Evidence session examining the London Fire Brigade's response to the Grenfell Tower fire, including operational decisions, command structure, and lessons learned.
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# Source: Local audio transcription (no YouTube captions available)
00:00:00 Would you ask Mr. Rowe to come back in please?
00:00:27 Thank you.
00:00:32 Right Commissioner, all ready to carry on I hope.
00:00:40 I am, thank you.
00:00:41 Well done, thank you. Yes Mr.
00:00:43 Yes, thank you Mr. Chairman. Commissioner, just reviewing some of your answers before
00:00:48 the lunch break, one or two things that I think have occurred to me to ask you about.
00:00:52 You described your plan, your forward looking plan, in two ways. First of all development
00:00:58 of internal leadership and management training with higher qualifications and secondly bringing
00:01:02 in skills and experience of management and change management from outside the LFB. Would
00:01:07 that be a fair pithy summary?
00:01:10 Yes.
00:01:11 Yes. Now Rita Dexter told us that there was a cultural resistance to having a non-operational
00:01:17 firefighter as a deputy commissioner. That is a summary of what she said. Would you agree
00:01:22 with that? At least during the time that she was there?
00:01:25 I think there has been resistance at times to bring in non-uniform members of staff at
00:01:30 a senior level and I think part of that is because the LFB sees itself as a primary and
00:01:36 operational service and actually I think it is important that for the people of London
00:01:41 it is led by an operational officer with an understanding of the operational environment.
00:01:48 But yes I would acknowledge I think there has been in the past some resistance to bringing
00:01:52 in very senior non-uniform people.
00:01:55 Is there a risk therefore that the use of non-uniformed external skilled managers and
00:02:02 leaders might generate some resistance from some quarters of the operational part of the
00:02:08 organisation?
00:02:09 Yes, but I think that is quite natural. I think it is what happens in lots of organisations
00:02:13 when you bring in people from the outside regardless of what your organisation perhaps
00:02:18 does and that actually the job of the very senior leaders within that organisation is
00:02:24 to ensure that people feel safe when we do so, that we help educate people as to the
00:02:29 value that those colleagues are going to bring to the organisation and help them recognise
00:02:34 that actually that does not mean we are going to deviate from our primary function which
00:02:38 is as an operational fire and rescue service acting on behalf of London and Londoners.
00:02:44 So I think it is actually natural for colleagues to perhaps feel anxiety to wonder whether
00:02:49 they have still got a place in the future of the organisation when they see a turning
00:02:55 outwards to other skills. I think that is a natural human inclination with people who
00:02:59 hold their own ambition, who have a great passion for the fire brigade. I think the
00:03:04 trick of leadership is to explain that this is not a threat but is actually an opportunity
00:03:09 to learn and grow and that is what we have attempted to do.
00:03:14 And in the abstract one can see that. How in practice are you going about that?
00:03:18 In conversation because we have had feedback that colleagues inside the fire brigade as
00:03:25 it currently stands did not feel comfortable with the number of non-uniform senior directors
00:03:30 that were put into position. But actually what we have done is given them the courtesy
00:03:35 of having the conversation about why we thought it was important, the skills and capabilities
00:03:41 that those directors brought. The best way I could characterise this is a conversation
00:03:44 I recently had actually with our Deputy Assistant Commissioners. I am talking in the last two
00:03:49 weeks to say look, when we see a major incident in London I turn to my Deputy Commissioner
00:03:55 Richard Mills who has nearly 30 years of operational experience leading some of the most challenging
00:04:00 incidents in London for his professional knowledge, experience, skills and the ability to react
00:04:07 to that very critical incident and lead the brigade in that way or to one of my Assistant
00:04:12 Commissioner colleagues who have a similar experience. But when I need someone who has
00:04:16 got a professional background in HR or the support to people I would turn to Tim Powell
00:04:23 who is my Director of People because he comes with that professional skill set. The one
00:04:27 thing does not undermine the other. I would no more ask Tim to lead a very significant
00:04:33 critical operational incident in London than I would ask necessarily Richard to solve some
00:04:38 of the more complex human resource issues we have in the fire brigade. I think once
00:04:42 you give people the benefit of having that conversation they can see it is not a threat
00:04:47 but is actually a part of natural professionalisation of the organisation as a whole.
00:04:54 Is there a benefit in bringing in senior officers from other fire and rescue services such as
00:05:01 AC Jonathan Smith who came in in 2019. Is there a benefit in that to broaden the outlook?
00:05:09 Absolutely, which is why to give credit to colleagues who employed Jonathan at that time
00:05:16 it happened. I think he brings a different sort of set of experiences in a different
00:05:21 setting but with good operational knowledge of the fire service and its duties and he
00:05:27 has been very successful in his leadership role. So I think we really gained the benefit
00:05:31 of bringing someone in externally. Are you capitalising on that benefit by broadening
00:05:36 that as a policy? Yes, so I could give you examples of officers at every level including
00:05:43 recent promotion rounds in the previous few weeks where we brought in colleagues from
00:05:48 other fire and rescue services in the country and we are very heavily engaged actually with
00:05:52 the NFCC's programme to consider multi-tier entry and high potential development schemes
00:05:58 as a national model. We are one of ten fire and rescue services in the country who are
00:06:02 directly engaged with that and seeking to shape the future direction of travel in that
00:06:08 regard as well. Turning to the question of training on the
00:06:11 watch, you told us this morning that watches are strong teams and they need to be and you
00:06:16 don't want to dismantle that. I just want to ask you one or two questions about the
00:06:20 practicalities. First, what impact does the station-based shift system have on the delivery
00:06:27 of training and professional development as things stand?
00:06:30 I don't think any one particular shift system necessarily impacts training for better or
00:06:39 worse. At the end of the day you have 24 hours in a day and you can cut it a number of different
00:06:44 ways. You have to be sensible in paying due regard to when you do, for example, noisy
00:06:49 training in an urban residential environment. We tend to factor that into the day times
00:06:56 but then in the evenings colleagues will train through theory and lectures or quieter activities.
00:07:02 So I think the shift is what the shift is. What is of more interest to me is a sensible
00:07:08 degradation policy which recognises that part of your resource model must, regardless of
00:07:14 shift, build in an element of your workforce held back for high quality training. So effectively
00:07:20 not on operations at that point. So you are in on your day shift but you are not going
00:07:25 to deliver operations to London at this point. Now in the past I think we have always focused
00:07:30 on minimising that. At the moment we are in the process of considering how far we might
00:07:36 degrade to put resourcing against training. The best example I would give would be something
00:07:42 like armed policing in London where it is routine practice to take large sections of
00:07:49 that, not large sections, the right number of that cadre out of operational service to
00:07:53 put them into a very realistic training environment down at Graves End. And that is built into
00:07:59 the resourcing model. So if I think about how many firefighters I need in London I don't
00:08:04 just think about how many firefighters I need on a fire station at any one given point to
00:08:08 maintain a six minute and eight minutes attendance times which is of primary importance to me
00:08:14 and the brigade and Londoners. I also need to think about those colleagues who are on
00:08:19 duty that day who I only want to train. And I think we haven't been as explicit about
00:08:23 that as perhaps we could have been in the past but we are doing that now.
00:08:28 And does it, do you perceive limitations in the time for training with non-operational
00:08:32 experts such as those from the fire safety department such as it might still be to work
00:08:39 alongside station based staff? I think there is always limitation, in any
00:08:45 big organisation there is a reasonable balance between the resources you need, the budget
00:08:50 available and the management of risk and proportionality in that regard. I would imagine that there
00:08:56 are some challenges in terms of a fire safety department that actually is well resourced
00:09:02 but because of the great pressure on the wider industry for experts. He's quite a high churn
00:09:07 of staff that's why we are developing so many in house. So I think there would be pressure
00:09:12 to make those colleagues available all the time but I think we would be constantly striving
00:09:17 to do that because that coordinated training and that cross fertilisation of learning is
00:09:23 very important. So for example the fire safety training we've just delivered to stations,
00:09:31 each station has a named fire safety area hub and officers who they can turn to for
00:09:37 further advice and education. I know that at times stations don't always get that advice
00:09:42 quickly enough and it's a problem we are considering at the moment. Some of that is I'm afraid
00:09:46 just the pressure of recruiting enough fire inspecting officers to constantly meet the
00:09:52 demand of the environment we are in. It's not even our establishment. Our establishment
00:09:56 is probably the right size. It's this constant need to refresh because of the churn people
00:10:01 are attracted to outside industry because of higher wage, retirement and then the need
00:10:06 to train people in quite a significant technical specialism. So I think what I'm saying because
00:10:11 that was a very long answer, apologies, is that some of this stuff is complex and there's
00:10:15 a balance between resources proportionally meeting the risk and planning accordingly.
00:10:20 So you recognise the challenge but what you've just said is an effort to overcome it, is
00:10:25 that what we are to take? Yes and the desire to continually improve. Now tell me about
00:10:30 CBT training. To what extent is station based training still delivered by computer based
00:10:35 training methods? A lot of it is in terms of the theory because it's the easiest way
00:10:40 to consistently make available a package of training to a station. So I was horrified
00:10:45 by the training package you showed me yesterday. I think it's a disgraceful example of how
00:10:51 not to train people. That is an example of a locally written and delivered training package.
00:10:56 We've done some investigations last night actually as to where it originated from and
00:11:00 we will be providing some education in that regard, not only to the whole workforce but
00:11:04 to the individual station concerned. That's important. But what that shows me is why you
00:11:10 really do need good quality computer based training to deliver a consistent package
00:11:14 because I'm not going to defend that particular training package but in defence of stations I'm
00:11:19 not sure it's okay that colleagues are writing their own packages on fire survivor guidance.
00:11:23 Surely I and the brigade should be providing them that. So CBT has a useful place in firefighter
00:11:30 education but it then has to be backed by good practical training delivered by their own officers
00:11:37 and then further still in those highest risk areas whether it's driving, high-rise, compartment,
00:11:43 firefighting or some of our technical rescue disciplines with good face-to-face training
00:11:49 delivered through the central contract, you know that hybrid methodology.
00:11:52 Well you said in your evidence a minute ago that you'd done some investigations last night
00:11:57 about that package. How did you know that?
00:12:02 Because you'd presented it to me that day and I got on the phone to the deputy commissioner
00:12:07 after I left the hearing to say that I wanted him to look at that evidence and try to identify
00:12:13 where the training package had come from and understand why that would have been presented
00:12:19 as you know, disclosable evidence into this process because it told me something about
00:12:24 the culture and kind of the practice of training and I want to understand it better.
00:12:31 Yes, I understand the reasons. I just wondered to what extent that conflicted with the warning
00:12:35 the chairman had given you not to discuss your evidence with anybody.
00:12:38 Apologies Mr Millett, I accept that. It was more a desire not to allow that to persist
00:12:44 in the organisation because what I wasn't sure about at that point is whether that was
00:12:48 still in existence, was still being used, was a package that was widely available and
00:12:53 was perhaps being used across a number of stations. I think that I would want to stop
00:12:58 that immediately because it is wholly unacceptable to me. I found that wholly unacceptable.
00:13:03 I understand the rationale and the desire to do that but can you tell us what other
00:13:10 conversations you had?
00:13:11 No, no, it was solely that one because that presentation had disturbed me to that extent.
00:13:16 Right.
00:13:17 But I apologise chair wholeheartedly if I have somehow stepped beyond the bounds of
00:13:21 the problem there.
00:13:22 Well, it may have been unfortunate that you couldn't wait until today to make the inquiry
00:13:26 but it obviously made quite a strong effect on you so I can understand why at least you
00:13:32 put the inquiries in motion straight away.
00:13:34 But apologies, fully accept that.
00:13:36 Can you give us an assurance that you have not?
00:13:38 I'll give you an absolute assurance that I will not be discussing the evidence from
00:13:40 the inquiry in any other regard nor have I done.
00:13:44 Right. Now just going back to CBT, it's still carrying on. Who is it on station who quality
00:13:52 assures the outcome of the training delivered by CBT, if anybody?
00:13:57 So currently the first line of assurance will be with their station commander.
00:14:03 So they will assess the watch's ability to deliver that training.
00:14:07 They'll do that both through periodised observation of training.
00:14:13 So they'll actually have a look, they'll go and have a look at a lecture, they'll
00:14:16 dip test audit, they'll go and witness a lecture being delivered or they'll have a look at
00:14:19 how that CBT is being delivered, they'll have a look at a drill.
00:14:24 On that point, we then got obviously the DAMOP system, which is both a mix of qualitative
00:14:32 and quantitative data, but primarily quantitative.
00:14:35 So how many people have completed a package?
00:14:39 And we're currently in the process because we asked our independent operational assurance
00:14:43 advisor to look at training, considering how we further supplement assurance of training,
00:14:50 because I don't believe that's an area we have fully addressed yet.
00:14:53 I was going to ask you about that, because do you perceive or have you taken account
00:14:58 of perhaps the risk that if you allow senior station-based staff, perhaps watch managers,
00:15:06 to quality assure, peer review the training or outcomes of the training done by the rest
00:15:13 of the watch, there is a potential for conflict to arise between their personal relationships
00:15:19 on the watch and an objective, critical approach to the outcome of the training?
00:15:25 Yes, which is why we're building, why we already have got an additional line of assurance,
00:15:30 which is your station commander that sits outside the watch structure in the first instance.
00:15:34 And actually within Jane Philpott's area of operational command, so all the fire stations
00:15:41 in London, she undertakes both borough and area reviews of training.
00:15:48 So she will bring officers from other areas and other boroughs to consider the delivery
00:15:53 of training in test piece exercises.
00:15:56 But I think we need to have a roving audit approach to this separate from that again,
00:16:02 and we're considering about how we implement that.
00:16:04 We already have an operational assurance function, but I think it needs to be further developed,
00:16:09 both in terms of its capacity and its freedom to roam across the organization.
00:16:14 People are giving thought to that now and how that will be taken forward because we
00:16:19 have had a number of reviews of training in the London Fire Brigade that have identified
00:16:23 assurance as a potential issue.
00:16:26 We've had the independent operational assurance advisor who reported to me, I'm afraid I don't
00:16:31 have the exact date, but I'm talking within the last month or so, his view of training
00:16:36 in the London Fire Brigade.
00:16:37 One of the parts he focused on was the continued need to build a really good set of assurance
00:16:45 protocols around training.
00:16:47 So I think we're better than we were, but we need to be better than we are.
00:16:51 Can I turn to a different topic, stay put.
00:16:56 Can we go to your first phase two witness statement please, LFB 00060655, page 9, and
00:17:04 let's look together Commissioner at paragraph 20, which is on the screen in front of you.
00:17:08 And you say there, in the paragraph at the top of the page, that the Grenfell Tower was
00:17:20 the first departure.
00:17:24 You see, you say that at the very end of the paragraph.
00:17:28 I note that to the best of LFB knowledge, the Grenfell Tower fire represented the first
00:17:33 departure from the standard stay put strategy in England and Wales.
00:17:38 Now Professor Torero, when he gave evidence, told us about the statistics that were cited
00:17:44 by Colin Todd in his phase two report, namely that in the period 2009 to 2010, that year,
00:17:53 there were 8,000 fires in residential high rise buildings, only 22 of which required
00:17:58 evacuation of more than five people.
00:18:00 And the reference is CTAR 701, page 109.
00:18:05 Now those statistics, are they familiar to you?
00:18:08 They are, because I've read that part, I don't know if it was in his or in another piece
00:18:13 of evidence, but I recognise the numbers, the 22 and the 8,000, yes.
00:18:18 Yes, and in your experience, would you say that those figures reflect your personal and
00:18:22 the NFB's corporate experience in the sense of the apparent rarity of evacuations of high
00:18:29 rise residential buildings at the time before the Grenfell Tower fire?
00:18:34 Yes, and again, those 22 occurrences, and I don't know each of the 22, this is my caveat
00:18:41 on this obviously, is I'm not sure whether they would have been seen as total evacuation
00:18:47 of the block or not.
00:18:48 It may have been partial evacuation, it may have been some part of the building, like
00:18:52 in Shepherd's Court, that we needed to carry an emergency evacuation out on.
00:18:57 We'll come to that in a moment, yes, you're right.
00:19:00 Would you also agree that the fact that an event is rare, infrequent, does not mean that
00:19:04 it is low risk?
00:19:06 No.
00:19:07 You do agree?
00:19:08 No, I do agree with you, apologies, sorry, I agree that no, it does not mean it is low
00:19:12 risk.
00:19:13 Yes, and presumably it would follow from that, that the perceived risk of an event takes
00:19:19 into account both the gravity of the potential harm if the event occurs, as well as the likelihood
00:19:24 of it occurring at all.
00:19:25 Yes, that's a very commonly understood approach to risk assessment.
00:19:30 In your experience, is there today, or was there before the Grenfell Tower fire, a tendency
00:19:36 on the part of the brigade to conflate rarity of an event with risk?
00:19:42 In other words, to see risk only in terms of frequency and not in terms as well of severity
00:19:48 of outcome?
00:19:49 No, I don't think that is a fair generalisation.
00:19:52 If I think about my own experience running technical rescue, some of the risks I was
00:19:58 responsible for defining policy against were actually very rare occurrences, i.e. total
00:20:04 building collapse, or the need to rescue people from the context of a building collapse.
00:20:13 If I give you an example, we've got 30% of all the specialist assets for building collapse
00:20:18 in London, our urban search and rescue teams, so the whole national resource, 30% of them
00:20:23 in London.
00:20:26 The training required to become a USAR technician takes place actually over a number of years,
00:20:30 if you look at it in totality.
00:20:32 These are people who effectively have the skills of miners to shore and make buildings
00:20:37 safe in the most incredible circumstances.
00:20:42 The modelling for that was based on two simultaneous bombings actually, the original modelling.
00:20:49 Now that is a very, very rare occurrence and we have not seen a repeat of that in London
00:20:56 in exactly that way.
00:20:58 We have seen very rarely total building collapse and that is a very expensive resource.
00:21:04 So USAR is very expensive, but it's a good example of knowing that whilst the likelihood
00:21:09 of something happening is quite small, the catastrophic impact of it when it does means
00:21:15 you must have the specialist resources available to deliver a response into it and that the
00:21:21 investment needed in the training to maintain that specialist response model is very considerable.
00:21:28 And how many total building collapses have you experienced in London in the period 2009
00:21:36 to 2017?
00:21:37 We have had a number of smaller ones, but I would imagine that there are fairly low
00:21:41 numbers in terms of turning that out.
00:21:42 It might only be say 10 a year and we are talking perhaps individual shops and dwellings.
00:21:48 So that is our normal experience of it.
00:21:50 But then of course we do have other examples and I cannot remember the name of the street
00:21:54 and I was not on the incident, but there was a building in Westminster that collapsed in
00:21:58 entirety when a builder removed the wrong structural element of it.
00:22:03 We ended up with the builder trapped under hundreds of tonnes of rubble and a complex
00:22:09 two day operation to release that individual.
00:22:11 We have seen some very difficult crane collapses in London, the Battersea Crane Collapse.
00:22:16 There was one out in East London not so long ago which destroyed a building and again that
00:22:21 is where those specialist assets were brought to bear.
00:22:25 And actually I have employed them operationally when we had a fire in the tunnels under Kingsway
00:22:31 which took four days to extinguish and required them to shore and extinguish as far as they went.
00:22:38 So we do use them, but it is relatively rare.
00:22:40 Again we could get that information for the inquiry if that would help.
00:22:46 I was interested in your USAR example.
00:22:50 Perhaps USAR stands for Urban Search and Rescue, I do not know the acronym, but taking that
00:22:56 as an example perhaps of rarity and severity.
00:23:01 Let us look at that in the context then of the apparent rarity of evacuations of residential
00:23:09 high rise buildings.
00:23:11 And against those two mixed backgrounds I have got a number of questions for you.
00:23:15 The first is this.
00:23:16 When Gary Reason gave evidence to the inquiry in September this year he said that the evacuation
00:23:22 of a high rise building was not something that was unusual.
00:23:27 That was day 181 page 119 line 24 to line 20 at 21.
00:23:32 He obviously said a lot more than that, but that was the gist of it.
00:23:37 That is inconsistent it seems, isn't it, with your evidence in the last sentence of paragraph
00:23:44 20 of your statement here on the screen that the Grenfell Tower fire was the first departure
00:23:49 from the standard state put strategy in England and Wales.
00:23:52 I am not sure it is Mr Millett because I think they refer to two different things if
00:23:57 I might say.
00:23:59 So I think without seeing the whole context of Gary Reason's evidence I think what he
00:24:03 is referring to is the phenomenon we experienced post-Lackinol which is residents took the
00:24:08 decision themselves to evacuate an entire block because frankly they did not trust the
00:24:14 state put advice because of what they had seen at Lackinol.
00:24:17 I certainly experienced that as a repeated phenomenon in the years after Lackinol and
00:24:21 then it tailed off.
00:24:23 I think I said this in my phase one evidence.
00:24:25 I definitely experienced that and the challenge of managing that when you turned up to try
00:24:29 and respond to a fire.
00:24:30 I think what is referred to there is the first known recorded time of an officer which in
00:24:38 this case was me taking a recorded decision to say the state put strategy is no longer
00:24:44 applicable in this building and this residential building where previously it stood and therefore
00:24:49 we must carry out a total evacuation and rescue of the block.
00:24:54 I think that is what that sentence means.
00:24:56 It does not refer to the fact we had not come up against self-evacuation many, many times
00:25:01 but it is rather the fact that this was a considered decision recorded as such that
00:25:06 the state put strategy baked in through years of understanding of the regulations simply
00:25:12 was not fit for purpose at that moment in time and therefore could not be employed.
00:25:16 Right.
00:25:17 Let us try and tease out some of the distinctions I think you are drawing.
00:25:22 There may be three.
00:25:24 The one is departure from the state put strategy by means of self-evacuation.
00:25:32 Another might be the departure from state put by way of managed evacuation and the third
00:25:40 might be total building rescue where everybody in the building has to be rescued.
00:25:44 Is that a distinction that you are trying to get across to us?
00:25:48 I think what I am trying to say is that this sentence refers to the, you know, and it does
00:25:53 say, you can't be asked it to the best of our knowledge, the first time that we had
00:25:56 a recorded decision far of this scale to explicitly reverse the state put strategy.
00:26:05 We had certainly seen evacuations in context of self-evacuation as described and obviously
00:26:12 we were very well used to evacuations, planned evacuations of commercial buildings that were
00:26:17 on fire.
00:26:18 So, we would have experienced evacuations in that context as well.
00:26:24 But I am certainly not aware of where previously, certainly in the London Fire Brigade, an incident
00:26:30 commander had taken the recorded decision that a state put strategy was no longer applicable
00:26:37 to that building in its total sense.
00:26:41 Right.
00:26:42 Well, I was just going to interrupt to ask whether a distinction has to be drawn here
00:26:48 between partial and total evacuation.
00:26:50 I don't know how often you have had to evacuate part of a building.
00:26:55 Do you know?
00:26:56 Much more frequently.
00:26:57 I think that is the right question to ask because again, Shepard's Court would be a
00:27:02 prime example of an incident commander at that point saying, okay, you cannot occupy
00:27:07 the floors above and below the fire floor.
00:27:10 Something similar happened at Mermaid Court, the fire I attended where a whole floor became
00:27:16 untenable.
00:27:17 That was not necessarily uncommon.
00:27:20 We had seen partial failures of compartmentation particularly across lobbies on more than one
00:27:25 occasion and certainly people had taken a decision to empty the floor above and below
00:27:32 whilst recognising that it was still safer in their opinion for the rest of the residents
00:27:37 to stay put in their flats.
00:27:39 Right.
00:27:40 Let me just show you what Gary Rees told the inquiry on the question of partial or full.
00:27:45 Can we please have his evidence at day 181, page 119, line 24.
00:28:00 And he is asked the question by me at line 13.
00:28:07 There is nothing we have seen in this on why it is that a candidate should consider
00:28:11 a full or partial evacuation as a result of the fact of remedial work being conducted
00:28:15 in the building and he is actually being examined there on the Holcroft House Command Decision
00:28:24 Exercise and his answer at line 22 is I will qualify that because I know this is an important
00:28:31 issue for the inquiry and I am sure for the BSRs.
00:28:35 Having high rise particularly but not just exclusively high rise wasn't something that
00:28:39 was unusual.
00:28:42 Partial and you know full evacuation was you know less frequent I accept but partial evacuation
00:28:48 and I think the inquiry has seen evidence of other fires in London and around the country
00:28:52 where partial or full evacuation has been conducted successfully and of course we don't
00:28:56 just evaluate fires we evacuate in chemical incidents and in gas leaks so it is something
00:29:01 that we do quite regularly as a fire service and the process of evacuation and we can
00:29:07 leave out the parenthesis is a sort of well ordered systematic approach of moving in this
00:29:12 case residents from a place of potential risk to a place of relative safety and is normally
00:29:18 done as a preventative measure to prevent those people being exposed to the products
00:29:22 of fire, heat, smoke etc.
00:29:25 Or if you know worse cases the fire starts to develop and it shouldn't be confused or
00:29:29 conflated with the process of search and rescue for which there is quite a significant
00:29:33 body of policy and training work in the brigade and I know you have seen some of that.
00:29:38 And then he goes on to say at 22 so I don't know if that helps just to put this particular
00:29:42 issue because I think sometimes evacuation and search and rescue get conflated for obvious
00:29:49 reasons and he goes on I don't think I need the rest.
00:29:53 Now the distinction I was putting to you could well be one of between partial and full but
00:29:58 it appears also in the Gaelic Reasons evidence to be one between evacuation and search and
00:30:03 rescue.
00:30:04 Now there may be two sets of distinctions operating here and what I am really seeking
00:30:08 to get a handle on is what is it seen in those terms that you are saying your decision at
00:30:15 Grenfell to revoke Staput was a departure from for the first time?
00:30:21 I think it was an acknowledgement that the strategy of Staput itself is very simple in
00:30:27 many ways that I understood that the consequences of reversing that decision were not actually
00:30:33 straightforward and that the outfall of it would not be easy to manage at all.
00:30:38 It was simply that we could not reasonably advise people to stay safely in their flats
00:30:43 anymore.
00:30:44 It was the wrong advice to provide.
00:30:46 So that was where I was coming from almost really regardless of what then followed because
00:30:51 it was clear to me that we were never going to save that building.
00:30:55 So therefore it was no longer possible because the only end outcome of that building was
00:30:59 total destruction and therefore we could not foresee a place where anyone could remain
00:31:05 safely in their flats.
00:31:06 That was the genesis of my decision that what then followed was actually enormously
00:31:12 difficult and actually at the point I was in command of the incident was certainly mass
00:31:18 rescue rather than either managed evacuation we were well beyond that or even what I would
00:31:23 call emergency evacuation which sits in a transitional space between the orderly evacuation
00:31:30 of a building, a point when actually there is not a threat.
00:31:35 For example a fire drill in a commercial building when the alarm goes off because of a very
00:31:40 small fire perhaps or some other premise like a school or even a hospital where it is more
00:31:47 challenging.
00:31:49 Emergency evacuation is what I think you do in the very early stages of an incident where
00:31:53 you are beginning to see a building fail in a residential high rise block or other
00:31:57 building for which has not been designed to support any sort of managed evacuation because
00:32:04 you are now going to have to work with a limited physical environment that does not support
00:32:08 that process.
00:32:09 And I think rescue, you tip into mass rescue at the point where it is no longer possible
00:32:16 for members of the public to get themselves out of that building with any degree of safety
00:32:21 at all but that is a grey area.
00:32:23 That transition from emergency evacuation to what is mass rescue I think that is hard
00:32:29 to define and equally hard to predict an outcome for.
00:32:34 And necessarily dynamic.
00:32:36 Very.
00:32:38 So that takes us to the question about training for evacuation of any kind whether it is self-evacuation,
00:32:47 managed evacuation or rescue as you would call it.
00:32:57 Mr Cowop described the training on evacuation as something of a blind spot for the fire
00:33:06 and rescue service sector generally in terms of policy guidance and training.
00:33:11 Would you agree with that?
00:33:12 I think looking back and recognising many of the issues we have discussed over the past
00:33:18 two days it was an area we should have devoted more time and resource to training our firefighters
00:33:25 too because I think we had quite a binary understanding actually.
00:33:28 I think this is a very useful point you are seeking to illustrate which is we had certainly
00:33:34 provided advice and guidance as to how you might take the information around managed
00:33:37 evacuation from a premises risk assessment.
00:33:40 So people knew they needed to understand how a building might be evacuated in a planned
00:33:46 way from the contingency plans that were available.
00:33:48 We would have checked that.
00:33:49 They certainly had a lot of guidance around what it might take to search for and then
00:33:56 rescue people even in a large scale incident.
00:34:00 It was this area in the middle around what you do when you are having to evacuate people
00:34:04 at pace from a building that is not designed for that purpose where we never provided
00:34:10 explicit training in that regard and which of course we do now because we recognise that
00:34:15 is an area of real operational difficulty that our crews and officers deserve the investment
00:34:21 in to kind of grapple with.
00:34:24 At the moment you revoked stay put at Grenfell at 2.47 you had reached the third of those
00:34:30 stages I think which was rescue.
00:34:34 So that is an example of a case, Grenfell is an example of a case which was not in fact
00:34:40 in the grey area, it had already gone through the grey area.
00:34:43 Absolutely, it was very clear cut to me that we were already seeing total building failure
00:34:47 and that everyone in that building who remained in that building at the point I took over
00:34:50 would have to be either assisted or rescued.
00:34:54 Does that tell us that the training that needs to go to incident commanders at any level
00:34:59 is to be alive to the risks of transfer from as it were level one where you can have a
00:35:08 managed evacuation if the building allows for it based on the premises risk assessment
00:35:13 into what you might call the grey area?
00:35:16 Yes, so you know and this is the training we have provided our incident commanders now
00:35:20 which you must consider this as a possibility at the earliest point of an incident and your
00:35:26 seeing the early signs of building failure is you have a window of time to do this after
00:35:31 which you will not have that opportunity because of increasing failure potentially and therefore
00:35:37 you have to address it at the earliest point of an incident and take that decision and
00:35:41 then work with the consequences of that decision because there are consequences.
00:35:44 Now we will come back in a moment perhaps to how you train incident commanders to do
00:35:52 that and what you are doing and we will come back to that in a moment but just before I
00:35:56 do I just want to ask you about two particular incidents Adair Tower in late October 2015
00:36:03 and the Shepherds Court Fire in August 2016.
00:36:05 There are two particular incidents and let's see if we can give them some kind of characterisation.
00:36:12 Adair Tower 31st October 2015 in North Kensington are you familiar with the circumstances of
00:36:18 that fire?
00:36:19 No I am not.
00:36:21 It was a 14 storey residential block on North Kens ground in which a fire started in the
00:36:26 flat on the third floor.
00:36:28 We have seen the internal incident reports.
00:36:31 Crews rescued approximately 50 people from the block and the contemporaneous documents
00:36:36 record that there were nine fire survival guidance calls.
00:36:39 That is what the documents say.
00:36:41 We heard evidence from Joe Smith that properly characterised there were only six fire survival
00:36:47 guidance calls but at all events more than at Lacknall and this is 2015.
00:36:53 Now the operational response is something worth looking at.
00:36:58 Can we please go to MET 00080605.
00:37:07 What I am showing you is a police witness statement.
00:37:10 MET, there it is.
00:37:17 It is a police witness statement dated the 17th of September this year 2021 by Tony Biles.
00:37:24 Now Tony Biles you will know I imagine.
00:37:28 I do know Tony Biles, he is now retired.
00:37:30 He was a group manager at the time of the Adair Tower fire and he acted as its incident
00:37:36 commander.
00:37:37 He had 34 years of experience as an active firefighter.
00:37:41 If you go to page 7 at the bottom of that page, he says, he arrived, and in the penultimate
00:37:53 paragraph I went through the usual process with Frank and that is Frank McCarthy who
00:38:00 was the watch manager who was there as an incident commander.
00:38:03 This is the handover.
00:38:05 Frank gave me a brief of what he implemented and I had to adapt his plan because we knew
00:38:09 there were a number of people trapped inside the building.
00:38:12 I was aware the fire was on the third floor.
00:38:14 The first thing I considered was why is the building causing the residents problems and
00:38:19 how am I going to get them out?
00:38:21 There were multiple people in that building that required rescuing or believed they required
00:38:26 rescuing so I formulated a plan to get them out.
00:38:30 As the building was a high rise, I knew I was going to get one fire rescue unit that
00:38:36 would be equipped with extended duration breathing apparatus, EDBA.
00:38:39 However, I ordered an additional FRU so I would have 10 EDBA wearers.
00:38:45 And then if you go to page 8, second paragraph, my initial thoughts and plans were to send
00:38:49 the EDBA wearers to the higher levels of the building in order to conduct rescues and bring
00:38:54 residents down to the lower levels and hand them over to standard duration breathing apparatus
00:38:59 STBA wearers who would guide residents out.
00:39:02 And then if you skip the fact that Adair had a stay put in place, he says this, whilst
00:39:10 I didn't revoke the stay put policy verbally or inform the control room of this, I did
00:39:15 revoke the policy as part of my plan.
00:39:18 Firefighters were briefed to clear the building but not verbally told the stay put policy
00:39:22 was revoked.
00:39:23 Although I had updated myself regularly on policies and procedures, there was nothing
00:39:27 that stated you had to verbally revoke the stay put policy.
00:39:30 There was no specific training on how to revoke the stay put policy around that time.
00:39:34 However, post-Lacknell House, there were a number of training packages in relation to
00:39:39 high rise firefighting and a policy change in relation to FSG.
00:39:43 Now, I've shown you quite a lot of that.
00:39:47 Would you agree, considering this description of Mr. Biles, group manager Biles of his operational
00:39:55 What he did in effect as incident commander was to reverse the stay put principle?
00:40:01 I don't think he did it in total measure because I think it's very important to state it verbally
00:40:05 and inform the control room because otherwise you might find yourself in a situation in
00:40:10 this grey area.
00:40:11 You know, you're not going to be able to completely rely necessarily on your own ability to successfully
00:40:16 emergency evacuate a building.
00:40:19 You do need your colleagues in control to be providing the advice to residents that
00:40:23 they need to leave the flat because it's going to be in combination of that advice and your
00:40:27 own attempts to then marshal these people as they come out.
00:40:30 You know, the fact that you had that many fire survival guidance calls there tells me
00:40:34 it would have been important to tell control of that decision because if they're on an
00:40:38 open line to people, those people themselves are going to leave the flat.
00:40:41 They might knock on their neighbours doors.
00:40:43 They are going to present themselves in the stairwell and therefore that's one less thing
00:40:47 you might have to think about potentially as an incident commander.
00:40:50 So I think to genuinely revoke the state policy, I absolutely recognise and respect Tony's
00:40:55 instinct there.
00:40:56 He's a good incident commander with a lot of experience but I would suggest that to
00:41:01 do that effectively, you must involve control in that passage of information because they
00:41:05 are going to mirror then any advice they give to either people who are already on the line
00:41:10 or who ring consequently.
00:41:12 Well, that's a very interesting observation, if I may say so, because one would, is this
00:41:18 right, one would expect the point you've just made to be reflected in the PRO or PRC
00:41:23 for this incident?
00:41:24 I don't know whether that would have been reflected but if I'd been involved and Tony
00:41:29 had been clear in the PRO or PRC that he had decided to revoke state put my immediate question
00:41:35 because that was my own question on the night of Grenfell, you know, and it all happened
00:41:40 in one go to be fair at Grenfell.
00:41:42 I would inevitably want to tell control because they are the other, you know, that we've got
00:41:52 a method of communication with residents on the fire ground, we're immediately there,
00:41:55 but the other line of communication to residents is via our control and in a situation where
00:42:00 you're dealing with a building that's not designed for a mass evacuation, doesn't have
00:42:03 any means of communicating on mass to residents readily or easily, that's not there in those
00:42:10 buildings.
00:42:11 You want to make sure all your communication is triangulated.
00:42:16 Yes, and what that speaks to, and this is something that comes out of what you've just
00:42:22 said, is that although Tony Biles in effect reversed the state put policy in ordering
00:42:29 the firefighters to clear the building, he didn't triangulate as you put it and comply
00:42:36 with policy 790, I think it is, to make sure the control room was kept in the loop.
00:42:42 I think that's a fair assessment of that.
00:42:45 On what we know to be fair to Tony, because obviously 790 does ask that you return information
00:42:52 in that loop.
00:42:53 And does that tell us that in this situation where the incident commander in 2015 decided
00:43:02 to brief his firefighters to, as he put it, clear the building, in other words, get everybody
00:43:09 out, this was idiosyncratic, done off his own bat, but not considering all of the methods
00:43:19 of communication and not considering the need to keep the control room in the loop.
00:43:23 And therefore that points to some defect in the training on evacuation.
00:43:28 Yes, to the last part of it, I think it points to the fact that we needed to train people
00:43:32 to operate in that space around emergency evacuation.
00:43:35 But what I think it also points to is some of my previous evidence around how a generation
00:43:40 of officers, and I would include Tony in this, he's a very experienced officer, many years
00:43:44 service, would absolutely not take state put as an article of faith.
00:43:48 Post-Lacknell would not have taken it as an article of faith because he would not have
00:43:51 arrived at that decision if he had taken state put as an article of faith.
00:43:56 And I know that myself and other colleagues would not have blindly adhered to that policy
00:44:03 if we thought the circumstances warranted the reversal of it.
00:44:08 I think what this speaks to is the fact that we unsupported Tony in the best possible way
00:44:12 by providing him with good guidance and advice as to what you might do if you arrived at
00:44:16 that decision, all the different kind of passage of information and the tactics you might employ.
00:44:22 Although I have to say what is described, and this is the first time I've read that
00:44:25 statement, is he has come very much to the right conclusions from my perspective as commissioner
00:44:32 about how you would employ breathing apparatus, for example, to conduct that evacuation.
00:44:36 His instincts are sound in that regard.
00:44:40 Given what he describes as his instruction to clear the building and the reasons for
00:44:47 doing so, would you accept that in fact Adair Tower was a reasonable example of an earlier
00:44:53 incident at which state put was reversed, earlier than Grenfell, that is to say?
00:44:58 Certainly in his instinct and intent, not carried out in a way as coherent perhaps as
00:45:04 we would want, but certainly presented a learning opportunity that if we had really recognised
00:45:10 that in the debrief process would have been useful, absolutely.
00:45:14 The second incident I want to ask you about is Sheppard's Court, and I know you're
00:45:17 familiar with that.
00:45:19 We have a witness statement from station manager Charlie Hanks who was at that incident and
00:45:25 I think was also in fact at Adair Tower as well.
00:45:30 He was station manager for Lambeth as it turns out at the time of the Sheppard's Court fire
00:45:35 and he acted as incident command in its early stages and it was he who gave the order at
00:45:40 Sheppard's Court to clear any flats in the direct line of travel of fire and to move
00:45:45 occupants to a place of safety.
00:45:48 I'll just give the reference for the record, it's LFB00032724 at page 4 paragraph 8.
00:45:57 On what I've told you and I appreciate it's quite limited Commissioner, in your categorisation
00:46:03 was that a partial evacuation or was it an emergency evacuation?
00:46:10 I would characterise it as an emergency evacuation because I think any form of evacuation that
00:46:15 occurs in a residential high-rise that has been built on the premise of stay put is an
00:46:22 emergency evacuation because you are carrying out an evacuation in a building that is simply
00:46:26 not designed for evacuation when an emergency occurs.
00:46:30 So it will by default be an emergency evacuation.
00:46:32 I would consider even the early evacuation of a high-rise residential block in London
00:46:39 at any point in an incident, even at the very earliest point of an incident to be an emergency
00:46:44 evacuation because there are dangers in carrying it out even in the absence of fire because
00:46:50 you are sometimes putting for example vulnerable people onto very tight stairwells.
00:46:55 You are sometimes doing that in the context of panic and fear if there is a smaller fire
00:46:59 somewhere in the building.
00:47:01 So I would still characterise that as an emergency evacuation and in this context it was a partial
00:47:06 emergency evacuation because to describe it otherwise is to somehow suggest that buildings
00:47:13 that are not designed for that purpose can somehow support the planned evacuation strategy
00:47:17 easily which they cannot.
00:47:19 Yes, so we can characterise the Sheppard's Court fire as an emergency partial evacuation.
00:47:28 Yes, partial emergency evacuation absolutely.
00:47:30 Yes, either way it is right to think that the Grenfell Tower fire was not the first
00:47:35 example of state put being reversed at an incident.
00:47:38 We have seen Edea and we have seen Sheppard's Court.
00:47:40 Both of those in their different ways were either a wholesale or a partial reversal of
00:47:45 state put.
00:47:47 I think if you present it in that way, yes.
00:47:49 I think what we refer to in the opening statement is the first explicitly recorded example of
00:47:55 where someone has taken the decision to say state put is not relevant here and required
00:48:00 all parties in that package of information to be informed.
00:48:03 But I think it is fair to characterise what you have just said as earlier reversals of
00:48:08 state put.
00:48:09 Yes, thank you.
00:48:16 So can one come to this conclusion that although partial or whole emergency evacuations or
00:48:26 building clearances are not, although they are rare, they are not usual, they are nonetheless
00:48:34 a feature of High Rise incident command from time to time in London and had been for some
00:48:42 years before Grenfell.
00:48:43 Yes, I think that is a fair characterisation and I think it is why it is referred to, although
00:48:48 not in enough detail and not with the training to support it, in the policies of the time
00:48:52 that it asks incident commanders to consider the possibility of evacuation.
00:48:58 Yes.
00:49:04 And would you agree, moving on to that last answer, that after February 2014 when GRA 3.2
00:49:11 in its latest edition, or later edition, was published, it was unacceptable that LFP policy
00:49:19 and training continued not to address how and when to reverse state put and proceed
00:49:26 to some kind of evacuation or rescue and specifically not to prepare incident commanders to carry
00:49:32 out an evacuation of a residential High Rise block in the face of rapid and unexplained
00:49:38 external fire spread in particular?
00:49:39 Yes, it is not an omission I could justify.
00:49:42 No.
00:49:43 Can you help in explaining it though?
00:49:46 Why there was that omission?
00:49:49 I am afraid I cannot because I think that omission is clear and to me is hard to justify.
00:49:57 So I cannot explain to you why that would happen.
00:50:00 Again, I was not part of the process to write or define the policy and certainly in light
00:50:07 of all the evidence that has been passed to this inquiry, it is hard to understand why
00:50:11 that omission was made.
00:50:14 One of the reasons given in your written opening statement at Module 5 to the inquiry is the
00:50:20 absence of any national guidance on how to manage or run a full or partial emergency
00:50:28 evacuation of a High Rise block.
00:50:31 That is also correct and actually until we brought into place the very detailed policy
00:50:35 we have now in London, that is still the case.
00:50:39 And of course I have noted previously that we have had a government working party who
00:50:43 I know are sitting and considering these matters who still have not been able to come
00:50:47 to matters of guidance in respect to this because of the difficulties around it.
00:50:52 But given, as you told us this morning, the way London is different, particularly in relation
00:50:57 to its population of High Rise buildings, the absence of any national guidance on how
00:51:01 to manage the full or partial evacuation of a High Rise building is not much of an excuse,
00:51:07 is it?
00:51:08 I would not see it as justification.
00:51:09 We have to hold our own responsibilities here.
00:51:10 I am very clear that as the London Fire Commissioner, regardless of national guidance which should
00:51:16 be in place and should be there, available to me, regardless of whether that was there
00:51:21 or not, we have a responsibility to the residents of London, laid down in legislation in the
00:51:27 form of the Fire and Rescue Services Act, to deliver our duties into those communities.
00:51:32 And I fully accept we hold that responsibility ourselves.
00:51:37 Yes.
00:51:38 And it sounds, forgive the glibness of the question, but it sounds as if the Brigade
00:51:43 simply overlooked the gap in policy and training despite the clear direction in GRA 3.2.
00:51:50 Potentially, I really couldn't speak to the detail of that, I am afraid, because I wasn't
00:51:53 involved in the process, but I can think that is the only possible reason for it, really.
00:52:00 And now in your written openings for this module, you have referred to steps taken following
00:52:05 the Grenfell Tower Fire in relation to the development of a new premises evacuation
00:52:10 and rescue policy.
00:52:12 First, do you agree that what you are doing now is what ought to have been done in response
00:52:17 to GRA 3.2 back in 2014?
00:52:21 Something similar to what we are doing now, yes.
00:52:22 I mean, what I would say is that much of what we are doing now builds on the learning since
00:52:27 Grenfell as well, because Grenfell has further developed our understanding of that risk and
00:52:31 the extremity to which it might occur.
00:52:35 In the context of what was known then, something similar based on the learning from Lackawnail
00:52:40 and what was known in other parts of the Brigade, yes.
00:52:42 And so we come then to the question of training.
00:52:44 Can you just describe for us perhaps in a succinct way what it is now that the training
00:52:51 on how to go about an evacuation of a residential high-rise block and when to start thinking
00:52:56 about it contains?
00:52:59 So it begins first of all with a theory package, which is about three hours long.
00:53:03 So it talks about all the different considerations you might make, but that is delivered across
00:53:08 three policies actually, because again, if we go back to the example of Tony Biles, it
00:53:11 is very important that in the minds of my firefighters and officers, they do not see
00:53:17 emergency evacuation, rescue, fire survival guidance or high-rise firefighting as separate
00:53:23 subjects.
00:53:24 They are all one and the same.
00:53:25 So whilst there are three policies that address the different issues, they are delivered as
00:53:29 a complete package, a whole package.
00:53:31 So they are asked to consider all the different factors that might take you from emergency
00:53:35 evacuation into mass rescue, how you might reasonably orchestrate an emergency evacuation,
00:53:44 recognising the difficulties.
00:53:45 That is the theory package.
00:53:46 Then there is a day of face-to-face training where they get the ability to discuss that
00:53:51 and their anxieties about it, because my experience of having gone and witnessed one of those
00:53:56 training days is that there is real anxiety amongst the operational workforce as to how
00:54:01 they might effectively carry this out.
00:54:03 So there is then debate, there is examples of operational incidents where you might have
00:54:11 delivered it.
00:54:12 I think we have built new providence wharf now into the latest evolution of that training.
00:54:17 And then what we do from theory to a day of face-to-face discussion is we are now beginning
00:54:23 to validate that in high-rise exercises, so taking it into the real physical environment
00:54:28 and having a go at it.
00:54:29 And I expect that cycle to continue and be built further in an urban firefighting course
00:54:34 which we will deliver in due course once we have commissioned it properly and found the
00:54:39 right location for it.
00:54:48 And is there station-based training that is delivered to station-based staff such as crew
00:54:54 managers and watch managers?
00:54:56 So we put all crew and watch managers through face-to-face training delivered by senior
00:55:04 officers who have been trained themselves to deliver the package.
00:55:07 So that was the acquisition training.
00:55:09 Obviously every single frontline firefighter and officer is involved in the exercise programme.
00:55:14 And then as part of maintenance of competency, those packages are now built into the, I'm
00:55:19 sorry, it's another acronym, a DAMOP process.
00:55:22 So it's built into the cycle of refresher training.
00:55:25 But I think we will, again, recognising the challenge from both the inspectorate, the
00:55:30 inquiry and what we have learnt ourselves, we will be coming back to how we sustain that
00:55:34 knowledge.
00:55:36 What is the interval of effectively repeating acquisition training face-to-face?
00:55:40 When do we need to do that again?
00:55:42 I think we'll probably meet the challenge of that in the urban firefighting course because
00:55:46 that we anticipate being approximately a week long, we'll train firefighters in firefighting
00:55:52 in lots of different complex environments, including high-rise on the basis of complex
00:55:58 carbonaceous burns.
00:55:59 And that will be something they get like their repeated validation of driving, like our instant
00:56:04 commanders now get their repeated validation of instant command.
00:56:07 That's what we're working towards.
00:56:09 You're working towards that.
00:56:10 Can you give Londoners any assurance as to when that might be rolled out?
00:56:13 I think we're looking about a year to 18 months from now.
00:56:15 And the reason I say that is about the capacity of colleagues to receive it as well.
00:56:19 So we are also on the brink of delivering a very considerable training package in respect
00:56:25 to counter-terrorism, which is equally important in the context of a threat that London faces.
00:56:31 So I think I'm content with where we are at the moment in terms of high-rise firefighting
00:56:36 and the refresher training in respect to firefighting generally.
00:56:41 I think it needs to be improved, but I want to deliver a very significant package around
00:56:46 counter-terrorism first, embed some of the knowledge around fire safety to a greater
00:56:50 degree as well, coming back round to that.
00:56:53 And then I think that will give colleagues time to commission a really good course, find
00:56:57 a good location for it, and secure the resources to deliver it.
00:57:00 So I think we'll commence that process, I hope, in about 12 months' time.
00:57:04 Right.
00:57:05 Can you just give us a sense of how you work out your priorities between counter-terrorism
00:57:09 on the one hand and the risk of tall building fires requiring evacuation on the other?
00:57:15 Well, it's quite a difficult challenge because they're both very significant risks and actually
00:57:20 equally important.
00:57:22 So my answer would be that we have to train against both, and it's about the level of
00:57:26 training we dedicate in any one period of time to both.
00:57:31 So we balance that risk continuously.
00:57:33 It's our assessment, and really what we're doing with counter-terrorism is a repeat of
00:57:37 what we've done with high-rise.
00:57:38 At the moment, I think we exist in an absence of what I would consider to be sufficient
00:57:42 training around counter-terrorism.
00:57:44 We give our crews the most basic form of knowledge around it, so it is there.
00:57:48 But I think we need to go out and do what we did with high-rise, which is a really condensed
00:57:54 programme of education to watches over the next year or so, depending on some other decisions
00:58:00 in the industrial relations environment.
00:58:03 So we have to get to the right standard in terms of what I would consider to be base
00:58:14 maintenance and good skills.
00:58:18 And then that will enable us, I think, to come back to other priorities which we need
00:58:23 to then explore in depth.
00:58:24 And I think this is something I would see continuing forever.
00:58:27 I think that's how good organisations manage their training.
00:58:30 So if you look at the military or policing, for example, they will rotate and balance
00:58:38 their training in respect to risk over periods of time, because it's simply not possible
00:58:43 to give everyone all the training immediately, particularly where you're looking at the
00:58:48 scale of improvement, I think, the inspection report in this inquiry laid out in front of
00:58:54 the London Fire Brigade.
00:58:55 Thank you.
00:58:56 Now, I'd like to turn to a completely different topic.
00:59:00 First Minister, I wonder how you're getting on and whether it would be convenient to have
00:59:03 a break slightly earlier than usual this afternoon.
00:59:06 Yes, not inconvenient.
00:59:08 I can tell you, Mr Chairman, I have about 40 minutes left of questions.
00:59:14 If we take a break now, then we can look over the notes and see if there are any further
00:59:20 questions.
00:59:21 Yes, I wasn't seeking to rush you.
00:59:23 I just thought that this might be a convenient moment.
00:59:25 Yes, very well.
00:59:26 Well, it's a bit earlier than usual.
00:59:29 Commissioner, but I think it's time we had a break and we'll stop now.
00:59:33 We'll resume, please, at 3.15.
00:59:35 Thank you, Chair.
00:59:36 All right.
00:59:37 Thank you very much.
00:59:38 Thank you.
00:59:39 Would you like to go with the usher, please?
00:59:47 Thank you, Mr. Bate.
00:59:48 3.15, please.
00:59:49 Thank you.
00:59:58 Thank you.
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01:14:28 Would you ask Mr. Ray to come back in, please?
01:14:48 Thank you.
01:14:49 Thank you.
01:14:59 All right, Mr. Ray.
01:15:00 Ready to carry on now.
01:15:01 Thank you.
01:15:02 Thank you very much.
01:15:03 Yes, Mr. Chairman.
01:15:04 Commissioner, I'd like to ask you now about brigade control.
01:15:09 To start, I'd like to take you to AC Jonathan Smith's briefing note, which he drafted for
01:15:13 you and AC Tom George in July 2019.
01:15:17 That is at LFB 00084097.
01:15:25 There's the first page of it, the date, the subject, who it's for and the author.
01:15:30 And if you please go to the executive summary at the bottom of page one, you can see that
01:15:38 he says, on a day-to-day basis, the control function within LFB mobilises resources, organises
01:15:43 and manages strategic fire cover and provides a vital communications link with the public
01:15:48 and partners' agencies.
01:15:49 Indeed, response times are coming down and control are a key driver behind that achievement.
01:15:53 However, the business' usual successes mask a department in need of significant and sustained
01:16:00 reform.
01:16:01 A number of its core functions, including training, policy development and assurance,
01:16:05 sit outside of the jurisdiction and oversight of the corporate centre.
01:16:09 When the system is placed under stress, the foundations are not there.
01:16:12 Let me turn the page.
01:16:14 The foundations are not there.
01:16:19 This means the LFB cannot be assured that key areas, particularly training and core
01:16:23 handling, are being delivered to an acceptable standard.
01:16:28 In addition, there have been a number of reviews, reports, briefings and findings from operational
01:16:33 incidents that have identified significant areas for improvement and, to date, progress
01:16:38 against a number of these key recommendations has been inconsistent.
01:16:43 There is a discernible sense of decision inertia amongst the leadership team at the London
01:16:48 operations centre, LOC.
01:16:50 Lack of direction, coordination and a visible presence have been notable themes brought
01:16:54 to my attention.
01:16:56 Now, you obviously received that report.
01:16:59 I did indeed.
01:17:00 In 2019.
01:17:01 That was before you were appointed commissioner.
01:17:04 It was.
01:17:05 It was in the process.
01:17:06 I, at that point, had been notified that I had been successfully appointed to the role
01:17:10 of deputy commissioner.
01:17:11 Tom George was the existing deputy commissioner at that point, director of operations.
01:17:20 It was part of the kind of journey to assume that role that I was made privy to this report.
01:17:28 When you read it, I'm assuming you did read it, did you ask the question that I'm going
01:17:35 to ask you now, which is why, despite the Lacknell House fire, the action plan, the
01:17:40 numerous reviews of control by Ned Kelly in August 2010, the MOPAC audit February 2015,
01:17:46 the Tom George review in July 2016 and February 2017, that the events that happened on the
01:17:52 night of Grenfell Tower happened as they did?
01:17:57 Yes.
01:17:58 And actually, particularly because I had visited control two days after the Grenfell Tower
01:18:04 fire.
01:18:05 And what I saw there was people who had held an incredible responsibility for the brigade
01:18:09 under the most tremendous pressure and appeared very vulnerable in that.
01:18:15 So I had a real interest in this and continue to do so.
01:18:18 Why is it that despite Lacknell, the action plan, the Kelly report, the MOPAC audit, the
01:18:24 George reviews, that even by July 2019, two years after the Grenfell Tower fire, the LFB
01:18:31 could not assure the public because it couldn't assure itself that training and call handling
01:18:36 were being delivered to an acceptable standard?
01:18:39 I think there's a number of reasons for it, which I think are highlighted in both Jonathan's
01:18:42 report and the subsequent control improvement plan that was brought to bear to control,
01:18:49 seeking to address multiple issues.
01:18:52 One was cultural, which was that for a long time, control had been seen as a separate
01:18:56 entity.
01:18:57 I can't explain to you why that was the case.
01:19:00 I genuinely can't.
01:19:01 But again, we have changed that.
01:19:04 integrated into a wider operational department now, led by an assistant commissioner, in
01:19:10 fact, John Smith.
01:19:11 We co-locate the staff of that department at the London Operations Centre so that operations
01:19:17 centre staff, control staff, aren't on their own out there.
01:19:21 They're with other staff from the London fire brigade and enjoy the benefit of the work
01:19:26 that either party is doing.
01:19:27 We have a command unit situated there now permanently to cross train.
01:19:33 Part of the issue was cultural, which was they were isolated for too long.
01:19:37 They were considered somehow separate.
01:19:41 I think it goes back to my general point that I've made a number of times over the past
01:19:46 couple of days around assurance about how we reassure ourselves of outcome.
01:19:49 I'm afraid I can't explain to you why control training was never integrated into the general
01:19:58 management and system of training.
01:20:01 But it was something that was immediately obvious to me.
01:20:03 And therefore, we have resolved that.
01:20:07 So I think the question why was definitely one I asked.
01:20:11 I think there's some of the answers that I came to myself.
01:20:15 And it's why the control improvement plan is so heavily focused on addressing all of
01:20:20 those different aspects, whether it's leadership, culture, even the layout of the room, the
01:20:25 technology available to them, the training and integration into the general organisation
01:20:31 and giving them a sense of pride that they are indeed, as I see them, the very front
01:20:37 line because they are invariably the first point of contact that people in a crisis have
01:20:42 with the London fire brigade.
01:20:48 Why were these issues still persisting?
01:20:51 I think this is the core question.
01:20:53 As late as mid 2019, even two years after Grenfell, given everything that had gone before
01:21:00 stretching back to July 2009.
01:21:04 Again, I think it's a similar answer to the one I've just given, which is we still perhaps
01:21:09 have not recognised the full scale of what we needed to do in terms of assurance, in
01:21:14 terms of change around training.
01:21:17 So I think they sit generally in the same place as much of the rest of the organisation,
01:21:21 which was we had not fully yet understood all of the issues that were arising from
01:21:27 Grenfell and perhaps prior.
01:21:30 And there was something around the culture and the leadership still, you know, is of
01:21:35 note to me that we have a different leadership model in control now and different leaders
01:21:41 there.
01:21:43 And that we have been explicit in what we expect our control operators to do and how
01:21:51 they should expect us to support them.
01:21:53 So I think it spoke to the process of change again.
01:22:00 Can you go to page seven in this document, please?
01:22:02 If you let the second paragraph
01:22:21 .
01:22:22 page. On that page. Can I ask you to go to a different document, which is the improvement
01:22:39 plan, in fact. LFB 00084092. This is AC Jonathan Smith's control improvement plan 2019-24.
01:22:51 And if you go please, first of all, have you seen this document before? Yes, I have. You have.
01:22:59 On more than one occasion. Right. And if you go to page seven in that, please, you will see on that page
01:23:06 underneath the bullet points, it says this. There is also the need for cultural change,
01:23:12 both within the London Operations Centre and across London Fire Brigade. The Control and
01:23:16 Mobilising Department is not a specialist add-on, but a fundamental component of our operational
01:23:21 response. There has been a perception that control is somehow different or distant from
01:23:24 the rest of the LFB, and this needs to change. Now, just pausing there, do you agree with
01:23:30 AC Smith's description of control being somehow different or distant from the rest of the LFB?
01:23:35 Yes, absolutely. That was how control had been perceived, and in effect,
01:23:41 it's self-perpetuating. It had been positioned, therefore, within the organisation for a period
01:23:46 of time. Yes, and indeed, Tom George, when he gave evidence, told us that the members of control
01:23:51 staff felt they were isolated from the rest of the brigade, didn't feel valued as an organisation,
01:23:56 or within the organisation. That was day 205, at page 17, lines 10 to 13. His explanation for that
01:24:03 when pressed was that it was an island unto itself, or a silo, if you like, and that was as a matter of,
01:24:12 essentially, geography, because since 2004, control had been based at its own premises with no
01:24:18 day-to-day contact with operational staff. That's the run-up to my question. Do you agree with that
01:24:24 description? I think it's part of the answer, yes. I think geographical separateness was one part,
01:24:30 which is why, of course, we've now brought other people into that environment. It's a really good
01:24:35 facility, secure, well-constructed, and we're making much wider use of it, both in training
01:24:42 and office space for people within the wider department that control is now subsumed into
01:24:48 to work from. So, actually, they don't feel isolated in that way, because there is a range of
01:24:53 professional skills and teams in that location. I think the fact that there have been repeated
01:25:00 moves of control, so that had happened over a number of years. We'd gone from Lambeth,
01:25:04 where they were at the heart of the organisation, literally, on the back of our old headquarters,
01:25:09 to a more remote location in the east of London, and then the change, again, to Merton, which is
01:25:17 a much better facility. But obviously, that level of repeated change will itself have had an effect.
01:25:23 Yes. But it's not just geography, is it? As you say, it's also cultural.
01:25:30 Yes, it is, because I think what the geographical separation did, to an extent, meant that
01:25:39 the officers in control were not exposed to the wider leadership of the brigade as frequently as
01:25:44 they should have been. I mean, I've visited control on many occasions now. I think it's very
01:25:50 important that they see themselves as part of the wider organisation. My assistant commissioner
01:25:55 works from control. Whilst he has a wider department to run, his primary location is there,
01:26:02 so that they understand that they are very much important to the brigade and are our
01:26:07 well, they are our primary interface with the public, generally.
01:26:14 Yes. Control, is it still based at Merton?
01:26:18 Yes, it is.
01:26:18 The LOC is still at Merton?
01:26:19 Yes.
01:26:20 So they've not geographically been moved towards the centre of the city?
01:26:24 No. We've moved more of the brigade to them, because the facility itself is first class.
01:26:30 It's a design built for purpose control room that is really, absolutely what we need in
01:26:37 a global city. What they needed was a feeling of being part of the rest of the organisation
01:26:42 and a recognition. I mean, it speaks to the policies around fire survival guidance,
01:26:47 high-rise and evacuation from my point of view. Although we've talked a lot about the training
01:26:51 of firefighters, you can include control staff in that, because I see the incident ground as
01:26:57 one that is both virtual and physical. And the virtual incident ground is the environment we
01:27:02 encounter in control, where decisions are also getting made. And therefore, the relevant parts
01:27:07 of that training has also been delivered to our control operating colleagues, because they need
01:27:12 to know what their colleagues on the front line are doing to inform their own decisions and recognise
01:27:18 the limitations of the advice they might need to provide.
01:27:21 If we go back to your briefing note, please, that's LFB3084097, page 11.
01:27:32 Under the diagram, what success will look like for the London Fire Brigade, it says this,
01:27:41 at the heart of this is the opportunity to make a step change, delivering a truly fresh start for
01:27:46 control and all the staff who work in the London Operations Centre. We need to ensure the LFC can
01:27:52 be assured that this risk-critical function is delivering a service fit for purpose and equipped
01:27:56 for the challenges ahead. This will require systemic and cultural change in order to ensure
01:28:01 improvement is real and embedded in the ethos of the department. There will also need to be a
01:28:08 fundamental reappraisal of the position of control within the broader LFB in order to ensure it has
01:28:14 quotes parity of esteem, close quotes, with the other component parts of emergency response.
01:28:20 Now, I'm interested in parity of esteem. Do you accept that at the time of this report in July 2019,
01:28:31 LFB's control didn't have parity of esteem with the other component parts of the LFB's emergency
01:28:36 response? Yes, I would accept that. I think that's how control operators experienced it,
01:28:42 and I know that because I've spoken to many of them at length. I think we still have some way to
01:28:47 go before we completely change the culture in control to really over time demonstrate that we
01:28:52 mean this and that they really are an integrated part of our frontline response. The plan
01:28:58 stretches over a period of years because we recognise the depth of what we needed to achieve
01:29:02 there would need to be attacked in the medium and the longer term. But I think Jonathan Smith is
01:29:10 accurate in terms of how people felt in control, even if actually so many officers like myself
01:29:16 held them in such great regard. I mean, gosh, I can't tell you how many instances I've had,
01:29:22 a very difficult instance as a senior officer where I've been so glad to hear
01:29:27 the calm voice of an experienced control operator and I've been well served by so many of my colleagues
01:29:32 in control over so many years. If there's something I could still get emotional about,
01:29:37 really emotional about in the context of the Grenfell Tower fire, there's probably two things.
01:29:41 One is the experience of sitting with the bereaved and survivors and hearing firsthand as I have
01:29:47 repeatedly their trauma, which is both humbling in the context of how they deliver it and their
01:29:52 dignity and their desire to find better outcomes. The second group of people who will take me to
01:29:58 that place are our control operators because on the night they were in a fallback location
01:30:04 without the support I would consider now right for them and they held such responsibility,
01:30:12 such a small group of people dealing with such an overwhelming volume of catastrophe that
01:30:18 the day I went and saw them, I actually couldn't speak. I walked into the lobby,
01:30:25 you know, and I'm quite a confident person, but I found myself unable to speak because it was this
01:30:30 small group of very, they looked very vulnerable to me. They were so shocked by what they'd experienced
01:30:35 and what they'd been asked to do. And it made me feel that we must do everything to ensure that
01:30:41 they didn't find themselves in that situation again and were able to best support people who
01:30:45 themselves, if we think to the bereaved and the survivors, were finding themselves in the most
01:30:49 terrible situation of their lives. And what are you now doing within the brigade in order to restore
01:30:58 or implement parity of esteem? Everything we can. So that runs from the small, so for encouraging
01:31:05 them to be part of our social media effort, actually having an output there which is led
01:31:10 informed by people in control, ensuring that stations visit control and have an awareness
01:31:16 of what they do. You know, the integration I've talked about already at a corporate level,
01:31:20 ensuring people actually work in control who are not just control. We've radically altered
01:31:25 the training, but we will need to continue to improve. We are considering changes to the shift
01:31:31 system and then, you know, advanced consultation with the representative bodies to do that, to
01:31:36 ensure that they always have the resources they need at the right time. So I think we're looking
01:31:42 at every single level from both the strategic and overarching to the tactical, the smaller actions
01:31:48 that demonstrate we actually have an interest and we care. Now we heard from AC George, Tom George,
01:31:54 that control staff felt isolated because systems such as STARS and the STEP system weren't developed
01:31:59 and adopted by control as a means of allowing them to plan their training systematically and
01:32:08 record their training systematically. We got a lot of that from him. Can you explain why the systems
01:32:15 developed for the operational side of the LFB were not also developed in parity for the control side?
01:32:21 No, I can't explain it, but it does explain why they are now fully integrated into that system.
01:32:26 So station diaries are available to them. They are integrated into DAMOP because they are, as far
01:32:30 as I'm concerned, part of the operational response of the London Fire Brigade and therefore both
01:32:35 deserve and need to be part of the assurance that that system brings. I mean the issue of recording
01:32:40 and planning training was an issue raised in station manager Kelly, or Ned Kelly as he was
01:32:44 known, his audit in August 2010, again in the MOPAC audit in February 2015 and in AC George's
01:32:52 review in July 2016 and again in February 2017 as the update to that. Can you explain why that
01:33:00 issue, the issue of recording and planning training, was allowed to persist for so long
01:33:05 to control's detriment? I really can't. I mean my only, and it really is just an estimation,
01:33:13 is that it must have related to not escalating that concern because personally I think if you're
01:33:19 sitting in my position and you hear that training hasn't been systemically recorded and delivered
01:33:29 in what is a fundamental part of our operation, you would have very great concern about it and
01:33:34 you would seek to do something to change that. Yes, I mean, and if you knew this, but from January
01:33:39 2015 when Joanne Smith came back from her CFOA secondment, the means by which Brigade Control
01:33:47 planned its training offering to staff was by using a wall calendar. I mean what does that tell
01:33:53 you about the systems available to control staff? It tells me we were expecting control staff to
01:34:01 deliver training without the systems to properly support them and people like Joanne and others
01:34:05 would have been up against it because we hadn't integrated them into what was already a well
01:34:10 developed system that would have enabled that planning and recording of training
01:34:14 and with some thought as we've demonstrated now could have integrated
01:34:19 control training into it because that's what we've done.
01:34:23 And why was that system allowed to fester? I can only see it as a function of culture and
01:34:30 leadership because someone would have been aware of that. You've made it clear that there was a
01:34:34 review in, I think you said 2010 was it, at the earliest instance? Yes, August 2010. And then there
01:34:40 was a review in 2015? There was a MOPAC review conducted by the Mayor's Office. So all I can think
01:34:49 is that that's about a decision taken at a point of leadership because clearly there were people
01:34:55 who were seeking to make that known. That's obvious in the documents I've seen even today
01:35:01 and therefore it's about a leadership decision to devote the time and resources to address it.
01:35:10 Now can we go back please to page three in this document? This is AC Jonathan Smith's briefing note
01:35:17 to you and Tom George of the 22nd of July 2019 and if we go to page three at the foot of the page
01:35:24 there's a heading Training Assurance and Professional Development and it says the
01:35:28 current provision of training assurance and professional development requires a complete
01:35:33 and systematic overhaul. Training is ad hoc and lacking in structure. There is no system for
01:35:38 quality assurance and the recording of training is inconsistent. The operational support team,
01:35:43 OST, who are providing training packages on risk critical subject areas are doing so against a
01:35:49 backdrop, turn the page, turn the page to page four please, are doing so against a backdrop,
01:36:02 I can see at the top of the page, are doing so against a backdrop of competing demands on their
01:36:06 time and outside of any substantive training plan. They are also responsible for delivering
01:36:11 the nine-week initial recruits training course and although the syllabus looks fit for purpose
01:36:16 it is not subjected to any external scrutiny or quality assurance. Now that's 2019. What I want
01:36:25 to show you before I come to a question is something earlier. Can we go to LFB 404724 please?
01:36:37 This is the main report on the role and actions of LFB control
01:36:44 at Lacknell and it's dated November 2012. It was prepared for the coroner
01:36:52 at Lacknell at the inquest which started in the January of 2013 and if we go to page 31
01:36:59 in this document, Commissioner, we will see at paragraph 167 the following.
01:37:07 Second paragraph down under the heading conclusion about LFB control officer training and knowledge.
01:37:14 167 an incomplete database record of training provided by the LFB to COs exists covering the
01:37:20 period from 1981 to 2011. This record includes initial continuation and refresher training given
01:37:27 to COs. Then at 168, FSG is only provided infrequently. Between 2005 and 2009, 77 notable
01:37:38 FSG calls have been identified. Of these there was one call with recorded fatalities, two,
01:37:44 where FSG had been given. Parag 169, although the available training records are considered to be
01:37:50 incomplete, there is evidence from staff that all COs received FSG training when it was introduced
01:37:56 in 1994 and those who joined after 1994 received FSG training as part of their initial control
01:38:02 training. In 2009, there was no structured regular FSG continuation straight refresher training
01:38:09 and then at 170. Whilst systems are in place to monitor performance within control,
01:38:14 improvements could be considered to further develop means to inform and influence performance
01:38:18 management. Now, would you agree that looking at the comments and conclusions made in the
01:38:28 control report by the LFB in respect of the Lacknell House incident about FSG refresher training,
01:38:35 those conclusions appear to be very similar to the criticisms made by AC Smith in 2019?
01:38:41 Yes, I would accept that. Do you know why it is that in a period of 25 years from 1994 when
01:38:49 Fire Service Circular 1093 was introduced to AC Smith's report in July 2019, the LFB could not
01:38:57 get to grips with ensuring that FSG refresher training in control was planned, structured,
01:39:02 recorded, monitored and quality assured? I can't provide any specific reason for that,
01:39:09 particularly in the context of that period of time. I think I would go back to where I
01:39:12 perhaps started my evidence to the inquiry yesterday, which is from my own perspective,
01:39:17 rising through the ranks of the London Fire Brigade. I had seen a gradual erosion over time
01:39:22 of professional standards, assurance of training and the competency that then arose from that.
01:39:33 Do you know why the training issues identified in the control report and indeed the Lacknell
01:39:39 actions and the reviews of control between 2010 and 2017 be remedied, not least because they were
01:39:45 identified to some extent in the Lacknell control report of 2012 that we are looking at?
01:39:50 Apologies, Mr. Millett. Are you asking whether I understand why between the period post-Lacknell
01:39:58 and 2017, despite the evidence presented here, we didn't make the improvements required?
01:40:05 Yes.
01:40:05 No, I'm afraid I can't speak to that. I think again it falls into a combination of,
01:40:11 my estimation looking back, and we have looked back, but my general understanding would be that
01:40:16 you could look at it both in the specific issues that relate to control, i.e. that feeling of
01:40:20 isolation, i.e. of being both geographically and conceptually separate from the rest of the
01:40:25 gates, so being allowed to do their own thing without a great deal of oversight.
01:40:31 And then I think the general point I've made around assurance and training and the need to
01:40:37 take a different approach to that. On the question of oversight, we heard from Scott Hayward,
01:40:45 who was the POM at the time of, at the time as we were looking at, that the management of control
01:40:55 was governed by a principle called reporting by exception, which appears to mean that he would
01:41:02 delegate work to his SOMs to do and would assume that what he asked them to do was done and done
01:41:09 properly unless he was told otherwise. That is effectively what he told us as his system,
01:41:14 and Danny Cotton also told us that the same system operated in respect to development of T-caps on
01:41:19 training on incident command. Is that a style of management that you recognise as prevalent
01:41:25 historically within the LFB, reporting by exception?
01:41:28 Yes, I wouldn't say it was prevalent. It depended who you worked for. I've certainly worked for
01:41:34 managers in the London Fire Brigade who had a great deal of grip on the detail of what they
01:41:39 were being asked to deliver and actually would seek to assure themselves that you had delivered
01:41:44 it by regular contact, face-to-face meetings and examination of whether you delivered an outcome.
01:41:49 So my experience is that it's mixed. There were certainly people who did not take enough
01:41:54 interest in assuring that the quality of the outcomes they were responsible for as managers,
01:42:01 but I've equally been managed by people who had an absolute regard to this and held me very tightly
01:42:07 to delivery actually at times. So I'm not sure it's prevalent, but it certainly existed in places
01:42:13 because I've experienced it myself and it's why there's such a focus on, I think, educating people
01:42:18 as to what assurance means. Because to be fair to a generation of leaders in the LFB, I'm not sure
01:42:24 we ever sat with them and really explained what assurance means. People think they know what
01:42:28 assurance means. They quite often really mean reassurance rather than actual assurance, which is
01:42:34 having a look at whether you got the outcome and if you haven't, working backwards to understand
01:42:39 where there might have been a fault line in the process to get to that delivery.
01:42:44 And yes, empowering people to deliver, trusting them to deliver, but not delegating the understanding
01:42:52 of that in entirety, going back to them. Your primary role as a leader is to go back and say,
01:42:56 have you got the outcome? Show me evidence of it. And also bringing other levels of assurance to
01:43:01 bear into that picture as well so that we're sense checking all the time. So I think it goes back to
01:43:06 that general point around assurance, which is a misunderstanding about what assurance actually is.
01:43:11 I take it from what you just told us, that you consider reporting by exception as an
01:43:16 unacceptable approach to line management. I think there is a place for reporting by
01:43:24 exception. For example, if you're dealing with a massive complex data where really you don't want
01:43:30 such an obsession with detail, because I've seen that as well in the brigade, where there is such
01:43:34 an obsession with layers of detail that you almost miss the wood for the trees. Sometimes you do need
01:43:39 people to report by exception and they need to alert you by exception actually where something
01:43:44 is going wrong. So actually I would say management by exception is also important, but what you need
01:43:48 to do is breed a confidence in your leaders that when you say exception, it means that they are
01:43:53 wholly honest about where things aren't quite working right. Because my understanding of
01:43:58 exception is when things aren't operating as they should be and need to be brought to the attention
01:44:03 of leaders with the utmost urgency. Would you have expected the deficiencies in line management
01:44:09 within control to have been identified and addressed by senior officers with responsibility
01:44:13 for brigade control? Yes, because that would clearly be within their remit. And so are you
01:44:20 able to explain how it was that managers who were seemingly not held accountable for brigade
01:44:26 control's failure to implement the reforms and remedy the defects identified variously in the
01:44:30 Kelly report August 2010, the MOPAC report February 2015, the lack of all pre-enquest actions
01:44:39 and AC George in 2016? I think it goes back to my general point around assurances, which is you
01:44:47 should never rely on a single line of line management assurance, particularly not in the
01:44:52 critical part of an emergency services operation. Because it's not that people aren't well intended,
01:44:57 it's sometimes about individual skill levels, a culture that might exist within just one part
01:45:02 of an organization, never mind the whole organization. You could find, like with control,
01:45:06 a fairly unique subculture that if it wasn't getting assured from a separate line of inquiry,
01:45:13 actually all the risk lies in a single line of escalation. So I think part of that would have
01:45:18 been that we were at times working within a siloed framework. And if you haven't got people who are
01:45:25 able to step back and take an objective view of what you're doing, sometimes even good people
01:45:30 can carry on making mistakes because of culture, because of an orthodoxy, whatever it might be.
01:45:38 So my view on that would probably, it probably speaks to the vulnerability of a single line of
01:45:43 escalation and a single line of assurance. On the question of training now in control,
01:45:51 are you able to tell us something of how you've managed to deal with
01:45:56 railing out training to control room staff, particularly for FSG refresher training,
01:46:02 given the shift system? It's systemized, it's recorded. There is a system in place.
01:46:07 We would like to change the shift system to make that easier because there are challenges around
01:46:13 the short shift. But even within the constraints of the current shift system, we have put extra
01:46:21 resources in place. We spent money on overtime if we've had to, to ensure people were available
01:46:27 for training because training is that vital to the good operation of a control room. So
01:46:31 we've worked within the constraints of the existing shift system, but we would like to get to a four
01:46:36 shift system at some point. And we're very well advanced in the consultation process to do that.
01:46:42 So I think it would be better for control operators, our ability to train them and the
01:46:46 numbers of control staff we have available in any one shift to deal with the sort of
01:46:51 critical incident. And we heard from Joanne Smith that one of the problems with training
01:46:56 control room staff is that you had to do it during the short shift, the four hour short shift,
01:47:00 or the overlap. And they would be taken into a training room and the bell might go down and
01:47:06 you might have to deal with an incident. So they'd be interrupted and then you'd have to reschedule
01:47:11 it. Has that problem been addressed by you? It has been addressed, but we would like to address
01:47:16 more completely by changing the shift system to address it. So we've addressed it really
01:47:21 in the interim by making sure people are available for training in a way that means they are less
01:47:25 likely to be disturbed, i.e. bringing them in to train them, taking them off the shift if necessary,
01:47:31 judicious use of overtime, or accepting that if there is that constraint, what you can't do is
01:47:38 tick the box to say you've completely trained someone if that training session is interrupted.
01:47:42 This is the same on fire stations. Much training gets interrupted on fire stations because so much
01:47:47 is delivered whilst you're on duty as well. But because we've now got a systemic way of
01:47:54 recording what training you have and haven't done, the message I would give to any of my
01:47:58 firefighters or crew managers, officers on a watch, is that if you haven't completed something,
01:48:06 don't say you have. It's entirely reasonable that in the passage of a day where you get
01:48:11 interrupted you might not have done. And we will need to be sighted on that and then we will come
01:48:15 back to it because we have got the systemic way of recording it now. It's the same in control as
01:48:20 it is on a fire station. Now I want to ask you about GRA 3.2 in the context of control.
01:48:27 Are you familiar with the text of GRA 3.2 so far as it relates to control? If not, I can tell you.
01:48:33 Not in complete detail. I've read the GRA on more than one occasion in preparation, but I wouldn't
01:48:39 be able to remember the exact word. Right. Let's just have up on the screen then. LFB
01:48:44 quadruple zero one two five five. I'll show you the first page of the document. There it is.
01:48:52 This is the February 2014 edition, Fighting Fires in High-rise Buildings. And if we get to page 20
01:48:58 in that document, in the second paragraph it says, fire and rescue authorities must also have
01:49:05 effective arrangements in place to handle fire survival guidance calls from residents and others
01:49:10 when they believe they are unable to leave the building due to disability,
01:49:13 poor mobility, illness or the effects of fire. Now clearly that relates to policy and practice
01:49:22 in control, doesn't it? It does and the advice that you're going to provide. Yes. Now we heard
01:49:27 both from Scott Hayward and Joanne Smith that they had never seen GRA 3.2 even as a document
01:49:36 until this inquiry, until they gave evidence in phase one and so far as Scott Hayward is concerned,
01:49:43 phase two. Now are you able to explain from what you now know as Commissioner how it was
01:49:51 that GRA 3.2 completely bypassed those responsible for amending policy and implementing
01:49:58 training in control, particularly on FSG? I can't speak to the specifics but I think it speaks to
01:50:02 the isolation of control and in fact I was struck by another bit of evidence offered in the inquiry
01:50:06 by Pat Hutting that in the formulation of policy note 790, which is the fire survival guidance
01:50:13 policy, he had not spoken to control in the formulation of that policy at that time. That
01:50:18 struck me as being significant because again I think it speaks to the isolation of control. So
01:50:23 whether you speak to the national GRA or the formulation of our own policy, I do not believe
01:50:29 it is acceptable nor would I seek to justify the fact that colleagues in control in senior
01:50:34 leadership positions have not seen this, were not availed of this. Now I just want to ask you one
01:50:41 or two questions about control policy. We heard evidence that when policy 539, emergency call
01:50:47 management, was amended in September 2010. The question that specifically prompted the control
01:50:53 room officer to ask the caller if they had any disability that might affect them or might hinder
01:50:59 their escape or their ability to protect themselves was removed. We've also heard that national
01:51:06 guidance FSC 5404, which specifically prompted the control room officer to assess the caller's age
01:51:13 and mental and physical disabilities, was deliberately excluded from incorporation into
01:51:19 LFB policy. That's what we've heard. Now as commissioner, have you undertaken any review
01:51:26 to find out why it was deliberately decided that LFB fire survival guidance policy should not follow
01:51:34 extant national guidance on assessing the caller which had been in place since 1994?
01:51:40 Not to the extent that I'm focused on that one particular item of detail, but it is certainly
01:51:47 explicit in the work that Jonathan Smith has undertaken where we are now
01:51:51 embedded at every level in the national planning process around. So we're in all the working
01:51:57 parties around NFCC development of control policy practice and guidance and they will have returned
01:52:05 to that question. Indeed, I know this is a live question because we are thinking about it in the
01:52:10 context of personal evacuation plans and personal rescue plans currently and the advice that people
01:52:18 might be provided with and what both our crews and control operators might need to do. This is
01:52:22 a difficult area, but it is certainly one we are coming back to and addressing.
01:52:27 Yes, but my question was really one of backward looking rather than forward looking.
01:52:36 Have you undertaken an internal investigation to find out why this question of assessing the
01:52:43 caller particularly for disability or any vulnerability that might affect their escape
01:52:50 was deliberately excluded from emergency call management policy?
01:52:53 We haven't undertaken a specific investigation in that regard. I would put it into the context of
01:52:58 us having gone back over every single piece of learning as it emerges from this inquiry,
01:53:05 all of the recommendations laid against us were unpicked to an extent how we got there. But again,
01:53:10 I think I do need to draw note to the scope of that improvement required. It is a very significant
01:53:18 undertaking. I don't believe we have taken a specific investigatory approach to this area,
01:53:24 which I fully accept should not have occurred. I think we are more focused on how we drive
01:53:29 progress against such a wide range of recommendations covering almost every
01:53:34 area of business of the London Fire Brigade. On the question of vulnerable individuals,
01:53:41 are you implementing a strategy or policy whereby station-based staff can collect
01:53:51 accurate and up-to-date information from building owners about vulnerable persons in high-risk
01:53:58 buildings? We are discussing that with central government now about the most practical way to
01:54:03 achieve that across thousands of buildings in London. I am certain that one of the things I
01:54:08 want my firefighters to know is where vulnerable people are in a residential setting, particularly
01:54:15 in a high-rise setting. Where the responsibility for that lies and the curation of that data is
01:54:20 very important because we don't have easy access to it. It will be held across multiple sources
01:54:25 of information, local authorities, care providers, the NHS. There are rules around the passage of
01:54:30 that data in the context of GPDR, the risk you expose vulnerable people to if there is easy
01:54:37 access to it. I believe that responsibility lies with the building owners. My preference
01:54:43 is that we see an encoded form of that information in a premises information box. I think the
01:54:50 practical reality of passing that level of constantly changing electronic data to a
01:54:55 fire and rescue service makes the challenge of managing it extremely difficult. I am very clear
01:55:02 that we do want that information because if we go back to the discussion we had earlier around
01:55:08 emergency evacuation, that is information you really do want as an incident commander. At the
01:55:13 point you take that decision and consider how you might affect either rescue of those individuals
01:55:18 or protection of them in the context of a developing incident. We also heard in evidence
01:55:25 that those responsible in control for amending policy 539, the RIFs and also creating FSG training,
01:55:34 particularly refresher training, never incorporated the warning which was embedded in paragraph 2 of
01:55:40 the 1993 Chief Officer letter, the fire circular, FSC 1093, that the normal procedure of calming the
01:55:50 caller may not be appropriate and may even be dangerous in some circumstances. That is what
01:55:55 we have heard. Again, as Commissioner, have you undertaken any review or investigation to find out
01:56:00 why it was that extant national guidance was not incorporated into domestic policy and practice in
01:56:06 the LFB within control? I think it falls again into the same kind of answer that I have given around
01:56:13 the omission from our high rise firefighting policy from detail that was in the national GRA.
01:56:21 I fully accept it is not acceptable. I cannot entirely articulate why it has happened,
01:56:28 but I have to be cognizant that the very resources I would send to investigate
01:56:32 the absolute detail of why this occurred are also the people who are most likely to have to be taking
01:56:37 work forward. There is a balance about you are absolutely right to suggest we need to investigate
01:56:42 and understand the past. Please do not think I am challenging that instinct. I think it is
01:56:51 really important to unpick why things have gone wrong to understand how you are not going to get
01:56:55 them wrong again. There is something about the scale of the challenge we are facing.
01:57:02 If we think about the range of subjects we have talked about over the past two days,
01:57:06 if we were to investigate every single occurrence of where either a piece of national policy had
01:57:12 not been brought into LFB policy or where there is an issue of individual decision making,
01:57:20 potentially, probably from personnel who may even now be retired, I think we would
01:57:27 not always have the capacity to move forward. So, whilst I would not seek to justify the fact
01:57:32 that we have not investigated every occurrence, I think we do have to pick and choose where we go
01:57:39 with understanding. For me, it is enough that this is unacceptable. We cannot let it happen again.
01:57:44 We have to make that message very clear to our colleagues that regardless of the reasons of why
01:57:50 we admitted this, actually, you all need to have due regard to national guidance. If you do not
01:57:56 agree with it, you need to tell us and escalate it. Then we can have the conversation in the
01:58:01 appropriate places at the national level to either get that guidance amended or accept that London
01:58:08 is going to take on that policy because there is good rationale and evidence behind it,
01:58:12 beyond the understanding of the boundaries of the London Farbricade. So, I think there is something
01:58:16 in a general acceptance that we needed to do better in recognising the value of national guidance
01:58:25 and then seeing it replicated where appropriate in London policies, procedures and training.
01:58:33 Now, you talk of picking and choosing. This one I have picked and chosen because this one
01:58:39 makes the difference between life and death. Can we look at the lack of
01:58:43 assurance control report, please, from November 2012, LFB 40724, page 50, paragraph 293.
01:58:52 Let us read it together. This is again part of the conclusions and the heading,
01:59:03 Expectations that callers would be rescued and state put advice. I will read it all to you.
01:59:08 COs had a clear expectation that fire crews would reach the callers quickly. Their experience was
01:59:13 that fire appliances arrive quickly and that people are rescued by the brigade. This is borne out by
01:59:17 the fact that only rarely where FSG is given do people die in fires, C section E3. As rescues by
01:59:24 crews were not immediate, there is a question whether the CO and or callers could have assessed
01:59:28 the risk of attempting to escape from the flat and whether the risk of moving closer to the fire but
01:59:32 escaping was less than staying put and awaiting rescue. COs relied on advising callers to stay put,
01:59:38 expecting that this would keep callers safe from fire.
01:59:41 As we know from earlier evidence, policy 539, the rifts and the training documents were never
01:59:47 amended after lateral in order to instruct CROs clearly not to give assurances to callers unless
01:59:56 they were based on solid verified information. But we also know that on the night of the Grenfell
02:00:04 Tower fire, the same reassurances were given to callers. The callers were not given any
02:00:11 are you able to explain as you sit there today why that specific lesson from Lacknell was not
02:00:17 learnt and embedded in practice in control, latest by 2012 but were doomed to be repeated
02:00:24 at the Grenfell Tower fire? I can't explain the passage that would the passage of time and
02:00:31 decision making that would have got us to that point but what I entirely accept is that it is
02:00:36 not okay. It was not alright that we found ourselves in that position again.
02:00:43 Actually in due regard to Jonathan Smith and in respect to your previous question, whilst as you
02:00:49 might imagine I'm offered a wealth of information on an almost daily basis, I think I should caveat
02:00:54 my previous answer if that's okay by saying I know that Jonathan Smith has unpicked almost every
02:00:59 single aspect of both the learning from Lacknell and Grenfell and may well have unpicked why we
02:01:09 arrived historically at a place where we hadn't taken that information that you would need about
02:01:18 people's vulnerabilities forward into operational procedures and practice for control. So it may be
02:01:25 that whilst I'm speaking from my level of knowledge what I see, Jonathan may well be able to offer a
02:01:30 greater level of knowledge if we can. Of course we will supply it to the inquiry in terms of the
02:01:34 specific investigation. Just on a personal point, again having met bereaved and survivors
02:01:42 on repeated occasions now, I fully respect and understand why you're asking this question because
02:01:50 it's not lost on me how so many of those lost in the fire were the most vulnerable disabled children,
02:01:57 those who were not finding it easy to communicate in English as a first language. I know and it is
02:02:03 my assurance to you as Commissioner that it is something that is particularly personally important
02:02:08 to me that we understand how we deal with those issues when we're providing advice to people in a
02:02:13 crisis and that has been built into the policies and practice of our control operators moving
02:02:19 forward and that is not without challenge because sometimes they are faced with providing advice
02:02:25 in the context of a lack of easily available options at the point of rescue.
02:02:30 So there is something about being aware of people's vulnerabilities so that you can prioritize either
02:02:35 protection or rescue. You know I do expect my control operators to ask whether you're a child
02:02:42 whether you have mobility issues or seek to find a way to understand the situation if English isn't
02:02:50 your first language. You know we're thinking about all the challenges around that so you know
02:02:53 available of a translate availability of a translation service very quickly. You know none
02:02:57 of these things are necessarily easy to solve but you're right we have an absolute duty to make sure
02:03:01 they are included within the training and the practice of a control operator. Commissioner thank
02:03:06 you and I've come to the end of my prepared questions so it remains for me to thank you very
02:03:12 much so far. I may have some further questions for you but at this point I'm going to ask the
02:03:17 chairman to take the usual break and to come back in after an appropriate time to finish off.
02:03:24 Yes well Mr. Millard of course we have the usual break using quarter of an hour is long enough.
02:03:30 I'd like to say I'd like to say quarter of an hour I'd like to say 20 minutes just in case
02:03:37 uh there are questions or questions that I haven't covered myself. Right thank you well
02:03:42 commissioner as you know um we have a break at this point to enable council to check that he
02:03:48 hasn't overlooked any important questions that he ought to have put and also to enable questions to
02:03:53 be considered that may come from others who are following the proceedings but not from the room.
02:03:59 So we will break now we'll return please at 25 past four and at that point we'll see if we have
02:04:06 any more questions for you. Thank you chair. All right and as before please don't talk to
02:04:12 anyone about your evidence when you're out of the room. Thank you would you go with the usher then
02:04:16 please. Thank you.
02:04:17 Thank you.
02:04:26 All right Mr. Millard thank you 25 past four.
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02:22:57 All right Mr. Rowell we'll see if there are any more questions for you. Chair thank you. Yes Mr. Millard.
02:23:03 Mr. Chairman yes thank you. Commissioner can you just tell us arising out of a discussion we had
02:23:10 earlier what consideration is the LFB giving to the pre-planning for high-rise firefighting
02:23:16 whether through the 7-2d process or otherwise for the evacuation of disabled or vulnerable
02:23:22 residents in the event that a whole building evacuation is necessary. We're considering that
02:23:28 issue as we speak so it's identified as an issue at a governmental level that needs to be resolved
02:23:35 through a number of functions not only our response at an incident but also the holding
02:23:40 of information by a variety of bodies around individual residents vulnerabilities so we're
02:23:46 working with the Home Office our central government department the NFCC and colleagues across the
02:23:53 national fire and rescue sectors to consider how we practically implement the the recommendations
02:23:59 arising from the first phase of the inquiry so I want my firefighters to be in a position
02:24:06 where they have access to detailed information around the vulnerabilities of people inside a
02:24:11 building so they can then best determine how in the moment they make best endeavour to rescue them
02:24:16 because at the point we mitigate this it will be best endeavour you know it has to lie with the
02:24:22 responsible person of the building to think about how best to house and support protect someone
02:24:28 in the context of their day-to-day lives if they have a vulnerability it is our job as a fire and
02:24:33 rescue service to take the information that that building owner has given us by some means
02:24:40 and then consider how we would enact that in a tactical response and an operational incident.
02:24:46 Yes you say that you were considering the issue as you speak so it's identified as an issue at a
02:24:53 governmental level can you give us a concrete some concrete pointers as to where you have all got to?
02:25:00 I can tell you where I am speaking on behalf of London Fire Brigade because I've been in
02:25:04 some of the meetings so where I am is that I recommend that we see encoded information
02:25:10 in a premises information box in every single residential high-rise in London if we're going
02:25:18 to take London as the example and that we work around the challenges of transfer of data in that
02:25:25 encoding because there is some understandable anxiety about the passage of information around
02:25:30 vulnerabilities where people are in a building and the fact it could perhaps be exploited by others
02:25:35 to the disadvantage of those residents but we're working with colleagues in government to consider
02:25:39 how we might do that. I also think there has to be some form and this is my personal opinion but
02:25:44 we're in discussion because there are practical challenges in implementing this but it is a view
02:25:49 shared by Mark Harding and my colleague who chairs the NFCC that there also needs to be a form of
02:25:55 personal evacuation plan in place in the first instance before you get to a personal rescue plan
02:26:01 the information encoded inside a premises information box in those most high-risk buildings
02:26:08 so it may be that they it doesn't apply to every single building but certainly if we think of the
02:26:13 thousand in London it is my opinion as London Fire Commissioner that if you're a vulnerable resident
02:26:18 in one of those blocks advanced consideration must be given by the building owner as to how
02:26:25 how you're going to be best protected or evacuated in that context because I think when people think
02:26:30 of peeps they think of it as a as a single issue actually a peep might encompass a range of
02:26:37 mitigations it could be yes you consider a concierge led rescue that's tricky and resource intensive
02:26:44 it could be actually depending on the vulnerability you have a different sort of alarm for example
02:26:48 strobe lighting alarm for someone who is hearing impaired or a different form of protection in form
02:26:56 in form in the form of increased protection in the built environment for a particular apartment that
02:27:00 that bit of building work prioritized so I think there's a range of ways we consider this it's not
02:27:05 an easy issue to solve but as a baseline fire and rescue services I believe and certainly we would
02:27:12 seek to implement this in London must have access to what has been called a personal rescue plan but
02:27:17 really is about where is that person in a building what is their vulnerabilities and then we think
02:27:22 about how we deal with it and then it's got to scale up I think in a in a in a tiered response
02:27:28 through peeps which is pre-planning around what you do to protect those individuals driven from
02:27:34 the responsibilities of the building owner in the highest risk buildings and then of course
02:27:38 ultimately at the top end of that hierarchy we need to drive the sort of change I talked about
02:27:44 earlier in the construction industry to both remediate these buildings at a pace
02:27:50 and not to build them moving forwards and that's how I see that hierarchy you start with the right
02:27:55 legislation the right guidance which I think is you know being brought into effect you know although
02:28:01 we'll need to see the detail of secondary guidance followed by a change in culture in the building
02:28:06 industry that means you both remediate at a pace recognizing it as a priority and you also don't
02:28:12 build any more of these buildings that are unsafe and that you consider fire safety as a priority
02:28:17 when you build buildings you know you put in more than one staircase you take a different approach
02:28:20 perhaps as on the continent and then falling down the hierarchy in the highest risk buildings
02:28:25 you may well have need for a people though that may well be difficult to to issue and construct
02:28:31 and enforce and then at the base level because that is what we are as an emergency response
02:28:37 we arrive knowing that we should have access to the right data provided by the building owner
02:28:42 and then we will enact a rescue plan at that point because that is our responsibility
02:28:46 now you and other commissioners before your time have referred in various respects and contexts to
02:28:52 industrial relations you've laid out today I think your aspirations for the transformation of the
02:28:59 brigade in many respects do you perceive industrial relations to present a potential barrier to change
02:29:06 I think industrial relations in any large organization potentially presents a challenge
02:29:11 in the particular history of the fire service both nationally and london it has certainly in the past
02:29:16 been an obstacle to change but what I would say is that is a shared responsibility of both leadership
02:29:21 of the union and the leadership of the fire brigade because it's somewhat like the question
02:29:25 you posed around the training contract it's all about the relationship you have and and whether
02:29:30 that is professional and courteous and and and is recognized as an important part of the makeup of
02:29:36 any organization so I think it is right that my employees have access to a strong trade union to
02:29:42 actually provide the sort of second line of assurance scrutiny and conscience that they can do I think
02:29:48 it's actually very important when we talk about assurance and and the ability of employees to hear
02:29:53 their have their voice heard I think with that with that opportunity and that right comes a
02:30:00 responsibility and that those who lead unions have a responsibility to discharge that function
02:30:04 responsibly just as I have a responsibility to recognize the value they bring to my organization
02:30:10 because they do and I hope that in the way we've moved forward in the past two years and we have
02:30:15 had to discuss some very challenging issues with colleagues at an executive level in the fire
02:30:20 brigade's union you know both through covid in respect to counter terrorism in respect to
02:30:25 high-rise firefighting policy whilst we have not always been able to agree on all those matters
02:30:30 and sometimes we have indeed implemented things that colleagues in the union did not agree with
02:30:34 we have not seen the scale of industrial dispute we saw in the past because actually I experienced
02:30:39 my colleagues at a senior level in the fbu to be rational and reasonable people who you can talk to
02:30:46 we will not always agree we can agree to disagree and sometimes there are points of
02:30:51 you know tension but I think it is the responsibility of both sets of leadership
02:30:56 recognizing the criticality of emergency services not to allow that to develop into very damaging
02:31:01 and long long-running industrial disputes commissioner thank you I've come to the end of my
02:31:08 questions for you and it only remains for me to thank you very much indeed for coming back to the
02:31:13 inquiry and assisting us with our investigations we're extremely grateful to you so thank you very
02:31:18 much yes and I know I can speak for all three members of the panel commissioner when I say
02:31:24 we're really very grateful to you for coming for a second time to give your evidence I think we've
02:31:28 all found it very interesting very informative and very useful as part of the evidence on which
02:31:34 we're going to eventually going to make findings so thank you very much indeed and you're now free
02:31:40 to go thank you chair panel Mr Millett thank you for the opportunity to speak on behalf of the
02:31:45 brigade thank you thank you very much would you care to go to the usher then please thank you
02:31:55 yes Mr Millett no now Mr chairman before we close the evidence for this part of module six formally
02:32:06 I need to read into the record a number of references to further witness statements
02:32:13 those can be found compendiously or will be found compendiously under one reference which is IDX
02:32:20 0882 and with that these witness statements are read into the record and will be publicly available
02:32:28 on our website as soon as they can be uploaded that does then formally close the evidence for
02:32:35 this part of module six good thank you begin the opening of module six second part of it on monday
02:32:45 thank you so there will be no hearing tomorrow but we shall resume on monday at 10 o'clock
02:32:54 when we shall hear opening statements I think is that right yes in relation to the other parts of
02:33:01 module six yes from those core participants who wish to make them indeed yes thank you
02:33:05 Mr chairman thank you very much 10 o'clock on monday then please thank you