're going to call an urban firefighting course so a week's residential course away probably somewhere like the fire service college or one of the other

01:04:52 service college or one of the other training centers in in the country that allow for realistic carbonaceous burn and i expect every firefighter to have that ideally on a yearly basis or at the very least on a two yearly basis where

01:05:03 very least on a two yearly basis where we start to embed that learning in a very realistic simulated environment so it's not that i'm even satisfied with where we've got to now i think we need to go further but that again will take time and we need to build people's knowledge to get

01:05:16 need to build people's knowledge to get effectively to that point and secure the investment resources to do so moving forward

01:05:22 forward now

01:05:23 now two things follow from that first do you accept on what i've put to you and on the assumption that what i put to you is fair and correct that this command decision exercise

01:05:34 that this command decision exercise holdcraft house didn't test the critical features of the latino incident as recommended by the coroner not not to the extent i would want to see as commissioner no

01:05:45 i would want to see as commissioner no no and the question then that follows from that is in addition perhaps to learning the lessons of grenfell did you go back over

01:05:56 did you go back over exercises such as this and ask why exercises such as this did not carry into effect fully the recommendations of the lack of coroner i i think it's less

01:06:07 the lack of coroner i i think it's less about asking the question why but recognising that we didn't have the syllabus in place my focus has been on taking things forward and in a way um i i almost um i'm not interested in

01:06:21 um i i almost um i'm not interested in previous

01:06:22 previous kind of relationships with the contractor i know what i need to do and my focus has been where we've seen a gap to fill it to just have that straightforward conversation

01:06:33 have that straightforward conversation with all parties responsible to say we haven't got this part of the syllabus and we we we unpicked every single part of high rise training to consider what was missing both in respect to the lack

01:06:44 was missing both in respect to the lack of

01:06:45 of house fire and the grenfell tower fire and then our energy has been focused on um

01:06:54 um developing the relationship where we can co-create effectively where we move forward in partnership with the contractor and provide the sort of materials that firefighters and officers deserve so taking it forward in a kind

01:07:06 deserve so taking it forward in a kind of construct of positivity certainly understanding where there were challenges and where parts of that commissioning system weren't working yes absolutely you say

01:07:17 weren't working yes absolutely you say i'm sorry did you want to finish no not apologies no no it's quite right you say that it's less about asking the question why

01:07:24 why and you're not interested in previous kinds of relationships with the contractor but are you not interested as part of your going forward to understand what happened in the past

01:07:36 to understand what happened in the past and to understand and this is an as by way of an example why it was that this training package the single command decision exercise just did not carry into effect

01:07:47 just did not carry into effect the

01:07:48 the recommendations from latino as part of understanding the organization you're seeking to reform

01:07:54 reform i i think that we could expend a great deal of energy and i'm picking every single

01:08:00 single aspect of where a training package hadn't met the requirements i would reasonably expect i think i think we could do that but actually perhaps it would be perhaps i've not

01:08:11 would be perhaps i've not answered in a way that truly reflects where i am on this is that i very early in my tenure as commissioner had a meeting with

01:08:22 meeting with the corporate offices of babcock limited and basically i drew a line in the sand and my line in the sand was that we have to acknowledge as the london fire brigade that we have not always

01:08:34 brigade that we have not always effectively acted as a commissioning client to you you have to acknowledge that you have not always given us the best value we needed as as the contractor and that needs to

01:08:46 as as the contractor and that needs to stop now because of the enormity of what happened at grenfell and we are going to move forward recognizing that we need to have a professional client

01:08:56 client contractor relationship where we recognize the value that each of us bring to that but also the shared responsibility and that whilst and i actually said it was i do not intend to

01:09:07 actually said it was i do not intend to unpick every single example of where relationships or design should have been better please take as a general principle

01:09:15 principle that something has to change fundamentally and quickly and you will be able to prove that to me by successfully delivering the improvements we need and at that point we had some very serious causes for concern laid against us

01:09:26 concern laid against us in respect to driver training instant command training and high-rise firefighting i think to the credit of the contractors they heard that and they moved very very quickly to respond

01:09:38 moved very very quickly to respond but i i would i would suggest that it was a shared responsibility a relationship on that scale and that scale of contract is always a shared responsibility so i i just knew that something had been wrong in the past

01:09:51 something had been wrong in the past and we were going to resolve that you know more positively moving forward but everyone needed to be clear of their shared responsibility because whilst we have had people i'm picking all of this in detail for example andy

01:10:02 all of this in detail for example andy bell's team have really deconstructed almost every element of training and professionalism in regard to high-rise firefighting i think we could have invested a lot of energy in unpicking individual relationships

01:10:14 unpicking individual relationships because some of this stuff will simply be down

01:10:16 be down to ineffect ineffective leadership ineffective relationships at a one-to-one level you know and again a lack of governance a lack of oversight and i already knew that those things needed

01:10:27 needed improvement so i think once we knew the general principle our energy recognizing the scale of the change needed was to focus on that and drive forward every part of the organization and our

01:10:38 part of the organization and our contractor relationship against those principles

01:10:44 going back to august 2018 after the fire year and a bit after the fire i showed you i think the first page of the document yesterday um but the brigade published something called the lachenal assurance review

01:10:57 called the lachenal assurance review in the august of 2018 we can't find anywhere in that document which says either subtly or in terms that there was no training package at

01:11:08 that there was no training package at any stage which fully met the coroner's recommendation in respect of the compartmentation principle in the same way that it had at lacanal i.e mass compartmentation failure

01:11:19 compartmentation failure if we're right about that omission can you explain it even in 2018 no i can't but all i can explain is that we have gone back over every single aspect of existing

01:11:31 existing high-rise training available to our crews we have considered the lessons learned from both lacanal and grenfell in the construct of an entirely new syllabus and we effectively in many ways started from scratch

01:11:42 started from scratch right so just to pin this down to a particular part of that document to be fair to you can we go to the assurance please at lfb 40s 4801 page 29. we saw this yesterday in fact

01:11:56 in the right-hand column action 3c and you'll see that

01:12:04 there is a a in paragraph two a reference to uh

01:12:14 to uh in passing i think to the holcroft house dex holcroft house exercise

01:12:20 but no consideration there as to whether that exercise or indeed any of the others substantively addressed the purposes which it was intended to address

01:12:29 address that's as it were the best we get from this document are you able to explain why

01:12:33 why this assurance was given yes and i'd better understand the question now actually thank you um i think this speaks to our maturity and understanding of how you carry out effective business assurance

01:12:45 effective business assurance so i think one of the lessons i've learned as commissioner and it's certainly been my own understanding that's developed over time it's not necessarily one i would have immediately arrived at on taking over is that actually genuine assurance of

01:12:57 is that actually genuine assurance of outcome is complicated and has to be multi-layered so i think what what you see there is a form of assurance based on

01:13:05 on statistical analysis of completion of a training package rather than qualitative assurance of what was contained within it and i think for many years that was the approach around assurance that lfb took

01:13:16 took and it is the approach we've changed fundamentally now because whilst is input it's important to understand that you have the right percentage numbers of people completing a package quite obviously it is also extremely important to understand how colleagues have

01:13:28 to understand how colleagues have experienced the package the depth of detail in the package whether it has met the conditions laid out in the commissioning process and you know we have gone on quite a

01:13:39 and you know we have gone on quite a deep journey of improvement in that regard and again i would suggest we still need to do more because whilst we have put in place i think a well-developed business assurance framework now which is based on best practice drawn

01:13:50 which is based on best practice drawn from other industries and places culturally we still need to catch up you know we need to really help educate first line managers particularly about their responsibilities as regards

01:14:02 their responsibilities as regards assurance and how it then feeds into the other tiers of assurance for example and i think what you have here is people again doing their best in terms of trying to assure the

01:14:14 in terms of trying to assure the corporate body at that time that we had considered all the different aspects of of of kind of the lack of house tragedy but they had used what was then the common commonly understood kind of

01:14:25 common commonly understood kind of approach to assurance in the london fire again

01:14:28 again and actually my guess is that andy belmay had been responsible for this and i think if you were to speak to andy bell today he would tell you that in his current role he has developed extraordinarily he has learned

01:14:41 developed extraordinarily he has learned so much in terms of the outside expertise we've brought in to help us around assurance and that in his role now you know responsible for so much of operational assurance and our drive to

01:14:54 operational assurance and our drive to progress against the recommendations from both this and inspection he has a different view of what assurance good assurance really means because we have taken the time to learn from elsewhere and challenge ourselves

01:15:06 from elsewhere and challenge ourselves so i think this points to a well-intended attempt to assure ourselves that things have been done a desire to examine ourselves but perhaps not having the professional skills and capabilities at that point

01:15:18 skills and capabilities at that point inside the lfb to really educate us out as to how good assurance was maybe going to be carried out and just one more question before the break i think you've answered it just in

01:15:29 break i think you've answered it just in your last answer but i feel like she'll ask the question and give you an opportunity to tell us that that was the answer to this question and it's this if the lfb if the lfb on the facts did not learn from latino

01:15:42 the facts did not learn from latino uh on the point we've been discussing namely compartmentation or indeed fsg calls or evacuation and did not admit that it had failed to learn from latino when it came to report in 2018

01:15:54 in 2018 why should the public now trust the brigade to learn the lessons of grenfell i think that the the public should judge us on the outcomes we deliver into london so i don't i don't ask for trust

01:16:06 london so i don't i don't ask for trust i don't think we deserve to ask for trust until we demonstrate different outcomes i think we are beginning to do that so if you look at the fire new providence war which happened earlier in the year may

01:16:17 which happened earlier in the year may 2020 that was a very significant fire in a complex clad building with a failure of

01:16:22 of internal systems that meant we had to rescue

01:16:25 rescue 35 members of the public using new equipment smokehoods employing a completely different approach to high-rise firefighting we evacuated the block and that was junior officers we're talking crew managers and watch officers

01:16:36 talking crew managers and watch officers taking that decision at the very start of that incident to empty the block out you know that that i think is where we can reasonably ask the london public to trust us because we

01:16:47 london public to trust us because we have demonstrated in that in outcomes for them that we have listened we have learned we have changed my promise to londoners

01:16:55 londoners is that we will continue to take that attitude forward into the future but i would expect them to hold us to hard account i don't want blind trust in the london fire brigade i

01:17:06 blind trust in the london fire brigade i want a public that is engaged and challenging to us and questioning us and we need to open ourselves up to enable them to make that challenge just as we need to enable those who reasonably scrutinize us such as the hmic to point

01:17:18 scrutinize us such as the hmic to point out deficiencies in our structures our processes our delivery because i i don't think you can run an organization of this scale and complexity facing the challenge we do in london

01:17:29 in london and get everything right i do not expect everything is going right in the london fire brigade as we speak under my leadership i expect the inspectorate to find things i will need to do better i welcome that and we will drive the

01:17:41 welcome that and we will drive the change necessary against whatever they find and whatever we find i think it's about a different approach a different mindset

01:17:49 mindset so i think they should trust us insofar as that we are open to the possibility that we don't always get things right that we will rapidly seek to remediate those things we either

01:18:00 to remediate those things we either discover ourselves or others discover and that we will continuously seek to improve when we're beginning to see that improvement manifesting the outcomes we

01:18:11 improvement manifesting the outcomes we deliver to ordinary londoners whether it was by high-rise firefighting or the 600 firefighters that crewed ambulances during the pandemic and have attended 156

01:18:22 156 000 emergency incidents you know i think i think we we we deserve to be and should be judged on what we deliver into the london public thank you very much mr chairman is that

01:18:33 thank you very much mr chairman is that a convenient moment yes i think it is well i think commissioner we ought to have a break at that point so we'll stop now we'll resume please at 25 to 12. thank you and again please don't talk to anyone about your evidence

01:18:45 don't talk to anyone about your evidence while you're out all right thank you thank you very much

01:18:57 thank you mr millet 25 to 12 please

01:35:23 would you ask mr ray to come back in please

01:35:37 right ready to carry on yes thank you thank you very much yes mr mr chairman thank you we'll leave incident command and turn now to two additional training topics which

01:35:48 to two additional training topics which we've heard evidence about in this and the last module the first is the decision control process and the lfb's non-adoption of that we heard some evidence about the detailed research that gave rise to it

01:36:00 that gave rise to it from dr sabrina kevin hatton and the additional research carried out to test it and its benefits and we know that the dcp was adopted by national guidance in july 2015

01:36:13 national guidance in july 2015 and the lfb declined to incorporate it in in place of its own decision-making model i mean we know that um the first question for you i have is to be clear you don't appear to have been involved in any of the internal

01:36:25 been involved in any of the internal discussions about whether or not to adopt the dcp at the time in 2015 is that correct that's correct yes right now in general terms can i ask you

01:36:36 now in general terms can i ask you in that case whether in your view that attitude to change was typical of the brigade at the time um

01:36:43 um no i'm not sure that is a fair characterization um on on the basis of that single issue i think it pointed to the challenge of changing something that

01:36:54 the challenge of changing something that had been

01:36:55 had been trained into the brigade for a very long time and and i don't know the um discussion behind the decision that was made at that point but i would imagine that recognizing the dcp

01:37:08 imagine that recognizing the dcp itself has its origins in the dmm there was probably a valid debate about whether

01:37:13 whether the scale of training needed to change the approach to decision making entirely what was backed by enough evidence at that point

01:37:25 backed by enough evidence at that point um

01:37:27 um recognising that many of the characteristics of the dcp are

01:37:32 are evolved from the dnm share a commonality to them so i'm not sure that is a fair characterization in in the context of that point

01:37:41 point um could i could i make a point if possible about decision-making processes yes

01:37:46 yes so i think there has been obviously been great focus on the dcp and the dmn can i just say you know to clear my hand i think they're both good models uh um i i think they both have um different aspects to them that are

01:37:58 different aspects to them that are useful so

01:37:59 useful so you know we are incorporating the dcp into our command practice that's part of the training and education program we're delivering now but i have used the dmm

01:38:10 but i have used the dmm for most of my operational career and found it very useful just as i've found the combat estimate in the military extremely useful and i've got a professional interest

01:38:21 professional interest in decision-making processes i've looked at similar processes in health

01:38:27 health in aviation policing and actually you know a prime example would be the jdm in jessip so the joint decision um model in jessic

01:38:38 model in jessic all different but all also very similar circular

01:38:42 circular forcing you to take account of situational awareness the events that are in front of you um making you think about the outcomes you want

01:38:51 you want uh before you plan and then building continuous review into it so i know sometimes for example the dmm has been painted as linear it's not if you really understand the dmm it's cyclica

01:39:02 cyclica i'm struggling to say that cyclical they're cyclical there you go circular thank you circular um in the same way the dc peers i think what all of this points to is the great question for me

01:39:13 points to is the great question for me and it always has been for me as commissioner is not so much the decision making process you might employ as an organization but how you train people to use it under the moments of high stress because again if i go back to one of my

01:39:24 because again if i go back to one of my answers yesterday the difference between the training i received in the military and the training i received here in the london fire brigade was that the dml dmm was common parlance it was understood but no

01:39:35 common parlance it was understood but no one ever really explicitly trained me to use it

01:39:39 use it as a tool to mitigate the stress you might be under whereas in the military the decision-making process they had at the time which has now evolved and changed again was the combat estimate very simple tool good tool

01:39:50 very simple tool good tool but the real value to it was that what they hammered into you was that

01:39:54 was that this was the tool you were going to use to take yourself from that place of shock

01:39:59 shock into a place of rational decision making so whilst i recognize the value of the dcp and we are incorporating what i think is a particularly a valuable additional feature which is it builds as a mandated part of the process

01:40:11 a mandated part of the process um an additional stage of reflection and review which it makes an instant commander take which isn't in the dmm to be fair actually i'm less concerned with the

01:40:22 actually i'm less concerned with the model because i expect models to evolve i think the dcp will evolve i think that our

01:40:27 our our consideration of it in a high-rise environment will help provide further evidence to as to its utility or need to involve potentially what i'm really interested in is how we take what are often very

01:40:39 in is how we take what are often very similar sorts of models but then really training their use to officers and crews because i think again that is where i think the improvement needs to be

01:40:50 the improvement needs to be bought

01:40:51 bought um

01:40:52 um what i'm interested really in is isn't the technical content of the dmm

01:40:59 the dmm set against the dcp in a comparative sense what i'm really interested in knowing from you commissioner is whether um the failure of the the decision by the brigade not to

01:41:10 the the decision by the brigade not to adopt the dcp even though it was part of national operational guidance at the time was a paradigm for london's inability to

01:41:21 was a paradigm for london's inability to change

01:41:23 change um i i wouldn't see it as symbolic of entirely that because i have had long experience of national operational guidance as well and i actually think that whilst national operational guidance for example is a hugely

01:41:35 guidance for example is a hugely important step forward in terms of the underpinning professional knowledge and understanding available to firefighters and officers in the uk you know look at the fact that we had this gap of so many years from what you know

01:41:46 gap of so many years from what you know and excuse my term is what they were called the manuals of firemanship through the gras which were useful but quite limited in their in their their breadth so i see

01:41:57 in their in their their breadth so i see nog as a very useful evolution but it's not very useful to a crew commander at three o'clock in the morning and sometimes aspects of it do need challenge it is reasonable for the largest service in the uk with the

01:42:08 largest service in the uk with the busiest operational environment to sometimes go back and say that that may not work for us you know we might need to consider doing something differently i think what marks out a mature organization though

01:42:20 out a mature organization though is the ability to go back with that constructive free feedback and offer help

01:42:24 help and and and kind of expertise to move the national picture potentially now i can't speak as to whether that was done and i don't know whether the example you're offering me because i wasn't sitting at that level is

01:42:36 sitting at that level is is testament to a kind of absolute resistance to change i wasn't close enough to the decision making to really know that so i think it'd be wrong of me to

01:42:46 to presume that was symbolic of complete resistance to change

01:42:51 to change i think what i what i would say is to go back to my answer from yesterday which is

01:42:57 is that not only in the london fire brigade but in the national service if you look at the outfall from the last two rounds of inspection and sir tom wins a state of fire pool change

01:43:08 sir tom wins a state of fire pool change resistance generally is a feature of the national service is certainly and has been a feature of the london fire brigade and the origins of that change resistance are complex and multi-layered

01:43:20 resistance are complex and multi-layered and are driven by all sorts of things from the experiences of industrial action to the way we promote and train leaders to

01:43:30 systems and issues of governance a willingness to look outside so i think that

01:43:35 that taking a single decision as something symbolic of a much longer and complex journey

01:43:41 journey um

01:43:42 um around change it i find that difficult if i'm honest dr cohn hatton said and i'll quote to you from what she said in her transcript for day 185 page 89 line 7 to

01:43:55 transcript for day 185 page 89 line 7 to 12

01:43:56 12 that quotes there is a culture in london that is very conservative i think there is great comfort in that that is familiar because it's seen as tried and tested on quotes

01:44:07 tried and tested on quotes would you agree with that i think i think that's a fair challenge to make to the london fire again i think part of the issues we've talked about over the past two days were that sometimes because of the scale of our operation

01:44:18 because of the scale of our operation experience the manifestly different risk we face as an organisation in comparison to any other service in the country i think it sometimes allowed us to become complacent

01:44:29 allowed us to become complacent and i think it sometimes allowed us to become slightly arrogant about about you know our level of knowledge and understanding and again if i can focus on where perhaps we've tried to change

01:44:40 on where perhaps we've tried to change that

01:44:41 that my belief is that there are useful lessons to be learned everywhere not only in the fire sector but in other industries you know in other organizations and actually good good organizations challenge themselves

01:44:52 organizations challenge themselves continuously as to the orthodoxies the sacred cows they hold dear so i think you know sabrina cohn's experience is is real that was her experience

01:45:03 real that was her experience that she she had i've got no doubt she's expressing that truthfully and i would have to accept that

01:45:10 that that there has been a degree of conservatism and resistance to changing the brigade but i do not think we are unique in that i think it is a challenge for the sector and and probably speaks a route to the

01:45:21 and and probably speaks a route to the lack of

01:45:22 lack of statutory inspection for example for many many years turning to the question of statutory inspection are you familiar with the fact that the inspectorates

01:45:33 inspectorates most recent report from february this year 2021

01:45:37 year 2021 noted that the lfb is the only fire and rescue service in the country or in england at any rate not to use the decision control process and that that position had been reviewed

01:45:48 and that that position had been reviewed again by the brigade since the inspectorates earlier reported in 2019 on this point and the decision had yet to be made for those who want to see the reference for that i won't pull it up but it's inq

01:46:00 but it's inq five zero three zeros one four seven nine five page thirty one first paragraph there that's for those who want to see it but in general terms can i just ask you is it still the case that

01:46:11 i just ask you is it still the case that a decision is yet to be made as to whether to um incorporate the dcp no we are incorporating the dcp into instant command practice we're taking

01:46:22 instant command practice we're taking all those aspects of it we think are useful and building it into the practice of incident command what i would say though is at the point that report was written we had bought in again in the spirit of challenge and

01:46:33 again in the spirit of challenge and examination external experts in decision making to look at the evidential base of the dcp and the dmm and consider what aspects of it were useful for decision making how we might

01:46:44 useful for decision making how we might helpfully

01:46:45 helpfully evolve both models and and the conclusion from those experts which were uh who were military in their previous careers work for a very large corporation focused on risk and decision

01:46:57 corporation focused on risk and decision making now in the us was that actually both models lacked really good consistent evidence over many years to to um really validate their their

01:47:09 to to um really validate their their positive features so it's not that they're not good models but actually there is simply not in the fire sector a very good body of evidence you know on a scale around what what good decision making looks

01:47:21 what what good decision making looks like and i think that's something the sector needs to develop in the future that doesn't mean we don't think it's a good model i do i think sabrina cohn hatton is an expert in her field and with the limited resources available to

01:47:32 with the limited resources available to her drove the best quality of research um she could but it doesn't mean it's been validated on a scale over many years across many incidents yeah and it is of interest to me

01:47:43 and it is of interest to me that the the jesuit programme who who also had sight of the dcp also at this point did not choose to adopt that in totality recognized its utility of uec aspects of it in the jdm

01:47:55 utility of uec aspects of it in the jdm i think

01:47:56 i think decision making and decision-making modelling

01:48:00 modelling is something like other parts of operational practice needs to be under continual challenge and evolution can i then turn to the second additional training topic um

01:48:11 the second additional training topic um which is

01:48:12 which is uh incident command revalidation and the program you may recall that dr cohen hadn't gave some evidence to the inquiry about that when she came to give evidence

01:48:23 when she came to give evidence first did you have any personal knowledge of or involvement in the revalidation program not prior to me taking over my role as commissioner since taking over as commissioner yes a great deal of

01:48:34 commissioner yes a great deal of personal interest in that process right do you recall whether as part of your own experience of acting as incident commander or indeed being being monitored perhaps or commanded by

01:48:45 monitored perhaps or commanded by colleagues when attending incidents you were conscious of the fact that there was no system for continual assessment of command competence yes you were

01:48:56 of command competence yes you were in other words once you passed the promotional assessment that was it you had refresher training so again it would be incorrect to to say that i have not been trained by the london fire again i've had repeated command exercise

01:49:07 i've had repeated command exercise training we did have instant command exercises but they weren't at that point of a pass fail nature if you did if you did spectacularly badly that there was there was a chance you would be taken

01:49:18 there was a chance you would be taken off the run that you someone would unpick the development points within that but it wasn't a systemic approach to validation of competency but of course that's what we've brought in now yes it's exactly that is a pass-fail

01:49:30 yes it's exactly that is a pass-fail process if you do not achieve 75 as a past mark within the you know the structured process of assessment then you know depending on where you fall in a range beneath 75 percent you

01:49:43 fall in a range beneath 75 percent you are

01:49:44 are then put either either stopped from taking that role in command or put on a considered individualized development program to get you to the point where you can pass successfully at the 75

01:49:56 you can pass successfully at the 75 threshold so we take a very systemic approach to it now when she gave evidence dr kevin hatton told us that all other fire and rescue services in england that she had contacted when researching

01:50:07 that she had contacted when researching her proposals for the revalidation program

01:50:10 program already had such a structure in place is did is is that consistent with your understanding at the time of the wider fire and rescue service landscape um i i

01:50:21 fire and rescue service landscape um i i think it's more nuanced than that and i i think that if you turn to the inspection reports across multiple services and the state of fire reports that there is no service in the uk that

01:50:33 that there is no service in the uk that should be complacent about how they're assessing and validating their instant commanders so i'm not sure as a sector we

01:50:40 we you know have fully matured in terms of our understanding of of

01:50:44 of what it means to assess someone to a level of competency and instant command i think there are other services that have done it better than lfb absolutely and we have learnt from them but to say it was consistently applied everywhere

01:50:55 it was consistently applied everywhere in the uk i'm not sure is is is accurate uh but i would defer to perhaps sabrina's greater knowledge on that because she'd obviously gone out and and done the work to have a look um i

01:51:06 and done the work to have a look um i mean i know when i talk to other chiefs that they grapple with the same issues that they

01:51:10 that they they are very concerned about ensuring that their colleagues meet the right thresholds of kind of instant command competency and the challenges of delivering that in in a realistic

01:51:21 delivering that in in a realistic simulated environment with the resources they have available it's a you know it's a continually evolving kind of discussion um

01:51:29 um that that would be my analysis of it does this mean that the system of revalidation was introduced under your aegis as commissioner

01:51:40 aegis as commissioner yes

01:51:41 yes now we know that the revalidation program had not been implemented at the time dr conhatton left the brigade in november 2017 and that the inspectorate in their 2019 inspection report noted that that

01:51:53 inspection report noted that that remained the case but said

01:51:56 but said in february this year that a a system of revalidation had now been implemented um this tells us that you introduced the system how much involvement did you

01:52:07 the system how much involvement did you personally have in introducing the um revalidation of incident command not the detail of it because i wouldn't have the capacity in my role as the strategic leader of the brigade to do so

01:52:19 strategic leader of the brigade to do so but in my very clear direction to my director operations our head of training our director of people that i expected as a priority a system of validation to be brought into place

01:52:30 be brought into place are you able to and that needed to be robust

01:52:33 robust and and we needed to see you know putting it frankly we needed to see people

01:52:39 people fail because statistically it's clear to me that not everyone can pass and that we should support those colleagues when they didn't meet the competency threshold to either develop because they had the potential be clear with them

01:52:50 had the potential be clear with them that they would never be able to hold that command position while they demonstrated the competency they had do you have any insight into why the lfb appears on her evidence at least uh

01:53:02 appears on her evidence at least uh the to be have been the anomaly in not already having a system for continuing assessment of command competence at the time

01:53:10 time dr kevin hadn't picked up that initiative in 2015. um i can't because it was something that the brigade had recognized actually if i think about conversations amongst senior officers was needed for many years i think it

01:53:22 was needed for many years i think it speaks to organizational inertia i think it speaks to some of the challenges of change so sometimes i think it's presented that the brigade is change resistant i'm not sure that's the case i think it's sometimes that the brigade is trying to change everything at once i

01:53:34 trying to change everything at once i mean trying to change everything at once rather than focusing wholly on a number of

01:53:40 of priorities you know takes a long time to get things delivered

01:53:45 delivered that again has been one of the lessons i've learned as commissioner is that in the desire to do everything you know we reckon we recognize and accept all 66 recommendations across inspection in the inquiry to deliver change against those

01:53:57 inquiry to deliver change against those recommendations though has to be periodic has to be prioritized in terms of the capacity of people to receive it but also our capacity to design and deliver i think sometimes because my general experience

01:54:10 sometimes because my general experience of firefighters and uniformed officers particularly is that they're fixers is that they want to fix 10 things at once so i don't think it was resistance to the concept because i i've yet to meet a senior officer and i

01:54:23 i've yet to meet a senior officer and i i can't think of a conversation where people haven't said why don't we do this and um you know how valuable it would be so i don't think there was resistance to it but you know i'll be the first to

01:54:34 to it but you know i'll be the first to acknowledge it took a very very long time to get to it yes when you put that down you say i think is this right to organizational inertia as opposed to resistance to change yeah i i think it's a different thing i think it's about the

01:54:46 a different thing i think it's about the ability of an organization to plan and deliver change effectively so that's not that that's about recognizing that you need to change but not being able to de-prioritize

01:54:57 but not being able to de-prioritize other items work so if i think about the team that would have had to have delivered that they would also have been responsible for some really fundamental policy development and change in other areas as well so within that department

01:55:08 areas as well so within that department which is relatively small you would have people who have been working simultaneously on instant command the development of other operational policies in respect to everything from um you know fire survival guidance to

01:55:20 um you know fire survival guidance to potentially high-rise fire fighting as well so a relatively small pool of expertise

01:55:26 expertise who perhaps needed clearer direction about what was the immediate priority at that

01:55:30 that time because i've certainly never experienced in conversation you know having not been directly involved in the process to deliver that any resistance to the concept of

01:55:41 any resistance to the concept of validation i think most officers i've ever spoken to recognized it would be both valuable and important in

01:55:47 in driving the sort of confidence and trust um

01:55:50 um the public you know does deserve to hold the fire brigade in she that is to say dr conhack also told us that in addition to there being no system for command revalidation in 2015

01:56:02 system for command revalidation in 2015 when she picked up that project there was also no command training at all for level four commanders uh uh

01:56:10 uh uh can you help us where that was i can't explain that because again i wasn't involved in that decision-making process all i can tell you is that i am the last level four commander to be trained in the current process i'm going

01:56:21 trained in the current process i'm going on december the 13th and the 16th to be trained and assessed and we do now expect all our level four commanders to be trained in a an externally recognised

01:56:33 trained in a an externally recognised um training environment on the classic place right on the question of level three commanders you'll remember i think that the inspectorates report from 2018 uh said that training for level three

01:56:45 uh said that training for level three commanders was not consistently in place is that correct that that was correct at the time it is not correct now we are above 90 probably 90 of every officer

01:56:56 above 90 probably 90 of every officer group in terms of command training so i think we're up at around 95

01:57:02 95 for junior officers which encompasses about 1400 odd people and we're above the 90th percentile for every other officer group so level 2 which is about 244 people i think on

01:57:15 which is about 244 people i think on current figures and then at level 3 which is a smaller carder we're again well well well beyond the 90 mark with people having been trained and obviously that's taking into account sickness and promotion and then at level

01:57:27 sickness and promotion and then at level four we bang on the 90 and that will change to

01:57:30 change to 100 when

01:57:32 100 when i go in december

01:57:36 can i then turn to a different topic altogether namely fire ground communications the inquiry has heard as you are aware i'm sure considerable evidence relating to communications

01:57:47 to communications in this uh in this part of the inquiry uh ron dobson commissioner ron dobson told us that it wasn't unusual for communications problems to present themselves at large incidents and that

01:57:59 themselves at large incidents and that the lfb had experience of communications problems

01:58:02 problems uh at large incidents going back at least to the king's crossfire in in 1987.

01:58:08 1987. uh

01:58:09 uh i mean first would you agree with that yes i mean it's one of the key findings from

01:58:13 from um seven seven from king's cross from from la canal you know communication lies at the heart of an instant commander's ability to gather situational awareness make effective

01:58:24 situational awareness make effective decisions and then translate their plan into you know orders and briefings for the crews invariably have to do the hard stuff

01:58:33 stuff now gary reason told us when he came to give evidence a day 182 page 30 to page 32 that the replacement of barry radio sets was due to take place in

01:58:44 radio sets was due to take place in early 2015 but hadn't taken place by the time of the grenfell tower in fire in june 2017 nor indeed in fact by the date of professor chris johnson's report to the inquiry in november 2020

01:58:57 the inquiry in november 2020 uh now that would suggest would you agree that the same issue we've just been discussing in relation to command training

01:59:04 training you might call it decision inertia perhaps

01:59:09 was bedeviling that problem no i think this was about taking a big decision because this was a decision that i took very early on as commissioner which is we needed to accept there was going to be a delay to procuring new integrated

01:59:21 to procuring new integrated communication equipment for firefighters because we needed to we needed to couple it with the procurement of new breathing apparatus incoherently for many years the two

01:59:33 incoherently for many years the two things have been procured in a different cycle so you were constantly held really in in a cycle of of going back to the same supplier effectively or the or the same model

01:59:46 effectively or the or the same model it meant we couldn't always access market innovation um because you were

01:59:52 you were you were procuring a piece of equipment that was

01:59:55 that was intimately integrated with another piece of equipment separately it made no sense so we took the decision to stop that to bring that back in line

02:00:06 to stop that to bring that back in line and we're in the process of procuring entirely new breathing apparatus with integrated communication equipment which is at the you know the market leading edge of what

02:00:17 you know the market leading edge of what is possible because by procuring it together you both get better value and and you you get the availability of all the best products on the on the market

02:00:28 market recognizing there was a risk in the interim however we also took a big decision around intrinsic safety you know early on at the start my commissionership which was about procuring a new generation of handheld

02:00:40 procuring a new generation of handheld radios of of a greater wattage power that still satisfied the the practical um

02:00:48 um need for some form of intrinsic safety and that we would enable in the absence of a new battery set those handheld radios to be used by ba crews so

02:01:00 used by ba crews so you know a measure which will improve communications in complex structures what is the new wattage the new wattage is four watts four watts and when will they be delivered and rolled out to be

02:01:11 they be delivered and rolled out to be um i would have to get the exact detail back to the inquiry i can i can find out in the break and i'll be able to give you a detailed answer on there but

02:01:20 we can we can find out separately i think that you're having to trouble uh yourself during the course of your evidence um looking back though in history uh professor johnson told us and explained in fact how buildings and

02:01:31 explained in fact how buildings and construction materials can block or degrade radio signals and both gary reason and ron dobson agreed in their evidence that that was a feature of incident ground

02:01:43 a feature of incident ground communications known to the brigade before lachlan indeed would you agree with that yes i think i think we've understood the challenges of complex structures and the communication within

02:01:54 structures and the communication within them from

02:01:55 them from well for for a very long time from king's cross certainly onwards yes do you agree that there was never any real attempt to overcome or mitigate that impact following latino

02:02:07 impact following latino no i think people would really grapple with that question i think the problem was and it was one i encountered very early on taking over in commissioner as commissioner was this debate which again is not unique to london

02:02:18 is not unique to london around what was available on the market because there isn't a lot of of useful alternatives so we had a if i think about my own decision we debate at length what was available in f in in the context of digital technology at the

02:02:29 context of digital technology at the moment in the market that was reliable you know could we use bluetooth technology um you know in the in the context of new barry says um actually was analog safer so we had a really well

02:02:41 was analog safer so we had a really well informed debate even at commissioner level and what presented back to me was actually there was very little on the market that would improve this situation so we ourselves went back to the market as part of procurement for

02:02:52 the market as part of procurement for the new radio sets and said look can we start looking at what is the reasonable limit of intrinsic safety knowing that that will give us a higher wattage and actually dr adrian bevin who's our head of health and safety had to work very

02:03:03 of health and safety had to work very hard with kind of national bodies to kind of

02:03:07 kind of develop the understanding of what might be a reasonable point to settle on in terms of intrinsic safety because the previous standard of intrinsic safety they've been held to by many of the fire and rescue services in the uk

02:03:19 and rescue services in the uk was developed in an american industrial context so in the in the in the in the context of a large chemical plant and the sort of gaseous atmosphere you might encounter there now obviously

02:03:31 there now obviously firefighters might get called to a significant chemical incident that could still be

02:03:36 still be the case but it is far less likely than being called to a vented

02:03:42 a vented high-rise fire for example so therefore is about finding the balance in a product that would give you enough intrinsic safety to reasonably go into the one environment but just work

02:03:54 into the one environment but just work better in the environment you were more likely to encounter in your day-to-day business in london and that's how we settled on that wattage and the level of intrinsic safety we now decide is appropriate

02:04:05 decide is appropriate for firefighters in the in the conduct of their daily operation does everything you've told us in your last answer um is all of that something that's happened during your commissionership

02:04:16 happened during your commissionership um i think the journey to that began prior to me taking over so adrian bevin had certainly started thinking about that before i took over because he came to me fairly early on in my my role to

02:04:27 to me fairly early on in my my role to say look we have got to sort this problem with radios out we've really grappled with it and this is what we think here's the recommendation to you commissioner and then we had a debate when was when was when did he come to you um again i think we'd have to

02:04:39 you um again i think we'd have to provide that information to you but it will be clearly articulated in corporate papers somewhere we can do that right what i'm really trying to get at is why that conversation that you've described and all the thinking in the and the um

02:04:51 and all the thinking in the and the um efforts that you've described in your last answer but one were not undertaken in 2013. in the light of the lack of coroner's recommendation why did we have to wait for grenfell for that conversation to

02:05:02 for grenfell for that conversation to happen i'm afraid i can't answer to that mr miller because again i wasn't at that level of decision making all i know is that as commissioner i was very aware that i'd seen a consistent thread of criticism through

02:05:13 criticism through inquiries

02:05:15 inquiries inquests

02:05:16 inquests reviews that pointed and actually from our own staff you know if you go to a fire station one of the first things they're going to complain about and i was very conscious i'd heard it in the first phase of this inquiry is

02:05:28 it in the first phase of this inquiry is the quality of their communications equipment and the challenges it poses to them an operational incident i thought we owed it to them and obviously the people they serve in london just to do something about it

02:05:40 do something about it but as an agent for change as you've been describing to us throughout your evidence why weren't you or aren't you interested in going back and understanding what it was about the

02:05:52 and understanding what it was about the organization that didn't respond historically in the way that you're responding now i think i think it would be wrong to say we haven't gone back and looked i have gone back and i could be disingenuous to

02:06:04 gone back and i could be disingenuous to say we haven't we have but

02:06:07 but i suppose what i took from your earlier questions was the level of detail to which we might go back into it you know i haven't gone back to unpick every corporate paper or try to

02:06:18 every corporate paper or try to interrogate people as to the conversations they had at that point what we've tried to do is look back and recognize where things should have been done differently and then if it was particularly poignant

02:06:30 and then if it was particularly poignant why

02:06:31 why things might not have been done differently but i think that's a you know if i think about those 66 recommendations you know that's that's two statutory processes that have delivered those

02:06:42 processes that have delivered those recommendations when we did our own analysis

02:06:45 analysis off the back of those 66 recommendations to produce a kind of transformation delivery plan at the start of 2012 and 20 and i was given a month by the home secretary and the mayor to arrive an initial plan

02:06:59 and the mayor to arrive an initial plan we had actually grown those recommendations under our own analysis to something closer to over a hundred when you're faced with that spread of required change and improvement i think

02:07:10 required change and improvement i think you don't have the capacity to unpick every single element of why

02:07:14 why you know one particular thing might not have happened i think what you have to accept when you're a leader in my position who's dealing with questions of broad strategy intent you know the absolute need to hold people to good

02:07:26 absolute need to hold people to good outcomes

02:07:27 outcomes you sort of almost have to accept the generality of it which is we need to improve we need to look to best practice elsewhere we need to recognize where there's been very specific obstacles to change where it's particularly pointed

02:07:40 change where it's particularly pointed but actually i need to devote the end my energy and the energy of my teams to because we owe it to the breed and the survivors particularly we owe it to anyone who lives in a high-rise block in london and we owe it to

02:07:53 london and we owe it to firefighters who were so courageous that night to bring that change forward and the energy has got to be as much as understanding the lessons of the past looking to the future and continuously challenging ourselves

02:08:05 and continuously challenging ourselves to improve but on comms particularly you've given us the evidence about that and the historical evidence about failure um let me ask it this way what is it in the

02:08:17 let me ask it this way what is it in the changes that you've brought about in relation to communication specifically that take account of the

02:08:25 the apparently endemic failure continuing failure

02:08:29 failure to

02:08:30 to carry into effect the recommendations of the latin coroner to ensure that that change is embedded i can't explain that all i can say to you is that i think this is about culture and leadership so i can't unpick because

02:08:41 and leadership so i can't unpick because for me the the reason that you would not have made that decision earlier is because

02:08:46 because there's something about the desire to question at all times you know i'm quite an annoying man to work for actually because i'm constantly questioning things i have an inquisitive nature i want my officers to have an inquisitive

02:08:58 want my officers to have an inquisitive nature not to accept what they are first presented so i think the answer to this perhaps lies in well okay the national standard for intrinsic safety commonly accepted by a fire and rescue service is

02:09:09 accepted by a fire and rescue service is this and this is why we have arrived at this point my starting point is always why

02:09:15 why so i think it's as simple as that i think it's about how you choose to lead an organization and if people can give you good justification as to why you're likely to carry on and it may would have been

02:09:25 been you know in defense of my predecessors that they did ask that question and the information they were provided at the time

02:09:31 time told them that there wasn't an alternative it may well be that in their defense they did go out and look at the market and something wasn't available but i think it's all in the questioning it's all in the why and that and i think it's my job not not

02:09:43 and that and i think it's my job not not to find the solution but always to ask the question why when people present me something and then demand to see the evidence that they've drawn upon to arrive at that recommendation

02:09:55 recommendation as far as we're aware i think it is right that the lfb did provide communications training um

02:10:02 um following grenfell but that training and it may have changed now you have to tell me but that training did not cover negative the negative impact that building and construction materials can

02:10:13 building and construction materials can have on radio signals is that first of all is that correct i'm not sure to that level of of detail to be honest because it wouldn't have been the training i received what what i do know is we've

02:10:24 received what what i do know is we've again taken a fundamentally different approaches so again we've brought people in from the outside because i think there's a great focus on communication equipment which is right but actually the practice of how you

02:10:36 but actually the practice of how you communicate an incident how you build a framework for communication at an instant is equally important so we bought in

02:10:43 bought in the british army actually to look because they are recognised as the preeminent experts in complex communication in a dynamic environment and we brought them in to do a whole

02:10:54 and we brought them in to do a whole scale review of our instant command communications both equipment and

02:10:59 and structure and how we train our people they're clear that there are areas that we need to improve in that and we're working on taking the learning we got from that review process that we commissioned into future

02:11:12 process that we commissioned into future training packages and a different approach to how we train instant commanders to employ all the different forms of communication they might have at their disposal whether it's you know a local point-to-point airwave network or

02:11:24 point-to-point airwave network or actually the reasonable use of runners if you need to how you integrate that into something that is understood as a whole

02:11:31 whole whole incident approach and how we better support officers to understand deliver i don't think we've got to the point of of educating all our people fully enough

02:11:42 of educating all our people fully enough in that i would see that as an area of continued improvement we need to make we haven't haven't delivered that you know we need to again prioritize the training we're giving and and that will be something that will

02:11:53 and and that will be something that will be very high up the priority list and i know is built into the instant command strategy and will therefore feature in the training that's delivered moving forward

02:12:02 professor johnson when he gave evidence to the inquiry describe the lfp's approach to communications as a culture of making do over an expectation of technical excellence within the lfb would you accept that

02:12:14 within the lfb would you accept that criticism of the lfb's approach to communications technology to date or at least until the time you became commissioner i'm not sure i i like the phrase making do i think that colleagues

02:12:26 phrase making do i think that colleagues previously we had some people who really understood comms inside the organization for example i worked alongside a group commander called jamaicor who was our lead for instant communication he really understood airwave he really understood

02:12:38 understood airwave he really understood analog communication the operation of radios we had a radio workshop that that built and and modified and maintained radios they were experts

02:12:49 maintained radios they were experts i think there was something though again about

02:12:52 about the sharing of expert knowledge because i think there were people within that environment who were probably frustrated about the level of of kind of um priority we gave instant communication

02:13:05 priority we gave instant communication and the level of training that we gave people to support it so i don't think it was a

02:13:10 was a a kind of mate do i think again there were people in the organization who knew it was important but it was that piece about how do you effectively integrate that into a practically

02:13:21 practically delivered schedule of training and exercising well is it i wonder jim acort was one of those responsible you may not know this but was one of those responsible for

02:13:32 but was one of those responsible for producing the um ingredients uh at least sephora's communications were concerned of the rule 43 action plan which was presented by collated by gary reason present and

02:13:44 collated by gary reason present and presented

02:13:45 presented um after the spring of 2013 to the latino house working ball working group and onward up to el fifa through the strategy committee um it wasn't a

02:13:56 strategy committee um it wasn't a question of disseminating it through into other bits of the organization like fire safety for example uh and we know what the outcome was of that um in relation to incident ground

02:14:07 in relation to incident ground communications there wasn't the wholesale revolution that you're i think apparently describing to us this morning

02:14:13 morning so my question really is why not um

02:14:17 um i think again it's about the quality of training delivered so i think i think people did recognize it that it was an important aspect of incident command

02:14:29 and i think that i mean i had long discussions if you talk about jimmy call with with jim mccor after the croydon tram crash about some of the challenges of

02:14:37 of bringing into that incident a kind of integrated approach communication because we found it very difficult to communicate at that instant actually because firefighters were down in the cut there was very poor um reception on the analog radio sets so

02:14:51 um reception on the analog radio sets so we put in a point-to-point digital um you know an airwave network a local airwave network which worked better but we still had to employ runners as well but as part of the briefs i was giving at the time i was

02:15:02 briefs i was giving at the time i was explaining to officers this is how we're communicating at the incident now i had not been trained formally to do that so if i was going to point to something that requires improvement and we still have

02:15:14 requires improvement and we still have not got there yet and i need to be transparent in that it's that we need to train instant commanders to use all of the capabilities they have in front of them whether human or

02:15:26 whether human or technical and think about communications as an absolute priority in its total sense within an incident so i'm not sure it's a bit like the discretionary decision-making piece it's

02:15:37 discretionary decision-making piece it's something we knew is important but pat's didn't give the depth of training required to our instant commanders so he really saw it as part of their practice now ron dobson gave evidence

02:15:50 now ron dobson gave evidence on day 212 that

02:15:56 because communications issues are common at all incidents and he said whilst we knew there were problems at lachnal house i don't think we believed they were extraordinary in terms of what we usually experience

02:16:07 terms of what we usually experience in your

02:16:09 in your uh

02:16:09 uh view and it is a view looking back on it in your role as commissioner does that approach in other words the failure to identify communications as a specific learning point because

02:16:20 learning point because the problems experienced of that incident were not extraordinary to tell us anything about the making do attitude that professor johnson has described

02:16:30 described in that context you can see why professor johnson may have used those words because he i think from the outside would view it that way i think there probably was a level of acceptance about the challenges of

02:16:41 acceptance about the challenges of communication in a very complex built environment in london and the limits of what available radio sets would give us i think that all i can point to is my own view on this is that i know

02:16:54 own view on this is that i know other industries do this sometimes differently they themselves have challenges you know if you turn to the military the first thing you know that soldiers will complain about is the radios and communication

02:17:06 about is the radios and communication you know communication in dynamic high-risk environments is always a challenge but therefore you should never really in my position be satisfied about it and i think we will see

02:17:16 see communications again evolve and improve as we see

02:17:19 as we see a greater um reliability in digital communication for example i think examples of us thinking imaginatively about this would be the system we've bought into control for example 999i

02:17:31 example 999i where a control operator can take over a member of the public's phone and control the phone to deliver contemporary images straight into con troll now from the member of the public that is or one of our officers with a

02:17:42 that is or one of our officers with a phone if necessary that is experiencing that incident you know the fire survival guidance app that we're we're launching right now

02:17:51 right now is an example of lfb challenging itself to work with industry to bring into place a product that doesn't exist so that an ability to transfer mass data instantly from

02:18:03 transfer mass data instantly from um you know as a kind of a spreadsheet a data set in control in a very usable you know easy to read form onto the back of a command unit on or onto the tablet that is on a fire engine so i think

02:18:15 that is on a fire engine so i think we're going to see as technology evolves the possibility of better communication incidents as we get a more reliable digital network um so therefore it's incumbent on us to try

02:18:26 so therefore it's incumbent on us to try and keep up with that and challenge ourselves in terms of the resources that are available to ourselves and our our instant commanders right you refer to an fsg app i'm quite interested in knowing a little

02:18:37 i'm quite interested in knowing a little bit more about that perhaps shortly but not not straight away would it be fair though in general to say that at the time of the grenfell tower fire the lfb did not have a holistic communications policy a

02:18:48 a holistic communications policy a holistic communication strategy or holistic communications training yes i think we approached it in parts so you know there was a great focus on making sure people

02:19:00 making sure people sent messages and information that was useful relevant succinctly and we trained people to that and we constantly went back to it we were you know we were very interested in the standards that people

02:19:10 people by way by the way people conducted cells and delivered information recognizing that that was important situational awareness so we did a lot of that and we did that quite well that again could be improved

02:19:21 improved um

02:19:21 um i think we talked about um the challenge of communications and a holistic approach to command communication in in the round in some of the training i received as a

02:19:33 in some of the training i received as a senior officer but didn't offer really well-articulated guidance about how you might get to it we did get specific training around airwave certainly one generation of officers but

02:19:44 certainly one generation of officers but i don't think we repeated it enough again i think there was that thing about sustaining the information we gave um so at the point you know and it speaks to my own evidence in phase one

02:19:55 speaks to my own evidence in phase one at the point you're asking for a repeater to be deployed into the tower of grenfell and in it you know what you don't get channel 2 when you want it i think of being coherent of me to suggest that we were in a place we needed to be

02:20:07 that we were in a place we needed to be around communication training and and usage an incident now the evidence we've heard so far uh suggests i would i would suggest to

02:20:18 uh suggests i would i would suggest to you that the approach of the brigade to communications equipment uh

02:20:23 uh was um perhaps limited or confused and i

02:20:27 and i by way of example draw to your attention the strict insistence on one what intrinsically saves barry radios which were undermined by

02:20:37 by the primary fullback mechanism of leaky feeders which were not intrinsically safe

02:20:43 safe that problem i've tried to summarize just now but um would you agree that that was a that was a problem um

02:20:50 um yes i think that again we knew about the issue i think that we had people inside the organization who did understand the challenge of this but we hadn't drawn

02:21:01 challenge of this but we hadn't drawn all the different aspects that support effective instant communication together which is of course why we've opened ourselves up to external scrutiny at this point and brought people in to look at it so we can get

02:21:12 people in to look at it so we can get you know an objective view of how we do our business in respect to communications and where we might improve

02:21:17 improve was this a lack of technical competence do you think or was it uh organizational inertia or scleroticism

02:21:28 scleroticism i think it i think it was not incompetence i think we had some really good radio engineers i think we had people who understood what was available on the market and would have been able if

02:21:38 if challenged to go out and seek uh and and consider all sorts of alternatives and if they you know have had that opportunity i think we might have been in a different

02:21:49 have been in a different place i think we're back again i'm afraid to the the issue of how you prioritize decision-making how

02:21:57 how all the different parts of the decision-making mechanisms in the brigade are cited on one particular issue and the governance in respect to risk management that supports that because of course if you

02:22:09 supports that because of course if you have a risk management framework in place that says actually communications is coming up as a repeated issue

02:22:15 issue in debrief in inquest in review what are we doing about it and it's seated on a departmental wrist register that's then escalated to

02:22:26 that's then escalated to directory level someone's going to answer the question but i think if you're working only in a silo sometimes you operate in an echo chamber so if it's only going up one way it might only come back down one way

02:22:37 might only come back down one way if if you're working within that kind of governance structure so i think governance and um

02:22:43 um decision making and kind of the frameworks of organizations probably feel very very dull to certainly firefighters but i think one

02:22:54 certainly firefighters but i think one of the things we need to do is explain why it's so important to them and really try to bring that to life to explain that actually what happens at my level will have a profound effect on their ability to

02:23:05 their ability to you know deliver deliver a really successful outcome to communities um so i think we are back to that and a lot of focus has been placed in the past two years to really challenging ourselves as to how we structure

02:23:16 ourselves as to how we structure decision-making and governance and we're not there yet you know this will continue to evolve and we'll continue to learn

02:23:23 learn and why did the technological revolution that you've just described fsg

02:23:28 fsg apps

02:23:29 apps tablets on pumps etc which is as you tell us happened or happening under your leadership as commissioner not happen in

02:23:40 commissioner not happen in 2013 2014 2015. again i can't speak to the decision-making of previous commissioners or senior officers although those involved in that all i

02:23:51 although those involved in that all i know is that my personal experience of the grenfell tower fire and the

02:23:59 and the you know unimaginable impact it has had on so many families and individuals um

02:24:06 um and and what it's done to my firefighters as well you know they've had years now of being told that they did not do the job they should have done and in fact it is a great mistake i think not to recognize that the

02:24:18 think not to recognize that the need for improvement in the institution does not relate to the courage and endeavor of those firefighters and it's been very difficult for them to hear this so i absolutely owe it firstly to the bereaved and survivors

02:24:30 the bereaved and survivors who in their dignity you know and their desire for answers of i think being an inspiration really and i owe it to londoners because that is our job and it is our covenant and it

02:24:42 is our job and it is our covenant and it is built into the dna of the organization we owe it to ourselves to to challenge ourselves continuously so i think the reason we've done it now is i'm afraid because the grenfell tower fire was the

02:24:54 because the grenfell tower fire was the most terrible shock to the london fire brigade because i saw firefighters and officers put in a position they should not have been put in

02:25:03 in i saw the damage it did to that community

02:25:08 community and i think it's not just me i would not take the the credit for any of this i think it is through every level of the organization there is this enormous desire to do

02:25:19 there is this enormous desire to do right by the people who suffered the most

02:25:22 most and to do right by londoners and by ourselves

02:25:25 ourselves you know to really to really um you know the military again talk about a covenant with soldiers you know i think decent

02:25:34 decent frontline firefighters and officers deserve us to honour that covenant by bringing forward these improvements have you yourself had any uh training or education in change

02:25:45 uh training or education in change management um

02:25:47 um only in the sense that we've brought in a lot of external advisors so we went through a process of consultation when i first took over with a well-regarded consultancy that provided training sessions to myself and all the

02:25:59 training sessions to myself and all the other directors about how you might manage change but more importantly we brought in a change specialist at director level who is very straightforward and provides me with education on an almost daily basis

02:26:11 with education on an almost daily basis actually in terms of what good change might look like and we've repeated that at different points in the organization we've brought specialists in at different levels around change management in lots of

02:26:22 around change management in lots of different parts of the organization so for example we've just brought in a more junior level a changed communication specialist because i'm afraid i think over the tenure of my own commissionership this is something that

02:26:34 commissionership this is something that we have not effectively addressed i'm not sure that if you went to a fire station they would always feel that we have effectively communicated change to them nor would they have seen a lot of necessarily what

02:26:45 they have seen a lot of necessarily what we've done under the skin of the organization i understand all of its importance that's what i think our responsibility at a corporate level to better communicate as a result we've brought in someone who does that as a specialist

02:26:56 specialist is that fiona dorman no that's someone who works for fiona dolmen but works in close coordination with the director of communication so we brought someone in at a more junior level whose sole

02:27:07 at a more junior level whose sole purpose is to better communicate why change is important what we're doing and most importantly drive a level of engagement from the front line because i actually think many of the answers this inquiry is

02:27:18 many of the answers this inquiry is seeking are known at the front line and people have tried to communicate them previously and we need to enable that we need to be better at hearing the voices of the people right of the coal face with communities

02:27:32 right of the coal face with communities and who was the well-regarded consultancy that provided training sessions um it was called engage and it was led by a man called andy brown since then we've had accenture come and consider our target operating model and

02:27:45 consider our target operating model and what we're going to do in terms of future development and what i would say is that whether it's consultants internal expertise the help of other bodies such as the gla or the cabinet office we've turned to a

02:27:57 or the cabinet office we've turned to a lot of different people colleagues in policing

02:28:01 policing we've turned to a lot of different people over time to challenge ourselves and try and find the best possible answers to what at times very difficult issues to progress and have you had

02:28:12 issues to progress and have you had advice from consultants or change management experts on how to go about training senior i use the expression advisedly managers in the nfb

02:28:24 in the nfb so that they know uh how to uh how to delegate how to supervise and monitor how to report how to operate lines of communication properly and how to disseminate vital information laterally

02:28:36 disseminate vital information laterally yes but we haven't delivered on that yet so we're embarking on as i said the biggest

02:28:40 biggest face-to-face leadership training program in the history of the brigade so

02:28:45 so that that's happening now and it will take some time to deliver i would anticipate 18 months to get to everyone we are focusing on providing more support to the most senior levels of leadership so bespoke

02:28:57 leadership so bespoke leadership training and that that is also rolling out and a discrete program for middle ranking officers as well but they are early in their delivery and it will take

02:29:08 early in their delivery and it will take time to feel the benefit of that and then and the consequent impact on outcomes i think that scale of cultural and leadership change just doesn't happen overnight it's

02:29:19 just doesn't happen overnight it's something that in a big organization again it would be disrespectful i think to the inquiry to pretend that we had solved that we haven't it will it may take some years to evolve the culture of the london fire brigade

02:29:31 the london fire brigade um to something that i would like to see as commissioner can i then turn to a different topic um section 72d of the 2004 act um often calls visit section 72d visits

02:29:45 um often calls visit section 72d visits um

02:29:47 first can i ask you please to look at lfb403116

02:29:56 now this commissioner may be something familiar to you from your phase one evidence please indeed i'm afraid yes

02:30:08 uh it's the ord entry for grenfell tower as it stood at the night of the fire and it's dated february 2017 as you can see now the deficiencies of the ord entry

02:30:20 now the deficiencies of the ord entry have been explored at length and findings were made in phase one and we're not going to go back over those what i would want to ask you about though is whether in your view and in your experience the ord entry for

02:30:32 your experience the ord entry for grenfell you see on the screen here and all its inaccuracies was reflective of a broader problem namely operational crews responsible for carrying out section 72d information gathering

02:30:45 section 72d information gathering either not understanding or not having the time or inclination to collect and record the required information so i think i'd like to start firstly by

02:30:56 so i think i'd like to start firstly by saying i don't believe a foreign risk any foreign risky service but particularly not the london fire brigade can deliver their duties under 72d

02:31:05 72d solely through station visits you know you have to take a holistic approach to 72d you know fire and rescue services discharge the 72d function through a variety of mechanisms so [Music]

02:31:17 [Music] you know

02:31:18 you know professional inspection desktop audit of based on risk the gathering of information from community um interaction so home fire

02:31:29 community um interaction so home fire safety visits may well give you some information that you need to be aware of um so i think we discharge our function in respect to 72d across a number of

02:31:40 in respect to 72d across a number of different teams mechanisms and that's how you build a composite risk picture as we are required to of what we face in london so i think one of the things i would identify is that

02:31:51 the things i would identify is that there was a historical reliance on discharging the function of 72d i think perhaps too much on station

02:32:01 station um personnel so if you look at the historic policy for 72d

02:32:07 for 72d um you know please don't ask me what porous stands for again but you'll see a representation of the the kind of all the conditions that you might expect laid out under under that kind of list

02:32:18 kind of list in support of 72d in the policy and an expectation that firefighters on the ground would deliver all of that analysis now i don't think that's practically achievable and if you look at the new policy for 72d you will

02:32:30 look at the new policy for 72d you will see that we only ask them reasonably to consider those aspects of risk that they are either professionally able to consider and that are pertinent to the

02:32:41 and that are pertinent to the that their role in defining the risk inherent within a premise um

02:32:46 um to guide their response and if they identify other things that is beyond their realm of of kind of knowledge or or require a

02:32:57 kind of knowledge or or require a different form of intervention they should escalate that into the relevant part of the organization um

02:33:04 um so i think that we had not always previously well supported crews to carry this function out i think it would be wrong to pretend otherwise in the face of you know what i personally experienced

02:33:16 you know what i personally experienced in the most um you know humiliating way actually in the first phase of the inquiry to read that entry i think stands for the issues that we faced uh at the point

02:33:28 the issues that we faced uh at the point of time that this visit was carried around out around crews understanding as to what you had to do on it well you know it's dangerous to call it a 72d visit i'd rather call it a premises risk assessment

02:33:39 assessment um but discharging part of the function of a 72d

02:33:43 of a 72d um duty

02:33:45 um duty and that and that we should have invested a greater level of training and assurance in in in that process to ensure that what was on the ord was accurate reflected the risk and was of use to the crews

02:33:56 the risk and was of use to the crews themselves because of course this was a very little use to me on the night yes now to be fair to you both uh ac brown and ac george had told us that the inaccuracies in

02:34:07 had told us that the inaccuracies in this ord were not typical of the general quality of the ord entry across london before the grenfell tower fire are you able to comment on that do you think um i'm not sure that that is accurate

02:34:20 i'm not sure that that is accurate so i i undertook an exercise as ac fire stations and my current assistant commissioner of fire stations has undertaken an exercise to go back over effectively every single entry on the ord and we found a range of

02:34:32 ord and we found a range of inconsistencies poor information a misunderstanding about risk and therefore we embarked on a mass education program to change that and we've had to go through two rounds of very very focused assurance to get to a

02:34:44 very very focused assurance to get to a place where i am broadly more satisfied with the standard of entries on that database and there is still more to do this again will take time

02:34:53 time to affect in terms of change i think a fairly poignant example of how we're beginning to affect that change would of course be

02:35:01 course be our process to inspect all 8 000 odd

02:35:05 8 000 odd high-rises in london over the course of the pandemic because we had approached this with such rigor what that inspection showed us

02:35:13 showed us was that 1107 of those buildings could not safely maintain stay put now i think that is another prime example where londoners can trust us because they are judging us on the outcome that showed me

02:35:26 judging us on the outcome that showed me that our operational crews have begun to understand just how important these visits were because they identified in the course of those thousands of inspections very serious deficiencies in the built

02:35:38 very serious deficiencies in the built environment and were able to escalate it that is proof of change but it has taken some time to get there can i ask you please to look at lfb triple zero three two eight two five

02:35:56 this is a briefing paper dated the 11th of december 2013 to dac george and ac brown from gm elwell service standard lead ss7

02:36:10 service standard lead ss7 and you can see in the second paragraph under the heading background it says this following a request from dac george via ac brown to review the current quantity of ord entries this paper sets

02:36:22 quantity of ord entries this paper sets out to explore this issue and the underlying factors with recommendations for improvement and

02:36:30 and he

02:36:31 he is

02:36:32 is charged there with reviewing the procedures under section 72d and

02:36:38 and um

02:36:40 um it goes i suspect i'm summarizing again rather wider than that first the first question have you seen this document before only only again in preparation for the

02:36:51 only only again in preparation for the inquiry right uh the the reason i'm asking you about it is that it appears from the presence of this document that as at december 2013 the brigade had identified room for

02:37:02 2013 the brigade had identified room for improvement across a wide number of areas

02:37:05 areas as the management of operational risk information was concerned and that was a matter very much on the minds of borough commanders historically would you agree with that i think that's an accurate assessment of

02:37:17 think that's an accurate assessment of some of the concerns that i would have had around ort when i assumed the post of assistant commissioner fire stations right so that was in 2016 was it um no i i took that post

02:37:30 2016 was it um no i i took that post after the grenfell fire actually so that would have been in december 2017.

02:37:36 2017. and it was an issue that i hadn't resolved to my satisfaction by the time i passed it on to my

02:37:42 to my colleague jane philpot who is the current assistant commissioner of fire stations it was a work in progress we had gone back and had to provide repeated rounds of guidance

02:37:51 guidance to colleagues on fire stations as to how you might best address this we recognized that there was radical improvement needed to be made to the policy note that supported colleagues on fire stations to deliver

02:38:02 colleagues on fire stations to deliver that as well um and there was something in making sure that we really you know um shifted the culture i have to say that the reason as ac fire stations i turned

02:38:13 the reason as ac fire stations i turned to that as one of my first priorities and i stood in front of all the borough commanders in london and stated this was because of my experience in side phase one of the inquiry

02:38:24 you were a group manager in 2013 weren't you i was yes yes do you remember having your own concerns in your capacity as group manager at that time on the subject of the um

02:38:36 that time on the subject of the um sufficiency of ord recorded information no because i held a very particular role in the london fire brigade i was i was at that point responsible for technical rescue so

02:38:45 rescue so everything that involved building collapse um flood water rescue technical rope rescue so all of the kind of rescue specialisms

02:38:57 so all of the kind of rescue specialisms and i was very focused really on delivering change and policy in that that area so this wasn't really relevant to my day-to-day um um

02:39:10 um um you know kind of work experience the only time i have had an intersection with this is as an operational incident commander and how useful it was or wasn't and i have to say my experience of

02:39:21 experience of um premises risk assessment entries was mixed sometimes you got a very good one an incident and sometimes you got a very poor one an incident and that'd be my

02:39:32 poor one an incident and that'd be my consistent operational experience did you ever draw that inconsistency to the attention of your seniors and we had discussed it i think within the ort group on more than one occasion and i would have expected therefore that

02:39:44 and i would have expected therefore that to have been passed by the dac responsible for rt into the senior leadership of the london fire brigade right did you ever note any improvement

02:39:55 improvement um i don't think that i ever went back to examine it as as part of my role as an ort officer i think it was along with our previous subject around radio communication something that had come up more than once

02:40:08 come up more than once but i didn't have corporate responsibility for considering the wider strategic change needed and i have to say i didn't go back to consider it again

02:40:19 can we look at recommendation six on page three

02:40:24 the recommendation on page three uh at the foot of page three is further training is provided to all personnel with a role in the mrd process to ensure they have the skills to meet the

02:40:35 they have the skills to meet the competencies required and if you just look at the paragraph immediately above that it says during the development of the service standard and at recent incidents a number of existing ord entries have been

02:40:46 number of existing ord entries have been examined a number of sub-standard examples were found this could indicate a poor understanding of the rationale and a lack of competency based on the above list in recording relevant risk and tactical planning information at all

02:40:58 and tactical planning information at all levels of the process wmsnbc

02:41:03 would you agree that looking at that it's a fairly clear indication that there was a problem with substandard entries on the lrd in late 2013. yeah and actually it relates back to my

02:41:14 and actually it relates back to my previous answer which is that information would only have been driven through ort and the die out process so that that i think is proof that it was discussed in those meetings and that someone

02:41:26 those meetings and that someone somewhere commissioned someone else to do a piece of work to look at those decision deficiencies because identifying that as a theme out of the back end of instant command was the role of ort officers

02:41:38 was the role of ort officers um you know to to collect together along with the team that helped manage the ort function all of the results from post-instant debriefs um

02:41:49 debriefs um issues of learning so i'm presuming that john elwell who is a borough commander at the time must have been commissioned to deliver that bit of work by the director of operations at the time i would

02:42:00 the time i would presume or the third officer as dave brown was known in that role or the ac service delivery fire stations you know they changed their names a few times and that would have been driven through

02:42:13 and that would have been driven through having been identified in an ort meeting or a number of rt meetings some analysis of

02:42:18 of um

02:42:19 um the imp

02:42:20 the imp database so the instant um management performance database um

02:42:26 um and that would have been escalated through what was then called opb which was a board that considered matters of operational operational professionalism or odcb again we do i'm afraid like too

02:42:37 or odcb again we do i'm afraid like too much of

02:42:38 much of a uh you know a a you know an accuracy so it was it it it would have flown through one of those processes and then someone would have taken a

02:42:49 and then someone would have taken a decision to commission a piece of work which is what this is and i think it it's absolutely on

02:42:55 on the issues uh

02:42:58 uh in regards to premises risk assessment 72d businesses they were known can you help the panel with whether the issue identified here by

02:43:06 by group manager elwell was on the lfb's radar

02:43:09 radar institutionally at the time of the grenfell tower fire i can't because i didn't i didn't sit at that level of corporate responsibility but it's certainly on our radar now it's something that we grapple with consistently because

02:43:21 consistently because actually there is something about how you

02:43:25 you adequately discharged this duty in london you know to put this in perspective if you think about the regulatory reform order the old you know regs as they were as we await you know the fire news fire safety will come in the regulatory reform order

02:43:37 come in the regulatory reform order alone

02:43:38 alone encompasses 800 000 buildings in london that are considered to be of enough risk that they require you know the potential to be audited so 800 000 buildings fall within the scope

02:43:49 800 000 buildings fall within the scope if we look at the new fire safety order and what may arise from the new um building safety regulations that number is likely to grow exponentially you know we not only have over three

02:44:01 you know we not only have over three quarters of the high rises in the uk in residential highs in uk and london we also have the one of the most densely populated

02:44:10 populated urban residential and commercial environments in the world you know islington is nearly as densely populated as hong kong for example so

02:44:20 so it's a constant balance of where do you look how do you assess the risk what do we actually get firefighters to visit and that and that can't be static because it changes with the nature of our understanding of

02:44:32 with the nature of our understanding of the risk at a corporate level it's a really difficult area of business in london because we're 5 000 operational staff about a thousand a day on duty serving a city of 10 million inhabitants

02:44:44 serving a city of 10 million inhabitants and millions and millions of buildings so

02:44:48 so you know this this is a real obsession

02:44:52 obsession certainly for me because if you get it slightly wrong you miss

02:44:57 you miss an element of risk that might then later as it did in phase one of the inquiry come back to really haunt you

02:45:06 haunt you i mean listening to what you've just said

02:45:09 said it sounds as if london is too big for one firearm rescue service i don't think it is i think we are resourced to the right level for london

02:45:20 resourced to the right level for london but it's about how you use those resources and how you intelligently and proportionately balance risk because the vast majorities of buildings in london are not dangerous actually

02:45:31 are not dangerous actually so therefore we don't need to inspect them it's how you or or audit them or visit them it's how you decide where the risk is and that and that's something different so i think that we are of the right size

02:45:43 so i think that we are of the right size i wouldn't want to see us any smaller i'll say that for the record but i think we are broadly the right size to serve this city in terms of our latent capacity in terms of our

02:45:54 latent capacity in terms of our geographical spread but the management of risk regardless of because the truth is you could have a brigade

02:46:02 brigade five times the size and still miss the risk

02:46:05 risk it you know it's about how you correctly analyze that picture and that is not straightforward because there is no single data set for the buildings in london it lies across multiple authorities

02:46:16 across multiple authorities organizations both in central government local authorities care providers all sorts of people to have the information you want

02:46:25 you want we don't have a single consolidated data set yet we're working on a very large it project called one risk to deliver that which will bring together both the ord

02:46:36 both the ord which is the operational risk database with faranal which is the fire safety risk database and the h of sv so the home fire safety visit database currently we're still working across

02:46:47 currently we're still working across three databases all of which can hold valuable information on one building and should be understood as a whole so that's where we need to get to you know i'm hoping that as

02:46:59 you know i'm hoping that as technology emerges particularly cloud-based technology we'll find our way to that somehow easier but it is of note that when we started the building um

02:47:09 um risk register process you know which was mandated by central government and rightly so central government in the form of as was then dc dc dclg

02:47:21 dclg they changed their deluge now aren't they um

02:47:24 they um informed us that they thought we had 8005 high rises in london we thought that we might actually have more but we had a record of about seven thousand four hundred and ninety

02:47:36 thousand four hundred and ninety as it turns out we've now found over eight and a half thousand so that there wasn't any one single data set in regard to london you you just have to go and look so i think we're all

02:47:47 have to go and look so i think we're all we're all struggling with that um but it's less about the immediate resources available it's about where you look and what we tell firefighters to do as a priority focusing back on 72d

02:47:59 priority focusing back on 72d ex-commissioner dobson gave evidence on policy 800 which is the the brigade's policy on the management of operational risk information published first i think in 2012

02:48:11 published first i think in 2012 and he told us at day 211 page 207 lines 8 to 16 for those who want to see it but in his recollection the policy made the process

02:48:22 recollection the policy made the process of 72d visits as he called them and the collection of operational risk information quotes too complicated unquotes for station-based crews and was quotes unrealistic

02:48:34 quotes unrealistic in what was expected of them would you would you agree with that

02:48:39 that assessment uh yes i would you would and do you think that the problem of apparently inadequate ord entries such as the one i showed you for grenfell tower was the result of a policy that

02:48:50 tower was the result of a policy that was simply too complicated and unrealistic for station-based staff um yes i would in part but i think it's also that we we also didn't train effectively to that policy they might

02:49:01 effectively to that policy they might have had a better chance at delivering it if we'd actually sat down repeatedly with them and and enabled them because you know we've got we've got lots of really intelligent well-skilled people sitting on fire

02:49:12 well-skilled people sitting on fire stations who i think actually would be capable of working through that flowchart process i think it was over complicated and the the new version is simpler but actually to carry out a premises risk assessment

02:49:23 to carry out a premises risk assessment problem properly in some buildings is quite complex it's why we have delivered fire safety training now to every single firefighter in london it's not just

02:49:34 firefighter in london it's not just about the fire safety advice they provide in a in a defined fire safety visit it's also going to help their knowledge in terms of carrying out a premises risk assessment for a different purpose for example so i think there's

02:49:46 purpose for example so i think there's something about the underpinning knowledge we gave people as well it wasn't just about the process and the policy it was about how we supported people to deliver it and what is the content of the training now

02:49:58 what is the content of the training now that is being delivered to station-based staff

02:50:01 staff on the collection of information about premises and the analysis of the risk presented thereby well it's based on the change policy and and it is about sitting and talking through with cruz

02:50:12 sitting and talking through with cruz how you deliver that visit again i think we will need to seek to continue to improve that you know we won't stand still on that and i hope as we deliver fire safety knowledge to a greater depth in

02:50:24 knowledge to a greater depth in um the fire brigade our competency in this area will continue to evolve i think the real key to this though is not just to provide the training but we're back to assurance which is you've then gotta go and have a look at the end

02:50:35 gotta go and have a look at the end results and really satisfy yourself that anything we have done actually changes the end point what i do know because of the rigor with which jane philpot in particular has approached this as our ac fire stations

02:50:48 approached this as our ac fire stations that we are seeing a markedly improved standard in ord entries which tells me that people are taking this more seriously

02:50:56 seriously but i would not encourage any complacency in this area because there will still be entries on that database that i would not be satisfied with that this is the reality of a big organization comprised of 5 000 human

02:51:07 organization comprised of 5 000 human beings some of whom do not always discharge their function to the standard i would like so we keep on going back round that loop of education

02:51:17 education delivery assurance challenge you know change the training again which should be fair to ron dobson is how he originally conceived the die out process is anybody actually

02:51:28 is anybody actually or has anybody actually done an audit of the rd database to weed out the the um substandard entries yes or more than one occasion now over the past two years

02:51:39 past two years back in and out of it right continuously but but don't forget this shifts if you you know if you were to look outside even the window now the scale of construction in london is still extraordinary so the built landscape is changing and i

02:51:51 so the built landscape is changing and i would expect in terms of managing that prioritization that things come on on and off that list the ord should be a live you know document you know a live database because you will find that you

02:52:03 database because you will find that you know one of the things we found was that

02:52:06 was that you know there had not been enough removal of things from the rd when we first went toward it because although the buildings might be there there was different usage or they represented a different risk so actually i would expect these things

02:52:17 so actually i would expect these things to flex and obviously as new buildings are built or occupied in a different way and therefore represent a different risk you're going to get new entries some of those entries will be to a standard i'm satisfied with increasingly so but some

02:52:31 satisfied with increasingly so but some still will not maybe it's a junior officer that hasn't yet had the benefit of all that education to the depth we want potentially it's someone who's not having their best day at work that's the reality of big organizations

02:52:43 that's the reality of big organizations i think the key is to recognize it can happen and then challenge yourself to go back round that loop to you know as far as possible drive a consistent and highest possible standard of event you know of any

02:52:55 you know of any you know activity yes you mentioned earlier in your evidence

02:53:01 evidence the two different databases the ord and farinho ord

02:53:06 ord from what you might call 72d visits and faranor being the work product or information database derived from information from enforcement under the rro so i believe um we heard some evidence from ac dan daley about that

02:53:18 evidence from ac dan daley about that and he told us that the flow of information did not work well between the two and was patchy uh inconsistent uh would you agree with that yes i would and why was that

02:53:30 that yes i would and why was that because the two systems are not directly aligned you're you're relying on on the sharing of data between the systems that is not intuitive or technically straightforward so you're relying on the human factor here you know there's an

02:53:42 human factor here you know there's an element of human intervention to take data from one place to another um so that's that that's one of the main reasons for why we're seeking to evolve our

02:53:53 our holding of data in a single place now it might mean that we still maintain the three separate databases but emerging technology shows us that you can interrogate those three separate databases through a mechanism to bring

02:54:04 databases through a mechanism to bring it into conglomerate it might be that we have to build one single whole database so i wait to see how that develops but it's complex because of the volume of information held in both

02:54:15 volume of information held in both and the fact that at the moment you know you really do need to support that transfer of risk information through human systems as well there's not straight

02:54:23 straight past across when he became commissioner was it a particular concern of yours that the ord did not capture the full picture of all high-rise buildings in london yes yes

02:54:35 high-rise buildings in london yes yes and do you agree we agree with ac dave brown's evidence that the ord should in fact record all residential high-rise buildings or at least the vast majority of them in the context of what we

02:54:46 of them in the context of what we currently understand to be the risk yes if we got to a place where we remediated the vast majority of those buildings and we were in a place where constructors started to build buildings that were genuinely safe

02:54:58 that were genuinely safe then we might find actually that we didn't need every high-rise that's a good example of where things might come off the ord but you would have to have a great level of assurance in the quality of construction and the remediation

02:55:09 of construction and the remediation works that have been carried out at that point to take that decision as it currently stands there is no way we could do that because of what both this inquiry our own analysis and the and the

02:55:19 and the and the kind of understanding from residents themselves has demonstrated around safety in the high-rise environment which is we are nowhere close yet to ensuring that it's safe for all london residents living in a high rise

02:55:30 rise now the lachenal assurance review from

02:55:34 from the 7th of august 2018 and as i said i don't need to take you to it unless you would like me to um tells us that as at october 2017

02:55:45 um tells us that as at october 2017 some 1700 residential high-rise premises had a premises risk assessment recorded against them out of a total of 6900 known residential high-rises in london

02:55:57 london when uh dave brown gave evidence in in the last module he suggested that those figures were inaccurate but he wasn't in a position to advance any alternative numbers first of all are you in

02:56:09 first of all are you in any better position than he is i'm not in a position to advance any greater understanding around historical um progress against inspection of high rises we understood it at that point no

02:56:21 rises we understood it at that point no would you agree that 1700 out of 6900 is a poor hit rate yes particularly because there was an intent to visit all of them post slack and has there been an improvement

02:56:33 and has there been an improvement in those numbers or numbers like them since

02:56:36 since october 2017 yes parsley so i know that at least um that we're up close to 8 000 for premises risk assessment entries ord entries

02:56:47 entries and where relevant we have over seven and a half thousand electronic premises information play entries

02:56:54 entries so it you know we've got to a point because we've looked at eight and a half thousand

02:57:00 thousand high-rises over the course of the building risk review process um

02:57:05 um you know we've ensured that as far as we know it and don't forget these numbers change almost daily that we have captured the vast majority of high-rises in london but that is a continuous process you're in a

02:57:16 continuous process you're in a continuous cycle there yes thank you mr chairman is now a convenient moment yes does that suit you yes it does yes well i think it's time we had a break for lunch it's just a road we'll stop there we'll resume

02:57:28 road we'll stop there we'll resume please

02:57:29 please at two o'clock and as before please don't talk to an owner about your evidence over the break okay thank you very much would you go with the usher please

02:57:47 thank you very much two o'clock then please