Grenfell Tower Inquiry - London Fire Brigade Evidence - Wednesday 22nd September 2021 (2/2). Deputy Commissioner Rita Dexter gives evidence on the LFB's incident monitoring and operational training systems, including the DIOT process, training packages, and organisational learning mechanisms.
00:19:09 would you ask mr dexter to come back in please
00:19:32 right ready to carry on yes good thank you very much yes thank you very much mr chairman um miss dexter before we start i wonder if i can just ask you to keep your answers a little bit shorter
00:19:43 your answers a little bit shorter and focus on perhaps more closely on the question that i'm asking i appreciate some of the questions i've asked for asked you in the early stages have been a bit open-ended but if you could just focus on the question that would be very helpful can we go go
00:19:56 that would be very helpful can we go go back to the september 2014 report to the odcb we were looking at before the lunch break and that's at
00:20:05 four lfb3067840
00:20:07 and just to reorientate you in the document we'll have page one and then let's look at page six
00:20:15 six so that's page one page six has uh as you can see from the screen some bar charts on the left and a pie chart on the right you see that and you can see um the voluntary on the
00:20:26 and you can see um the voluntary on the left hand side the voluntary element is in light blue and the mandatory element in brown do you see that i do
00:20:36 that i do and um
00:20:37 and um you could see that the vast majority of those submitted are reports where they had to be submitted
00:20:45 um you can see the figures none sorry 34 and therefore 100 of prc for pro 817 with only 56 being voluntary
00:20:58 for pro 817 with only 56 being voluntary and other eight 856
00:21:02 856 as mandatory with 272 as voluntary so
00:21:08 so first would you accept just looking at the document the vast majority are mandatory
00:21:13 mandatory yes yes
00:21:15 yes yes and and would you agree that as at september 2014 that split was a fairly representative one historically i don't recall
00:21:26 i don't recall um it
00:21:28 um it whether it was or it wasn't would you agree with this that that on the page the
00:21:33 the um presentation of the statistics that we can see would would suggest that only a minority of lfb officers were voluntarily using the impd system to feed back information about incidents
00:21:46 to feed back information about incidents performance and operational matters that's what that data suggests yes now the inquiry has a witness statement from a doctor sabrina cohen hatterton
00:21:57 from a doctor sabrina cohen hatterton you may whom you may have heard uh who explains that the receipt of an imp point which would be added to a personal development plan if verified was regarded by many
00:22:08 was regarded by many in the service as negative or punitive um would you agree with that i think i used the word punitive before the break yes you did yes um does that account
00:22:20 does that account uh
00:22:21 uh looking back on your time did that account to the way you saw it at the time for the imp's low take-up among operational firefighters
00:22:31 where it was voluntary
00:22:35 it was the most used explanation um you know it's it's feasible that there were other reasons too uh but i'd only be
00:22:46 reasons too uh but i'd only be speculating about them but but yes that was that was the common understanding of why the take-up was low did the odcb
00:22:56 odcb do anything to address that problem uh
00:23:00 uh yes yes so before the break i said that we used operational news on numerous occasions to remind station-based staff about
00:23:14 remind station-based staff about the impd process and to explain that it was it was part of an improvement process
00:23:20 process and not and not something punitive or which would result in you know for example disciplinary action i don't i don't personally recall that ever happening in relation to any firefighter
00:23:33 happening in relation to any firefighter in relation to an operational incident so we did our best to reflect back that it was genuinely intended to be an improvement tool
00:23:45 improvement tool but
00:23:46 but [Music]
00:23:47 [Music] but clearly there was still some reluctance to to
00:23:51 to engage with it and sorry and i also mentioned that dave brown will have used his uh efforts as a as a line manager in order to
00:24:00 order to um
00:24:01 um chase it down further in his department was there any discussion during your time on the odc about taking slightly tougher measures to make sure that those who didn't have to file inp
00:24:13 that those who didn't have to file inp reports
00:24:15 reports nonetheless did so for example perhaps by making it all mandatory
00:24:20 mandatory no why is that
00:24:28 well by making it all mandatory by making it all a requirement um
00:24:46 so i'm just trying to go back and think about this
00:24:54 uh i don't know why why not mr millet but i don't i don't ever recall
00:25:01 a discussion of that nature um
00:25:05 um i don't
00:25:07 i don't well
00:25:08 well no i don't i don't recall that discussion you know i'm i'm completely clear that it it wasn't actually part of the fire brigade culture to be
00:25:19 fire brigade culture to be punitive uh to use the phrase that sabrina has used and which i use myself and so
00:25:27 and so in one sense that was more actively discounted [Music]
00:25:33 [Music] and
00:25:34 and you know on things like visits to fire stations one would have discussions with watches about what the intention was and what the intention wasn't um but but it was a hard it was a hard
00:25:45 um but but it was a hard it was a hard lesson to teach and and talk only with limited success
00:25:52 in the effect do you agree that such a limited take-up of the impd where it wasn't mandatory was a significant limitation on its
00:26:03 was a significant limitation on its efficacy as a reporting tool
00:26:11 uh i don't know mr millet so we talked earlier about um what the relationship between the number of entries and 47 000 incidents were and i fear that's created
00:26:27 a deceiving picture of the extent to which the system the process in the system was capturing
00:26:36 the most important information um
00:26:41 um and i and i just i can't make a judgment about that based on what's before me today but my inclination would be that what was going into the system was at
00:26:52 what was going into the system was at the more important end of the spectrum that i i'd find it difficult to evidence that here before you now with without being able to go back and look at some further documentation i
00:27:03 look at some further documentation i understand that and we are only looking at an arithmetical representation rather than a qualitative one i accept but
00:27:11 but my question is did nobody at odb odcb level or indeed to your knowledge any other level ever look at these statistics and ask the question
00:27:22 and ask the question whether
00:27:23 whether four percent is good and representative or insufficient bad and unrepresentative
00:27:34 uh and sorry the four percent is the measurement against the forty seven thousand yeah is that right um
00:27:42 i think i think i think i've exhausted what i can say about the relationship between the four percent and the 47 000 you know the 47 000 you know potentially was a misleading headline in terms of
00:27:54 a misleading headline in terms of where the report was trying to trying to take the reader um
00:28:00 um so what i'm really trying to get get to the bottom of is whether anybody actually positively thought uh looking at the four percent well that's fine because that fairly represents the
00:28:12 because that fairly represents the incidence in respect of which meaningful information can be gathered did anybody actually
00:28:17 actually analyze that analyze the makeup of the four percent analyze the makeup of the 96 percent and and get to the bottom of whether four percent was good enough
00:28:29 i i think you might be asking me whether
00:28:34 um whether anybody asks themselves
00:28:39 uh
00:28:42 whether anybody sought to benchmark the four percent against the 96 of things that were not known as it were although for 96
00:28:53 for 96 um
00:28:54 um uh is statistically correct but conceptually wrong um so
00:29:00 um so i i guess that could have been done mr miller i'm i'm not sure i'm not sure it wasn't a quick dead end but i i i don't think i ever asked anybody to do that exercise but my suspicion is that it would have been a quick dead end
00:29:12 would have been a quick dead end um uh if i'd asked somebody to do that i mean i have to say about the brigade it was a remarkably um data rich organization and made good use
00:29:24 data rich organization and made good use of data so it's not that people didn't think about statistics and their presentation you know there were some parts of the organization which were better at it than others um uh and you you're right you know if your
00:29:37 uh and you you're right you know if your proposition is there was room for improvement i i don't disagree with you no that that isn't well i prop my my pro i'm not making a proposition i'm just asking the question whether anybody actually if you like benchmarked or
00:29:49 actually if you like benchmarked or qualitatively assessed uh
00:29:52 uh the four percent and ask themselves is that a fair representative of the figures we're looking at well i think gary reason may well be able to give you a better answer on this because
00:30:03 give you a better answer on this because he was responsible for the operational assurance department and he may have greater insight than i have into
00:30:11 have into what the operational assessment department did so i think it's extremely unlikely that these questions will not have occurred to them and that they tried to address them but but gary reason for sure will know will possibly
00:30:22 reason for sure will know will possibly know better right but can we leave it like this with you that to the best of your recollection the the the topics that you and i have just been discussing just now since the lunch break never erased the discussion at the odcb
00:30:35 erased the discussion at the odcb well not not quite because i i think i have said
00:30:39 have said actually we were concerned about the extent of take-up and we were taking action to improve it now going back to the dioct policy at page five if we can lfb3055171
00:30:53 page five let's look at 310 at the top of the screen emerging operational issues can also be recorded on the imp by any station based staff in consultation with
00:31:04 station based staff in consultation with their crew and watch managers this provides an organizational as well as an individual benefit from observations placed on the imp in the form of improved procedures and equipment and what type of emerging operational
00:31:16 and what type of emerging operational issue would you expect to be or did you expect at the time to be identified and recorded by a member of station based staff
00:31:28 issues with equipment um
00:31:33 um is is
00:31:35 is is the more likely uh
00:31:38 uh first topic uh i think so they might report problems with
00:31:48 door breakers they might report problems with barry roving equipment um
00:32:00 so i i think station-based staff were reasonably vigorous about reporting what they felt were problems with in particular equipment um
00:32:16 that's a shorter answer right now um
00:32:21 um did this policy contemplate at all that babcock
00:32:25 babcock could add
00:32:27 could add comments
00:32:29 comments in other words feed into the impd process by adding comments on their observations of performance during training sessions no
00:32:36 no so if some firefighter fell asleep during a training session that wouldn't work its way onto an impd i don't think it would work its way into an impd i i like to imagine it would work its way into the system so um
00:32:47 work its way into the system so um there were parallel systems for um monitoring what was happening on training courses and they were the subject of separate reports i see now um a julian spooner
00:32:59 a julian spooner of the lfb has given a witness statement to the metropolitan police in october 2020 that's at met 30 58859 and if we can have that up please
00:33:10 and if we can have that up please and while that's coming up i should just explain he gives his occupation as a firefighter but he explains uh and perhaps you can help us with this uh that he was as a
00:33:21 as a 2020 at least a group manager within the incident command policy department are you familiar with this gentleman yes you are i think i think julian worked for me at one point yes right now let's look at page two of his statement please and look at the first
00:33:33 statement please and look at the first line on that page uh he says i am responsible for the policy for the performance review of command prc process and then if you go to the next paragraph
00:33:45 and then if you go to the next paragraph down
00:33:46 down he says
00:33:48 he says part of my role is to identify organizational learning through incident monitoring trends in our reporting systems individual incidents or a national issue once i've identified these issues it would be put before a board and the board will decide the
00:33:59 board and the board will decide the appropriate way to deal with it now
00:34:03 now is this in effect a summary of the deodorant odcb system it's a very brief one yes it is now if we go to page four of his his statement please page four he goes
00:34:15 his statement please page four he goes on to explain the change from the lfb's dot policy to the newer operational improvement process or as one might expect oip if we look at the final paragraph on that page mr spooner says this
00:34:28 that page mr spooner says this prior to the introduction of oip the organization would probably only have had information drawn from our information management system ims ims had a lot of positive points but it is only as good as the information
00:34:39 is only as good as the information people put into it if shepard's court wasn't entered multiple times to make it a trend as the organization looked at trends and not individual incidents necessarily then the information
00:34:51 necessarily then the information wouldn't have been identified now of course you were not at the lfb at the time of shepherd's court in august 2016
00:34:58 2016 so i'm not going to ask you about that incident but do you accept that the dr process was too heavily focused on operational trends and therefore susceptible to missing a serious learning point from a single
00:35:10 serious learning point from a single incident or event
00:35:14 could we go back to the previous page please of course page four bottom of the page
00:35:24 you might want perhaps to look at the the paragraph just before the one i was showing you which starts the shepherds caught fire as an example of where the information passed by the fire safety department under the old process
00:35:37 uh sorry without seeing that final paragraph
00:35:42 paragraph uh together um
00:35:46 i'm i'm just a bit unclear about whether julian's view is about the limitations
00:35:54 oh thank you okay so um i i don't think i agree with julian on this um
00:36:02 um so
00:36:03 so uh
00:36:05 uh in odcb
00:36:09 in odcb uh
00:36:10 uh the scope of the impd reports during my time was expanded at my request
00:36:18 request and they were expanded very specifically to include intelligence from the fire investigation team and the fire safety department
00:36:29 team and the fire safety department and but this was in its early stages and i you know i don't claim they were well developed processes because i don't think they were but also intelligence to use that phrase
00:36:40 intelligence to use that phrase from control so i think in somewhere in one of my statements or one of the documents that is attached to it i have been very clear that
00:36:51 i have been very clear that um
00:36:54 um from the point that i was appointed deputy commissioner i could see there was
00:36:58 was potential much more potential than maybe had been
00:37:02 had been being realized to make use of fire investigation findings fire safety findings and uh
00:37:10 uh and information about aspects of control performance although i don't pretend that that was systemized um because i'm not sure it was um and so
00:37:21 um and so i've watched a great deal of the inquiries work and i i've i've heard observations similar to this one about shepard's court and i've and i've been at home and thought
00:37:33 at home and thought i'm sure that shepard's court would have found its way to odcb in my day in one sense i'm not in any in any doubt about that um
00:37:43 um uh no i i don't know what happened after i left but i i'm clear that uh the scope of impd was expanded maybe graeme ellis who was the dak ops
00:37:55 maybe graeme ellis who was the dak ops assurance at that time maybe his statement
00:37:58 statement um has the expanded list so we looked at that document earlier on from october 2013
00:38:05 2013 about the contributions as it were to the considerations odcp and i don't think that mentions fire investigation findings or control
00:38:16 findings or control but i'm sure there are other documents you know i can't recall which ones there are but in the preparation for today there are there are definitely other documents which refer to the fact that we were starting to bring forward um
00:38:28 we were starting to bring forward um that information into uh odcb well we we we'll come back to shepherd's court later and if there's a document that um we want to show you to follow up on that then we'll we will
00:38:39 to follow up on that then we'll we will find that um but subject to that can i then turn to diot stage two which is deciding and
00:38:47 and this is at lfb3055171
00:38:53 and this one is at page 7.
00:39:04 uh and uh on page seven under step two deciding let's just look at 326 and 327. 326 says organizational statistics and trends from the imp are analyzed and a
00:39:15 trends from the imp are analyzed and a formal report produced by information management and incident management policy groups informing odcb of organizational trends and recommended topics to be considered for communication to operational
00:39:26 communication to operational staff and then it says at 3 27 the odcb report summarizes the information described in section 3 and identifies the eight most prominent subjects as well as any other significant trends to
00:39:38 well as any other significant trends to be included as articles within operational news at six monthly intervals i either march in september odcb meetings four or five operational themes are prioritized for inclusion
00:39:49 themes are prioritized for inclusion within operational news based on performance and safety event data on a risk-assessed basis these themes become the priority for targeted training activity and form the content of the communications message to operational
00:40:01 communications message to operational staff
00:40:03 staff now
00:40:03 now is that
00:40:05 is that there uh
00:40:07 there uh the six months a reference to the incident monitoring six monthly report i think so yes now let's look at an example of such a report can we go please uh to uh
00:40:20 report can we go please uh to uh uh well we can go back i think to the september 2014 report which we've been looking at before lfb three zero six seven eight four zero it's the most easily
00:40:31 it's the most easily reached uh mr miller may i just say one thing uh
00:40:36 thing uh this is a version con oh no i i know that's where i wanted to go we'll get back to it let's go back to the policy lfb3055171 page seven well just the page that we were on
00:40:49 well just the page that we were on yeah is instructive um
00:40:53 um so
00:40:54 so this
00:40:54 this this version i doubt that it's substantially different but i just want to say that this version is not the version that was as it were in force when i was in post
00:41:06 as it were in force when i was in post so when i was in post if you look at 328 there was no assistant commissioner health and safety and interestingly in the list of attendees or members here it includes
00:41:18 attendees or members here it includes the head of information management and performance well just pause there can we just look at the very bottom of the screen yeah go scroll down to the foot of the page because um you may not have spotted but this is this issued on the 11th of april
00:41:30 this is this issued on the 11th of april 2013. that's two years before you i i appreciate that's what it says but i'm i'm
00:41:36 i'm i'm almost certain there was no assistant commissioner health and safety when i was in post and the head of information management when i was imposed was the head of information management division and he attended
00:41:48 management division and he attended uh
00:41:49 uh uh
00:41:50 uh as it were upon invitation so i mean he attended regularly but he was not he was not a member of odcb i i say that only because
00:41:59 because there is something about version control and dates um uh that but i i personally haven't been able to get to the bottom of it
00:42:07 of it who drafted this i don't know mr miller i i think this version comes i mean i don't know if you go to the back page you can see as i recall the back page had um a
00:42:19 as i recall the back page had um a version control table um let's go to page 15. because you you wanted to make a point about it to be fair to you i'll show you the the version history
00:42:31 the the version history okay uh
00:42:32 okay uh so we can see certainly one amendment which would be the predicted one for after i left um
00:42:41 but um you know we did not have an assistant commissioner health and safety while i was chair of odcb and so that that paragraph does not that paragraph certainly does not reflect the
00:42:52 paragraph certainly does not reflect the position when i was impressed right uh it may be then the issue date of 11th of april 2013 was the original issue date and that what we're looking at is some is a set of subsequent versions which would explain this but but uh leave that on one side
00:43:04 this but but uh leave that on one side can we then go to the uh
00:43:07 uh um
00:43:08 um the document i wanted to go back to lfb3067 eight four zero please which is the september 2014 report we were looking at before okay now let's just go to the very start of that i showed you this page i didn't
00:43:20 that i showed you this page i didn't show you the summary let me do that now this report for the september 2014 operational directorate coordination board adcb outlines operational performance trends individual team and organizational for the reporting periods
00:43:32 organizational for the reporting periods of the quarter 4 2013 to 14 and quarter 1 2014 to 15 first january 2014 to 30th of june 2014.
00:43:43 2014. um
00:43:45 um does that then and it then sets out it it compiled utilizing data and information from the following sources and there's a series of bullet points under that um does that set out comprehensively all
00:43:56 does that set out comprehensively all the diode sources i think so yes and and of course that refers as i said a few minutes ago to uh contributions from fire investigations and control
00:44:09 investigations and control yeah and is it right that it was the responsibility of the incident management policy team to analyze these sources and create this report for the odcb to consider yes yes now if we look at the bottom of
00:44:21 yes yes now if we look at the bottom of the page it says and we need to scroll down it says for decision odcb is requested to consider the subject barriers listed below and agree the topics to be featured in operational news 28 in addition odcb is requested to
00:44:34 news 28 in addition odcb is requested to agree which of the featured operational news articles should be accompanied by a dedicated training package or other training interventions and then if we go over the page to page two we see a heading proposed articles
00:44:46 two we see a heading proposed articles for operational news 28 and it says under that uh the following list identifies the subject areas which odcb may wish to consider as the basis for articles in
00:44:57 consider as the basis for articles in operation on news 28 and
00:45:00 and they're
00:45:02 they're they're set out underneath that um
00:45:06 um is it
00:45:07 is it it's is it right to take from that that the um the idc
00:45:14 the idc sorry the imp report or this report in fact was at the heart of the odcb's decision making yes yes was that typical of the diop process during your time as deputy commissioner
00:45:26 during your time as deputy commissioner yes
00:45:28 yes now can i just show you mr reason's statement at lfb 3032747 page 12
00:45:37 page 12 and on that page let's go please to paragraph 42
00:45:41 decisions relating to the selection of operational news can you see that yes and he says this decisions relating to the selection of operational news items were informed through detailed professional discussion
00:45:53 through detailed professional discussion relating to how frequently the development issue appeared in the performance data and the risk exposure stroke impact the issues presented to the brigade therefore items were sometimes chosen even though they only represented a
00:46:04 even though they only represented a small percentage of the issues reported issues that appeared in the report were not chosen for the next operational news publication were maintained in a running log and brought to the next meeting of
00:46:15 log and brought to the next meeting of adcb for consideration this approach ensured no performance issue that had been captured in the incident management database and reported to odcb was lost first do you agree with what he says
00:46:27 first do you agree with what he says there yes
00:46:29 there yes what sort of factors would inform this professional discussion as he refers to it among odcb members uh
00:46:38 uh the risk to firefighters so um i was only able to briefly scan the page we looked at previously in the impd report which
00:46:49 previously in the impd report which addressed the topic of news items for ops news 28 but from that brief view of it
00:46:59 of it i think it recommended an item on ppe because of concerns that a small number of people were experiencing experiencing i don't know if it used the words heat exhaustion but
00:47:12 if it used the words heat exhaustion but were
00:47:14 having experiences that we wouldn't expect
00:47:18 expect as a consequence of the ppe now we did sometimes have problems and issues with ppe uh sometimes we discovered that that was to do with the layers that were being worn between ppe
00:47:31 layers that were being worn between ppe beneath ppe for example um but
00:47:36 um but that would be an example if we thought that um
00:47:39 that um firefighters were uh experiencing or exposed to risk or experiencing um
00:47:47 um you know
00:47:48 you know unintended discomfort from their experience of wearing ppe we might want to say something for example about the number of layers or the combination
00:47:59 the number of layers or the combination of layers to be worn beneath the ppe so that's that's that's an example where uh
00:48:07 uh of something where the problem might not have presented often but we'd want to address it anyway um so risk to firefighters were certainly uh high on the agenda
00:48:22 operational risk more wide widely so um
00:48:27 um i don't know um [Music]
00:48:30 [Music] i think we've probably had a feature on what i would describe in what i hope our late terms exploding manholes we had a you know period in london where that seemed to happen with
00:48:43 seemed to happen with unexpected frequency and there were some things we wanted to say to fire crews about
00:48:50 about the risks associated with an event like that
00:48:54 that some of it was seasonal you know we might want to say something about
00:48:58 about barbecues on balconies during hot summer seasons um so it it was a combination of factors now um i showed you mr reason's statement where he had said that there
00:49:11 statement where he had said that there was a running log kept of of matters which were not chosen for the next operational news i read that out to you you agreed with it um
00:49:22 you agreed with it um he has provided us with a second statement in which he said that that was a mistake and there in fact wasn't such a log are you able to help is he is he writing his recollection or wrong do you think
00:49:34 his recollection or wrong do you think i could show you his statement if you want me to show it to you
00:49:39 i don't think i can help no right i'm trying to recall uh an enormous level of detail and i i think if you go to the minutes of odcb you'll find
00:49:52 minutes of odcb you'll find not only the minutes of individual meetings but attached to the minutes and this might be what gary had had in mind a running log which i think fairly meticulously
00:50:04 i think fairly meticulously um sought to make sure that kind of nothing fell off the end accidentally and i i personally spent you know quite a lot of time and effort
00:50:16 quite a lot of time and effort um in making sure that things weren't accidentally mislaid in the process and making sure that they stayed on and maybe that's what at the time gary meant by the running log um that a record of
00:50:29 by the running log um that a record of those things was maintained but i don't say for sure that that is the thing that gary
00:50:35 gary uh recalled but but has since corrected no i'm not i'm not asking you to try to work out what he does and doesn't remember let me try it differently do you remember yourself ever seeing a running log
00:50:46 ever seeing a running log of matters which didn't make it into the operational news list for that next issue which might which might be considered next time round it uh
00:50:55 uh the odcb minutes themselves in addition to the minutes was i don't think i called it a running log i'm not sure i called anything a running log but attached to the odcb minutes
00:51:06 attached to the odcb minutes were things that were outstanding or as it were needed to be continued
00:51:13 whether that for sure contained items that were not selected for operational news i just can't say maybe some things were not selected because we decided not to do them
00:51:26 because we decided not to do them um
00:51:27 um you know not that we decided not to do them now but we decided not to do them at all but um
00:51:32 um that's the best i can do mr millet
00:51:41 now let's go to step three uh diot acting application of interventions if we just go back to the policy please at lfb three zeros five five one seven one page eight
00:51:57 uh we'll see this uh set out there uh and uh if we've already touched upon operational news articles which i think you've agreed were a key form of adcb intervention
00:52:10 form of adcb intervention um is it right that incident management the incident management policy group uh
00:52:16 uh was sitting within the operational insurance department was responsible for drafting
00:52:22 drafting the operational news articles
00:52:26 uh
00:52:29 i think it's more likely that they were responsible for making sure they were drafted so i think they will have asked the subject matter experts to produce a
00:52:40 the subject matter experts to produce a draft and they will have reviewed it right i think i think that's more likely right let's look at 338 top of the page once odcb has selected the topics for
00:52:51 once odcb has selected the topics for operational news the incident management policy group will inform the relevant team stroke individuals who will usually be subject matter experts that they need to compile an article for operational
00:53:02 to compile an article for operational news
00:53:03 news just just focusing on some specifics here
00:53:07 here who in general were the relevant teams or individuals who would usually be subject matter experts
00:53:16 experts were they when i say who they were were they high level or low level uh
00:53:23 many of them will will have been at um
00:53:28 um i think i'm it's not a question i've ever thought of before um
00:53:33 before um and so with that qualification many of them will have been a group manager level so
00:53:39 so if you ask me to choose a rank uh it would be group manager or equivalent level right looking at the first part of 338
00:53:48 338 once odc have selected the topics for operational news now clearly it's the odcb that makes the decision and we've seen the note that says for decision and i've asked you about some of the
00:53:59 and i've asked you about some of the factors that go into that
00:54:03 but the identification of the subject areas in the end what was the baseline trigger for deciding whether to have it
00:54:14 trigger for deciding whether to have it in or not have it in uh
00:54:21 the risk of injury to firefighters to firefighters
00:54:27 yes sorry i didn't understand your question as asking me to choose one well let's go back and do this by way of example perhaps without getting drawn into whether they're good or bad examples can we go back to
00:54:40 or bad examples can we go back to the september report we were looking at september 2014 at lfb3067840
00:54:48 and on page two we can see there as i've shown you already proposed articles for operational news 28 and then there's a list of three ppe is one two is uh if you
00:55:02 of three ppe is one two is uh if you scroll down fire investigation removal of samples from the fire ground and over the page the third is fires in basements and voids in commercial buildings the list actually goes on
00:55:13 list actually goes on in fact um to some others there are two others ventilation induced fast bed and refreshment and rehydration of incidents now that's the five there's a list of five there
00:55:24 five there um you can now see them
00:55:28 how would those select how are those selected and others left behind what was the key
00:55:33 the key litmus test if i could put it that way which decided that those should go into not operational news 28 and others would have to wait
00:55:43 uh there wasn't i don't think there was one thing mr miller i think i'd i wouldn't be being truthful if i said there was one thing
00:55:51 one thing so
00:55:51 so if if six items came as propositions odcb
00:55:57 odcb as a group would consider them and
00:56:01 and would take into account a number of factors so risk to firefighters would always be high on the list we didn't want firefighters to be avoidably injured in incidents
00:56:16 avoidably injured in incidents exposure to health and safety prosecution might be for the organization might be another [Music]
00:56:28 facing outside um uh
00:56:32 um uh the internal um
00:56:35 um preoccupations of the organization uh i don't know um the avoidance of uh the avoidance of fires spreading
00:56:46 uh the avoidance of fires spreading beyond the room of origin if there was a way to achieve that uh
00:56:51 uh the avoidance of unnecessary cutting away if that was possible i mean i'm making up these examples because um
00:57:01 um because there's a speculative and no that would be unfair it's not a speculative aspect to your question but um
00:57:08 um it was a wide spectrum of things and i think it's important to say that at odcb were
00:57:15 were eight
00:57:17 eight of the most experienced fire officers in the country you know there were london fire brigade directors and assistant commissioners with
00:57:27 with in in a combined sense hundreds of years of experience before them and i know in the fire service there's considerable concern about skills fade but london is still a relatively busy
00:57:39 but london is still a relatively busy fire brigade and these people had enormous experience and and in one sense they were enrolled to
00:57:47 to use that experience and to turn it into decisions
00:57:51 decisions forum with the organization that we would act on so it wasn't a checklist it wasn't a matrix there wasn't a scorecard um it it it was
00:58:02 um it it it was uh taking the evidence that um in this case graham ellis put before us and then reaching a view about it and graham would be there in this case himself and you know he's a very
00:58:13 himself and you know he's a very forceful and very experienced individual and would have a substantial contribution to make to the discussion so can we summarize your answer perhaps like this that the selection of articles
00:58:24 like this that the selection of articles for operational news was based on really
00:58:28 really judgment and discretion by
00:58:32 by derived from the experience of those who are making the decision on the basis of information that came to them through the imp process yes
00:58:42 yes now um did you have sight or did the adcb have sites of the articles prior to them being before they were published they didn't go back to odcb as a group
00:58:54 they didn't go back to odcb as a group so
00:58:55 so the imp
00:58:57 the imp team
00:58:58 team would assemble the material i don't i never asked gary but my guess is they'll have sent it to gary when they'd put it all together and he would have reviewed the draft they then sent
00:59:09 have reviewed the draft they then sent it to me as cherub odcb i will have reviewed the draft right and then they sent it to the commissioner and he reviewed the draft so there were multiple layers of checking yes and all of you were is this fair
00:59:21 and all of you were is this fair entirely reliant on the sufficiency and accuracy of information coming up to you through the diat process particularly steps one and two
00:59:32 steps one and two no we weren't entirely reliant on it you know uh
00:59:37 know uh those assistant commissioners were still attending incidents you know they were monitoring officers sometimes they were incident commanders um no and in addition
00:59:49 and in addition um
00:59:50 um we've not mentioned senior accident investigation reports but they were you know crucially important documents in terms of understanding what happened at
01:00:01 terms of understanding what happened at some in some incidents where uh firefighters did acquire you know very serious injuries so there was a whole breadth of information
01:00:12 there was a whole breadth of information or experience outside odcb as well as inside odcb so yes and we saw the list of things that odcb would consider and the first one on the list i think was the sai
01:00:24 one on the list i think was the sai yes
01:00:25 yes so
01:00:26 so would that tell us that when selecting articles for um
01:00:31 um for operational news you would look at the information coming through the imp team but also other information that was coming to you from
01:00:40 from outside that process including said which would be incident specific yeah i think it would be fair to say that i mean monsters there would have been no point in having an odcb meeting if
01:00:54 point in having an odcb meeting if you know if if if there was no ability to say well actually
01:00:58 actually you know this thing over here was so serious you know it may not feature in the impd report for you know for a range of
01:01:05 of legitimate reasons but it was so serious that we've got to act upon it and so you know the wandsworth incident where a fire a firefighter got terrible burn injuries you know that stays in my mind
01:01:17 injuries you know that stays in my mind as an example of something that was very influential in terms of you know wanting to make sure that firefighters um had a sufficient grasp on door
01:01:29 um had a sufficient grasp on door procedure we had something called door procedure it sounds strange if you're not part of london fire brigade but you know there are good ways of opening doors that fires and there are jolly dangerous ways of doing it you know and as an incident
01:01:40 as an incident you know it made a big impression on us um and so there was always the potential for that group of people to say actually you know uh it would be really silly uh you know it would you would not
01:01:51 silly uh you know it would you would not be able to explain why you had not acted on this thing over here even though it didn't feature in the impd report uh
01:01:59 uh now
01:02:00 now i think you agreed with me earlier in fact that you told me actually that some operational news articles were accompanied by self-study computer-based training or cbt packages i don't think i told you but that is
01:02:11 i don't think i told you but that is correct yes right uh well um you i think you yes okay good now um i'd like to look at an example with you um could we look please at lfb3032744
01:02:24 which is uh operational news issue number 27 from june 2014.
01:02:31 okay
01:02:36 uh i'll just take this quick quite quickly if i can if you there are 10 articles in this issue take that from me and uh if we go to page five we can see
01:02:47 and uh if we go to page five we can see that there are articles which relate both to far survival guidance and the incident monitoring process database you see that on the page
01:02:56 page and on page eight if we go to that on the last page of the letter there's a section which is headed watch training packages and there are some watch training packages set out and there's a list of 10 articles in a table and that it's color coded um which
01:03:10 table and that it's color coded um which says and it just just helped me with this it's i just confirmed red's used to show that training is mandatory and the new training material is available amber is used to show that training is mandatory but existing training
01:03:21 mandatory but existing training materials should be used is that right yes so before this there'd be also been a green
01:03:27 a green category but i think we decided to drop that well there is a green and that would signify or not in this one but there was a green uh which would signify that training was optional yes yeah um d how was it decided
01:03:40 um d how was it decided whether training would be mandatory or optional
01:03:45 i could be wrong mr millet but i think we moved to everything was mandatory i think uh i think i'll i could be wrong but i think after a period of time you won't find any green entries in
01:03:56 won't find any green entries in operational news i could be wrong but that's my recollection now um if you look at the first entry uh
01:04:04 uh on this table it shows that messages from incidents um that's colored red to show that it had mandatory new training doesn't it yes and the second column shows that the training consisted of an article and a cpd package on big
01:04:16 article and a cpd package on big learning
01:04:18 learning is that big learning or big learning um where where is that mr um
01:04:24 um yes
01:04:26 yes big learning vocabulary has come to me during the inquiry if we were using it before i left right nobody used it in front of me um it is big learning i think how did the od
01:04:37 od well
01:04:38 well sorry let me take a step back who made the decision at the point in time when this document was created so this is june 2014 uh whether the training um would be
01:04:50 uh whether the training um would be mandatory or optional or is it that by this point there was it was all mandatory i think it i think it was i'm sorry and of course big learning obviously was in use when i was there because this was due in 2014.
01:05:02 because this was due in 2014. and how did well who was it who decided whether articles warranted a bespoke cbet package or not was that the odcb a bespoke package
01:05:15 a bespoke package odcb
01:05:19 would be made aware of where there were existing training packages or whether or where there was a hole as it were there was nothing
01:05:30 a hole as it were there was nothing and
01:05:30 and odcb would decide based on advice i think from the ac training and subsequently babcock that
01:05:42 that based on our objectives for that issue um that an existing training package needed to be updated or amended or added to
01:05:52 to and and where there wasn't an existing training package there would be a need to develop a new one right to be fair to you gary reason says in his second statement that in fact the incident management policy team would
01:06:03 incident management policy team would would decide whether uh
01:06:06 uh there would be an accompanying cbt package
01:06:10 package does that accord with your recollection well gary
01:06:15 is probably in the same report and that that would be their recommendation yes you know in formal terms odcb would decide you know i'm sure we could have said i don't think we ever did but actually you know no we won't we won't
01:06:27 actually you know no we won't we won't do that but it was available to us to do so right let's go let's look at his statement uh his second statement that said lfb3067846
01:06:38 and let's go to page 19.
01:06:42 uh paragraph 35 he says and let's pick it up seven lines down he says factors that influenced these decisions and he's talking about what would go into operational news
01:06:54 what would go into operational news publication factors that influenced these decisions included consideration of the cullen current policy provision for the theme levels of risk as identified through safety reporting data what existing training support materials
01:07:05 what existing training support materials and interventions were already available and the complexity and scope of what the article was aiming to address um do you agree with that yes it says it in a much better way than i just have
01:07:17 in a much better way than i just have yes right is there anything you would add to that list
01:07:29 no there isn't anything i'd add no then two lines on he goes on to say uh the board uh was we're all also mindful do you see he says the board were also mindful that
01:07:40 he says the board were also mindful that the training generated through the operational news publication needed to be completed within three months and was in addition to all of the core risk core risk critical training that was already mandated through the development
01:07:52 already mandated through the development and maintenance of operational professionalism demop policy
01:07:58 i'm not asking you to interpret his words but
01:08:01 words but then
01:08:02 then was it the case that in practice the odcb was quite restrained in its approach to developing additional cbt packages to accompany operational news
01:08:14 i don't think so no
01:08:18 no um
01:08:23 no but um but london fire brigade is policy rich which is not to say there aren't improvements and there aren't gaps but
01:08:34 improvements and there aren't gaps but there are if somebody adds up the number of
01:08:38 of extant policies i'm sure it's in the hundreds um and there were many many training packages that went with many of those policies
01:08:48 policies [Music]
01:08:49 [Music] and so there needed to be some care about
01:08:52 about as it were you know adding to an already very extensive catalogue but but there wasn't anything which was restraint in or austerity terms as it were that that
01:09:05 or austerity terms as it were that that wasn't
01:09:06 wasn't that wasn't a consideration if if we needed it we needed it um i think it's the position now we heard from peter groves yesterday
01:09:15 yesterday to the effect that daymop was the responsibility of local station through the head of the uh local stations rather than odcb or
01:09:26 uh local stations rather than odcb or the training department would you agree with that so far as your your time is concerned uh
01:09:34 uh i don't know that i would have constructed it in quite that way as in day mop is the responsibility of stations but that doesn't mean it's wrong it's just um i'd need to think quite hard about whether
01:09:45 quite hard about whether that that feels right i'd need to look at the documents again to be frank to see whether i thought that was the right way of characterizing it but in its in its essentials um uh
01:09:55 uh you know
01:09:57 you know there was uh training
01:10:00 training at training venues and there was training at stations uh yes yes i mean let me try it differently did did odcb during your time
01:10:11 did odcb during your time ever
01:10:11 ever uh analyze the content of damp policy training uh and work out whether it was good enough no no so is it so these sources of training were is this fair quite
01:10:23 of training were is this fair quite disjointed you have station-based training daymob and you have the operational news programs put together by uh the um incident management policy team and then overseen by the adcb
01:10:35 by the adcb uh i don't think they were disjointed and i mean anyone says what gary reason was for
01:10:40 was for was to amongst other things amongst many other things was to make sure they weren't disjointed and so they were you know it may not have happened in odcb but the business of
01:10:51 but the business of as it were achieving coherence and a comprehensive approach happened further down the organisation right you don't like disjointed all right let me try it differently
01:11:02 right let me try it differently there were there were there was more than one source and therefore somebody was needed to draw the sources together to make sure they cohered uh there was more than one source
01:11:13 uh there was more than one source i'm sorry more than one source of training
01:11:37 yes and we have odcb and the incident management policy team and gary reason sitting in the middle to make sure they cohered factually is that right during your time yes thank you now let's
01:11:50 during your time yes thank you now let's turn go to the next page please of his statement page 20 paragraph 36 he says the board was also mindful that the investment in new training materials or solutions should be proportionate to
01:12:02 or solutions should be proportionate to the performance issue identified this included understanding the resource commitments that would be placed on both the leed brigade department and on babcock in terms of producing the article and working to develop the associated training material
01:12:15 associated training material now now i'll show you that let me give you something else um peter groves told us uh yesterday and i summarized that the tcap process uh was it was a compass was cumbersome
01:12:28 uh was it was a compass was cumbersome and the developing training packages could be a resource and time incent a resource and time intensive process do you agree with that uh i didn't have any personal
01:12:41 uh i didn't have any personal involvement in tcap but
01:12:44 but my reputation it was resource intensive so i you know i heard many colleagues complain about it do you agree with what mr reason says at
01:12:55 do you agree with what mr reason says at paragraph 36 on the screen there in front of you um i'm not sure i do actually um what do you not agree with
01:13:06 maybe in odtb gary reason was sitting thinking oh my goodness how are we going to do this thing that odcb are on the verge of deciding they want to do maybe as the manager for that function
01:13:18 manager for that function he was worrying about um how are we going to achieve that but
01:13:24 but i can't say i can bring to mind an example where we had a discussion about whether we could in terms afford to do something or not i
01:13:35 in terms afford to do something or not i i don't i genuinely don't remember myself that there was
01:13:40 some kind of rationing process i i i i think it's entirely you know i i have been a senior manager i'm sure that it's entirely plausible that you know outside of odcb
01:13:52 plausible that you know outside of odcb there was somebody managing a rationing process and having to bring it back but the rationing process as such was not happening within odcb i i think we were unconstrained in being
01:14:04 i i think we were unconstrained in being able to say you know we want this or we want this or we want this and
01:14:09 and i don't recall any examples of either the ac training uh before the externalization or babcock coming back saying oh that's impossible you've only got 10 trading days left or or anything
01:14:22 got 10 trading days left or or anything like that so do did it come to this that you don't recall any discussion at the odcb along the lines that investment in new training materials or solutions
01:14:34 training materials or solutions needed to be proportionate to the performance issue identified as he says or something of what you were mindful i think the statement is true but i
01:14:45 i think the statement is true but i don't know that i would attach the words the board was mindful i don't know how gary you know knows the board was mindful of that in particular right um
01:14:54 what was the board odcb that is at any point dissuaded from producing as many training packages as it would have liked by any factors such as
01:15:05 by any factors such as resource availability proportionality or cost
01:15:10 cost i don't think so i don't recall any examples of that being the case but that's you know that could be about
01:15:18 about memory and recollection and today um but no i don't i don't think so mr miller no right mr graves also referred to the concept of a training burden i think it was a word he used and to the fact that
01:15:29 was a word he used and to the fact that as he said you couldn't release everybody to do all of that training at the time
01:15:37 to your recollection did the odcb share that concern or harbour it uh i'm sure we will have touched on uh we will have touched on that
01:15:49 we will have touched on that um
01:15:50 um i just want to say that you know my comments in the last two or three minutes are not intended to suggest that you know
01:15:57 you know training was an endless supply in london fire brigade and there were no limits on it that's not that's not i've been trying to answer your questions truthfully and accurately but i i don't
01:16:08 truthfully and accurately but i i don't i don't
01:16:10 i don't i don't want them to amount to more than the answers were um
01:16:15 um but in terms of um making
01:16:19 making firefighters being able to make firefighters available for training the work that we did to create what's called the strategic resource which must have been in
01:16:33 which must have been in 2006 maybe what was very very important in terms of uh being able to mandate time mandate time for
01:16:44 time for uh fire station based staff to undertake training so in the years before the creation of strategic resource training was very often interrupted by
01:16:55 training was very often interrupted by appliances to have to go out and shouts but i think it's part it's either the second or the third london safety plan we
01:17:02 we created this thing called the strategic resource and the effect of that was to guarantee time for fire station based training
01:17:11 training and there were allocations of time the same for outside duties or um seven two days as as they're sometimes called so for outside duties for training and for other specified uh activities um
01:17:24 other specified uh activities um although and i can't think of what they might have been but for those two key things
01:17:29 things we knew that we needed to make guaranteed time available for firefighter training and we did that so the problems of making being able to make personnel
01:17:40 making being able to make personnel available for training and for that time to be guaranteed was very actively addressed and with a large measure of success
01:17:49 success um and um
01:17:51 um and um there will have been considerations about
01:17:54 about you know how much can you you know if you've created a one liter pot that's available for training you know are the proposals for the following year more or less than one liter so there was still a supply
01:18:06 one liter so there was still a supply and demand kind of thing to be managed um
01:18:10 um but um but we we did during my time make enormous strides forward on being able to guarantee time for firefighter training because we regard it did it as
01:18:21 training because we regard it did it as so important sorry that was a very long answer it was and i'm sorry it only partly answered my question let's look at it a different way around was there any way in which the odcb's decision
01:18:31 decision to recommend training constrained by any of um matters such as resource availability or cost
01:18:41 or cost no
01:18:42 no now in the instances where odcb decided that a bespoke cbt package was needed for an operational news article was the board involved in the development of the package
01:18:54 development of the package uh and the creation of its content or was that left uh to um somebody else uh
01:19:01 uh the board was not involved was not involved do you know who was depending on the topic right now
01:19:11 can we leave aside for the moment babcock and their production of cbt packages is it right that you expected babcock to revise all of their training packages to
01:19:22 revise all of their training packages to take account of information and feedback being received by the odcb
01:19:30 uh not all of their training packages but
01:19:35 but my memory is that as part of the process the
01:19:39 the existing
01:19:40 existing the training packages that existed which had a relevance to the topic concerned were reviewed to see whether they needed to be amended in the light of whatever new
01:19:53 in the light of whatever new detail or emphasis um it was that we wanted to bring to the topic right so can we take it the the babcock would be the end point
01:20:05 be the end point for the training that you the odcb wanted to happen um
01:20:13 um yes but with a great deal of assistance along the way indeed but they're the end point now can we get back to the diat policy please lfb3055171 at page seven let's just pursue babcock a bit more
01:20:26 let's just pursue babcock a bit more uh
01:20:26 uh page seven paragraphs three three one and three three two um it says here babcock 331 babcock attend the six monthly adcb meetings to be informed of areas highlighted by odcb
01:20:38 be informed of areas highlighted by odcb which require further training emphasis topics identified by odcb are distributed amongst the relevant curriculum heads within the babcock organizational structure to identify enhancement opportunities within their area of training delivery
01:20:51 area of training delivery and then 332 during the odcb meeting babcock also feedback on the topics highlighted at the previous meeting held six months previously which required further training emphasis and inform on the actions undertaken
01:21:04 actions undertaken is it right that babcock's feedback on previously highlighted topics was presented regularly to the odcb uh yes so
01:21:15 uh yes so there were two parallel reports uh yes one from operational procedures and one from training or babcock it's possible that in the early years or
01:21:27 it's possible that in the early years or the first year of babcock being impositioned that there were problems with that so if you pointed me to a gap in that in babcock's early early days i
01:21:38 in that in babcock's early early days i i wouldn't be surprised but they did they did grasp the requirement and the approach and that was implemented right i think the next document i'm going to show you may be an example of that can we please go to
01:21:49 example of that can we please go to lfb3067808
01:21:54 this is a set of minutes uh of the odcb for the 4th of march 2013.
01:22:01 and if you look at the agenda which we have here item 4 dynamic and intelligent operational training update attached hrd babcock and hrd
01:22:13 and hrd stands i think am i right for human resources and development yes and is this what um babcock's six monthly updates were known as yes diot or deod updates right so was
01:22:25 yes diot or deod updates right so was this a six monthly was this six monthly report exercise something of a joint venture between babcock and the lfb's training department well we didn't have a training department by that time um hrd then
01:22:38 department by that time um hrd then uh
01:22:40 uh i i'm sure hid were involved in it right now the report i'm sorry i've said i'm sure
01:22:46 sure i think that was always my impression right now the report for this meeting is that lfb 303
01:22:54 sorry three lfb three zeros three six seven nine six
01:23:01 let's look at what it is that's discussed at item four in the agenda here it is it's a babcock report to the odcb 4th of march 2013. if we turn to page 2 we can see a summary
01:23:15 this report provides members of the odcb with an update on the actions taken by babcock to support the publication of operational news edition 24 published in september 2012.
01:23:26 september 2012. uh and then if you go to page three we can see a table
01:23:30 uh there it is uh with um from left to right the subject of the article um the training courses in which the the subject was contained uh um information up to date and the
01:23:42 uh um information up to date and the proposed remedy which sets out how the training would be amended
01:23:47 amended now broadly speaking it was this the regular format of babcock's reports to the odcp uh
01:23:55 uh broadly speaking mr millett can you remind me if you know when did the contract with babcock start uh
01:24:03 uh 2012
01:24:05 2012 2012 2012. yeah i mean
01:24:08 i mean i think i've just said in terms you know that they
01:24:13 that they they they did grasp the requirement but it was it wasn't brilliant at the beginning um so i was only asking because i was wondering how close to the beginning this was and i and i can't
01:24:24 beginning this was and i and i can't remember well but but yes essentially march 13. yes um my question is on the basis that this was broadly speaking the regular formatter the way in which
01:24:35 regular formatter the way in which babcock's reports were presented to you did the odcb scrutinize the content of these reports closely or were they simply taking at face value no i think they were scrutinized right now let's
01:24:46 they were scrutinized right now let's look at uh bottom of page four at the bottom of page four we see an entry on fire survival guidance policy and the
01:24:56 and the uh a
01:24:58 uh a training course uh box says no dedicated training delivered in this area however delegates receive inputs in im courses fast survival guidance policies discussed with all
01:25:09 guidance policies discussed with all delegates from supervisory management upwards as part of tactical decision exercises
01:25:14 exercises information up to date n a and then proposed remedy incident management training includes fast survival guidance as an inject to about 50 percent of sm and gm tactical decision exercises and within
01:25:25 tactical decision exercises and within certain incident command exercises supervisory managers also receive emphasis on this subject area as part of their courses and the control information form carried on appliances is also discussed
01:25:37 carried on appliances is also discussed and then over the page is something about command units all cu training command units cu training includes discussion on forward information boards all i am management
01:25:50 information boards all i am management development training includes discussion on control information boards and multiple choice questions are used to test knowledge so
01:25:58 so in a nutshell do you agree that babcock was effectively saying that this issue the issue of fast vibrant survival guidance training was already covered in existing training
01:26:10 existing training could you go back to the previous page yes of course page four
01:26:17 under the proposed remedy in summary i'm just putting it to you babcock was saying that effectively the issue was already covered in existing training
01:26:46 i mean it says what it says and i'm just asking you to agree with this summary could you go back to page two please
01:26:55 yes can we go back to page two okay
01:26:59 okay um
01:27:00 um sorry i'm back to uh whatever the page was page four is it or it's different uh sorry
01:27:08 sorry back to the table i'm sorry right back to the table page three i think yeah
01:27:14 yeah so
01:27:15 so your question is were babcock saying it's already covered sorry page four is what i want page four yes yes first survival guidance policy proposed remedy basically they're saying are they this issue's already covered in existing
01:27:27 issue's already covered in existing training do you accept that
01:27:35 well not quite uh in the sense that it doesn't quite say that uh well let me try this differently we can read it and form our own view but but question of fact did the odbc go
01:27:48 but question of fact did the odbc go away and check that babcock's training did
01:27:51 did in fact adequately address these issues
01:28:00 the question of this document so i i can't remember how it was received at odcb
01:28:07 odcb um but i have before being invited to do so being frank with you that they got off to a shaky start with these reports um and they improved over time
01:28:19 um and they improved over time um uh so i can't i i can't remember at this at this distance whether you know this was one where i went to james douglas and said look you know this
01:28:29 this is not cutting it for me i just can't i can't remember that at this distance but i know you know in the early days uh i certainly had discussions with james who was then responsible for overseeing the
01:28:40 was then responsible for overseeing the contract and said look you know these reports have got to be more like the reports we would have had from ac training when the service was was in house and they did improve uh they did improve
01:28:51 improve um so i can't you know i cannot remember how this report in march 2013 was received at odcb but but i feel i can say that if we had any doubt about what babcock were
01:29:04 any doubt about what babcock were claiming in this area of training
01:29:08 training we would have gone away and checked it we we wouldn't have taken it on face value and just passed on now do you remember whether uh uh whether babcock ever went away and
01:29:20 uh whether babcock ever went away and changed their training uh
01:29:23 uh by the to a greater or lesser extent following an odcb meeting
01:29:30 i don't know no you don't know no because they pres this this report gets presented there's discussion at the meeting do you remember an incident an instance where babcock as a result of what was
01:29:42 where babcock as a result of what was discussed at that meeting went away and enhanced or narrowed their training i think it's more likely mr millet that by the time that babcock were coming back to us to say
01:29:54 back to us to say you know this this is what we've reviewed and this is what we propose to do
01:29:59 do um
01:30:00 um that was that was as it were at the end of the production line rather than early on so i think that they'll have gone away from odcb and they'll they'll have done their own piece of work and they'll have come back
01:30:12 piece of work and they'll have come back and
01:30:13 and liaised with james douglas and or peter groves and all the subject matter experts and said this is what we're minded to say you know is that doing it for you
01:30:22 for you and those people will have said yes or no so by the time this got back to odcb
01:30:28 odcb um
01:30:33 we could be reasonably confident at odcb that what we were getting was you know at least very close to if not exactly what we wanted um but it but if you know these these reports weren't noted for information
01:30:45 reports weren't noted for information they were scrutinized they were important parts of the process well let me come back to that in due course let's just look at some minutes for the odcb from july 2014.
01:30:56 for the odcb from july 2014. lfb3040719
01:31:01 and if we look uh at the first page you can see that the date of the meeting is the 30th of july 2014 you are there in the chair and you can see who is present and if we
01:31:12 and you can see who is present and if we go to page uh
01:31:15 if we go to um a little bit lower down the screen same page item six notes of the meeting 16th of june impd exception report can you see that yes
01:31:26 yes you can see a note uh under item four which says the dc fep just pausing that am i right that that's that's me that's yeah the deputy commissioner um requested that a record
01:31:38 commissioner um requested that a record is kept from when issues regarding training are raised and when they are implemented as a training solution she suggested that the two actions detail that item four should be tracked through the system it was agreed that the h o
01:31:51 the system it was agreed that the h o o a
01:31:52 o a the head i think is of operational assurance yeah would monitor progress first question why did you consider that a record needed to be kept from when issues regarding training were raised to when they were implemented as a training
01:32:04 when they were implemented as a training solution because i wanted some assurance about it
01:32:08 about it and were there were there you wanted some assurances about it but was there a particular problem that you were seeking to solve by that proposal
01:32:17 um
01:32:22 i don't remember i don't i don't remember that but you know uh i i will have asked for some monitoring uh because a concern had occurred to me
01:32:35 a concern had occurred to me do you remember what that was no you don't no um can we then go back to the diode policy
01:32:43 well before i do was a record keeping system actually implemented uh
01:32:48 uh i like i like to hope so but i but i don't know for sure you don't know for sure and therefore you can't tell us when if it was when it was implemented no i'm sorry no in your experience and it's a very
01:32:59 in your experience and it's a very general point your question how how speedily did babcock action training issues when the odcb had identified them uh
01:33:10 well given that given that they had to report back every six months every six months uh i imagine they were relatively higher priority items just because you know
01:33:22 priority items just because you know they
01:33:24 they i i don't think they found odcb easy or
01:33:29 easy or complacent uh you know it odcb was the most difficult thing i did in london fire brigade without a doubt um you know it was it was difficult work and it was intricate and it took a lot of effort
01:33:41 intricate and it took a lot of effort and detail and they saw that when they came to odcb so
01:33:48 you know they came back at the following meeting which was the expectation now can we get back to the deox policy at lfb
01:33:55 lfb fire three zeros five five one seven one and now go to page eight
01:34:01 uh mr chairman i'm just looking at the time actually before we go on to that document maybe now is a convenient moment for the break well if you're going to a new document or a new nine o'clock i'll go to an old document but a new part of it yeah all right
01:34:13 new part of it yeah all right i think it's time we had a break today in the afternoon um so we'll stop there we'll come back at 25 to 4 please and
01:34:21 and again please don't talk to anyone about your evidence when they're out of the room all right good thank you very much we'd like to go to the usher then please
01:34:40 thank you mr miller 25 to 4 please
01:54:20 uh you ask mr dexter to come back in please
01:54:43 all right ready to carry on thank you yes mr man thank you mr chairman um mr extra can we get back to the dioct policy please at lfb3055171
01:54:53 and i'd like now please to go to page 8 and look with you at paragraph 3.41
01:55:02 and 3.41 it sits under step three so we're still under that acting application of interventions and it says this on the rare occasions
01:55:14 on the rare occasions the topic identified by odcb requires change to or instigation of a new policy the incident management policy group will inform the relevant team who will usually be from either operational
01:55:26 usually be from either operational procedures or operational resilience that they need to start the risk assessment and operational policy writing process this procedure will in turn
01:55:35 turn require the author of the new or amended policy to undertake the training commissioning and alteration process tcap
01:55:44 tcap now um
01:55:47 now um just unpacking that or perhaps standing back from it why was it according to this passage rare for odcb to consider that there should be a change to policy
01:55:59 should be a change to policy i've no idea did you ever discuss that question with anybody else at the odcb no right
01:56:12 does it surprise you to see
01:56:15 to see that this uh policy the diod policy says that
01:56:22 says that it's only on a rare occasion that topics identified by adcb's required changes to or instigation of a new policy yes
01:56:32 i i think it's um i think it's an unnecessary statement uh and it sounds a bit complacent uh the paragraph could simply have said you know
01:56:42 know if the policy requires to change blah blah blah so i don't know what motivated the author to say that right right um
01:56:51 was it in fact rare during your time up to march 15 that a topic identified by the adcb would require change to a
01:57:02 the adcb would require change to a policy or an instigation of a new policy
01:57:07 i don't remember but i'm relying on memory here and you know uh
01:57:13 know uh memory has its faults i don't remember there being occasions where the diot op report so we looked at the training diet report but there was a parallel
01:57:26 diet report but there was a parallel operational procedures report i don't remember there ever being an ill return as in you know there's nothing there's nothing nothing to report based on the decisions of odcb last time um
01:57:38 um so
01:57:40 so i i think it's more likely than not that
01:57:45 no no i'm sorry i'm um
01:57:49 um if operational news as it did uh contained um some articles which were about
01:58:00 new equipment i can see that you know references to new equipment might require a change to an operational policy which was not significant in substance but which
01:58:11 substance but which needed to be recorded in that policy um
01:58:14 um if an operational news article was seasonally related you know watch out for barbecues on balconies uh that that's much much less likely to give
01:58:25 that's much much less likely to give rise to a need to amend a policy um sorry
01:58:29 um sorry it's difficult i'm sorry i feel it's difficult to answer the question i don't did you
01:58:35 did you this policy um
01:58:37 um it was issued in april 2013 and was went through a number of amendments during your time
01:58:43 your time did you note uh paragraph 3.441 and the statement on the rare occasion etc or was that a later edition after your time i don't know if it was a
01:58:55 after your time i don't know if it was a later edition i i don't i don't remember this wording which is not to say it wasn't there during my time it could well have been right were you very familiar with the diot policy uh
01:59:06 familiar with the diot policy uh and its language or did you only have a passing familiarity uh
01:59:12 i didn't have a passing familiarity with diat as the process um i didn't regularly re-read the policy now right
01:59:23 now right thank you
01:59:24 thank you now um
01:59:26 now um the the process we've gone through so far diot and we've got to stage three uh
01:59:33 uh collating information through the diot sources identifying operational news articles considering consequential changes to training and policy over the six month period um
01:59:44 six month period um i it is what it is how long on average did it take on average from an issue being identified to it being addressed in a training uh package
01:59:56 being addressed in a training uh package or a policy
02:00:00 i don't know right a year more than a year i don't know right now let's go to lfb3045960
02:00:15 uh now um this uh is um as you can see uh the
02:00:20 uh the it's a joint document authored by the lga and the uh cfoa the chief fire officers association and you could see that it's called the fire pier challenge report for the lfb
02:00:32 fire pier challenge report for the lfb march april 2015 which is on the cusp of your departure date isn't it it is if we go to page 12 paragraph 37 you can see it says this
02:00:43 paragraph 37 you can see it says this under paragraph 37 in general there is a culture of seeking the best solution to issues rather than the most utilitarian despite this intention this sometimes manifests itself in some clunky complex processes sheep dip training
02:00:56 processes sheep dip training and non-tailored renewal of competencies and training that was their assessment do you agree that the odcb's processes were clunky and complex
02:01:09 i agree they were complex but i believe necessarily so i i don't believe they were clunky do you agree that its main output to operational firefighters namely operational news could only ever provide
02:01:21 operational news could only ever provide generic and superficial training for officers on the ground
02:01:26 no
02:01:30 you don't agree with the expression sheep dip training then no
02:01:34 no you don't agree that they were non-tailored renewal of competencies and training nope did you ever see this document at the time no right who um
02:01:44 who um who did see it or would have seen it from the best of your knowledge of the structure of this organization at the time the corporate management board right
02:01:55 the corporate management board right and
02:01:57 and is this a document that the corporate management board which is the cmb would have passed to the odcb no what would they have done with it corporate management board uh
02:02:11 they will have um drafted a response to it and um they probably reported it to a committee or to the authority what what committee
02:02:24 what what committee do you think if it was a committee it would have been governance performance and
02:02:32 and gee what's the c for it's a long time ago gpac uh governance performance and
02:02:41 uh i know what the c stands for but i just can't drag it to the front of my mind
02:02:45 mind either to gpac uh as mentioned this morning so there was gpac strategy appointments uh finance uh etc and where did that where did gpac sit
02:02:56 and where did that where did gpac sit in the three directorates it didn't sit in the three directorate so
02:03:01 so el fipa was an old-fashioned local authority a 1972 act local authority so there weren't many of them around after the early 1990s where did
02:03:12 around after the early 1990s where did sorry is it g-pack was a committee of the authority right so it was a member body but not part of the lfb no it was the governing body for it was part of the governing body structure
02:03:23 part of the governing body structure thank you i think that's all i needed to to know now um let's turn to step four diat about evaluating um well evaluating um if we go back to the policy please uh lfb three zero five
02:03:36 the policy please uh lfb three zero five five one seven one page ten we see evaluation mr miller may i just say one thing about that paragraph uh yes we need to get back to it so let's just do that so i can follow your
02:03:47 let's just do that so i can follow your whatever it is you're going to tell me um lfb3045960 page 12 paragraph 37 just the first sentence in general there is a culture of seeking the best solution to issues rather than most
02:04:00 solution to issues rather than most utilitarian i i'm just bound to say that i've seen an expert's report which says there was a make-do culture in london fire brigade which feels to me to be the opposite of
02:04:11 which feels to me to be the opposite of what this says and i i just feel in some sense of loyalty to london fire brigade um that i want to say that uh that seems to me to say the opposite of what i've seen in some other reports uh
02:04:23 what i've seen in some other reports uh addressed to the inquiry so you're commenting on the evidence for the inquiry am i allowed to do that well i i just want i'm sorry if i'm not allowed to do that can we take it from your
02:04:34 your what you've just told us just now that you disagree uh with the observation of paragraph 37 by the london but by the local government association and the chief fire officers association i'm i'm
02:04:45 chief fire officers association i'm i'm simply observing that it is the opposite of what some others have said well it might be thought to be a rather opaque express for opinion anyway indeed indeed yeah i think we probably could move on
02:04:56 yeah i think we probably could move on then well okay indeed and i i want to go to the diode policy please which is where
02:05:02 where we were or trying to get to a page 10 which is
02:05:06 which is lfb3055171 page 10. paragraph 5.6 now this is under the heading step 4 evaluating uh paragraph 5.7 uh it's rather long but let me just um
02:05:20 uh it's rather long but let me just um show you
02:05:21 show you this
02:05:22 this 5.67 in order to evaluate the operational efficiency of staff various methods are used which identify trends patterns and gaps in the lfb safety management system evaluation processes
02:05:33 management system evaluation processes should specifically identify the effectiveness of interventions published within operational news and then 5.7 and i'm sorry it is long i'll just i'll show you most of it and we can look at the rest if you like the
02:05:44 we can look at the rest if you like the cyclical nature of the diop process enables comparison of trends both short-term from one three-month period to another as well as long-term back to the instigation of the diop process records are maintained by the
02:05:55 records are maintained by the information management team enabling enabling accurate evaluation of the effects of the training intervention as well as an analysis of how trends for a particular subject have developed over
02:06:06 a particular subject have developed over time methods of evaluation employed include the following there are three bullet points there which i i i won't read out to you but just just looking at that
02:06:17 just looking at that do the references to identifying trends and the cyclical nature of the diop process mean that ultimately the odcb's main evaluative tool was to check whether a
02:06:28 evaluative tool was to check whether a particular issue represented itself in a future deod report
02:06:37 i'm sorry i lost the beginning of i'm sorry mr miller ask me the question again well yes let me try it a different way
02:06:46 at 5 7 there's a reference to the cyclical nature of the diode process and at 5 6 a reference to identifying trends patterns and gaps i i've read that all to you
02:06:58 i i've read that all to you do those references there tell us that in the end the odcp's main tool with which it would conduct an evaluation under the diop process would be to check whether particular problems
02:07:10 whether particular problems arose more than once
02:07:17 oh let me just um think
02:07:30 i'm sorry i'm not grasping the question i am sorry um well let me try a different way i read that to you yes um was the main tool with which the odcb would evaluate sorry what it had got
02:07:41 would evaluate sorry what it had got from steps one to three the question has it come back is it repeat is it a repeat problem largely yes
02:07:52 largely yes but
02:07:53 but largely yes but um sometimes uh for example significant events uh allowed us to see whether
02:08:04 allowed us to see whether something had been solved or improved or remedied so you know the lack of house fire for example wasn't um wasn't part of the diet process but
02:08:15 wasn't part of the diet process but generated
02:08:16 generated a great deal of material to help us understand what happened at the fire and
02:08:23 and what the implications and consequences were for firefighting and for training so there were things that happened outside the diet process which also contributed to the organizational understanding of whether
02:08:37 organizational understanding of whether some
02:08:38 some issues or problems were being solved or improved yes and leaving aside cases individual cases like lachenal if an issue did not
02:08:49 if an issue did not reappear in a diode report would the odcb simply assume that the problem had been resolved
02:08:58 would uh
02:09:02 i don't think any of us ever assumed that anything would never occur again it's just not that kind of organization um you know they do you know the scope of what they do day
02:09:14 you know the scope of what they do day in day out is you know it
02:09:17 it is broad and wide so there were no assumptions that something was good or great because you didn't see any evidence to the contrary we didn't take i don't think we took anything for
02:09:28 take i don't think we took anything for granted well was there ever any follow-up by the odcb in respect of an issue which had come past
02:09:37 past and gone off and been dealt with uh but have not reappeared was there any follow-up
02:09:42 follow-up they had not reappeared um i can't think of a document that did that um
02:09:50 that um i think
02:09:52 i think that some of the impd reports sometimes not often but sometimes offered a commentary that you know something seemed to have improved as a result of
02:10:04 improved as a result of xor y intervention um but i can't think of a study in the terms that you described no let's go then to step five of diot which is feedback and that we can see at page
02:10:17 is feedback and that we can see at page 11 if we just scroll down to that please and let's look at paragraph 5.16 and 5.17
02:10:23 5.17 uh 5.16 an appropriate method of feeding back performance outcomes for each of the evaluation processes is in place feedback is necessary to inform on the effectiveness of the chosen training
02:10:34 effectiveness of the chosen training solution and complete the diat cycle information is gathered from various sources to ensure that the feedback process is both appropriate and thorough some of the information to support feedback is gathered through trend
02:10:46 feedback is gathered through trend analysis trends may be identified as a result of inp submissions surds reduction in surds for a particular activity are indicators the behaviors conduct and performance is
02:10:57 behaviors conduct and performance is improving in the areas of communication delivered through the diot process pdps
02:11:03 pdps and brigade specialist officer comments which are reported to odcp on a six monthly basis this comparison enables the effects of
02:11:14 this comparison enables the effects of training interventions on the behaviors of operational staff to be monitored just help me what absurds uh please there's safety events uh so i think third is the safety image recording database right and of course i'm reading
02:11:27 database right and of course i'm reading that and thinking actually the health and safety sphere is probably a better example than i have been recalling of an activity you know
02:11:39 you know there's a clearer invisible relationship between an intervention after a safety event and what happens subsequently in terms of whether it's improved or not so there's probably a mine of
02:11:50 there's probably a mine of positive discoveries if one spent more time on health and safety data which i haven't focused on is the feedback stage just a matter of relaying the findings of stage four
02:12:02 relaying the findings of stage four evaluation to the various different individuals departments groups below um
02:12:09 below um your directorate or within your directorate
02:12:14 and other directories yes yes the latter all the directors yes yes
02:12:21 yes yes now can i then turn to your witness statement
02:12:26 now i think as we've seen the five stages of the diod process i want to just pick pick up some comments that you've made in your statement about the efficiency or efficacy of the process in your uh statement if we can go to your
02:12:38 your uh statement if we can go to your first statement of page six please paragraph twenty let's go to line seven now you say there that having reviewed the agendas and minutes for the odcb
02:12:49 the agendas and minutes for the odcb between january 2011 to december 2014. um this is in the middle of the paragraph you say this has reminded me can you see
02:13:02 you say this has reminded me can you see not yet
02:13:03 not yet picking it up halfway down the paragraph i've reviewed the agendas and minutes of the od cb for the period 20 january 2011 to december 2014 and some editions of
02:13:14 to december 2014 and some editions of operational news from before and after the latter house fire and this has reminded me that some new policies and or training interventions required active development and implementation for years after
02:13:25 for years after for example because of the delays introduced by judicial or political inquiries or because we depended upon national policy guidance or because new equipment was required or because the lead-in time between
02:13:36 because the lead-in time between identifying an issue and delivering a training intervention was often lengthy and sometimes because the training had not embedded in practice as we would have hoped now when you say there the policies and or training
02:13:48 there the policies and or training required active development and implementation for years after this is what you say there are you are you suggesting that the lfb's development of new training or policies sometimes took extended periods of time
02:14:02 sometimes took extended periods of time uh
02:14:03 uh i believe i'm saying that from an event there could be a very extended period before
02:14:14 a very extended period before delivery of the whole range of interventions that we decided upon including training were in place
02:14:23 in place for the reasons that i set out some of them were
02:14:26 them were in our control but quite often they weren't in our control
02:14:32 that's certainly the impression those words give now mr graves gave evidence yesterday on the delays caused to certain areas of training particularly incident command because of babcock's lack of subject matter expertise
02:14:44 matter expertise uh
02:14:45 uh is that
02:14:47 is that um
02:14:48 um one of the delays that you're referring to or or some other source it's not a delay that i was referring to no i didn't have that in mind when i made my comments why is that
02:14:59 made my comments why is that um
02:15:03 i find it difficult to
02:15:07 imagine a topic that babcock would be working on that didn't have a subject matter expert in london fire brigade was the absence of subject matter
02:15:18 was the absence of subject matter experts
02:15:19 experts or
02:15:20 or the lack of availability of subject matter experts to assist with babcock's development of training programs ever a problem which came before the odcb to the best of your recollection no right
02:15:32 was it a problem that ever came ever came before any of the departments sitting within your directorate to the best of your recollection
02:15:43 uh
02:15:46 no which which is not to say that i was not aware
02:15:52 not aware that
02:15:54 that that in some places in the organization the need the the extent of the work needed with babcock was i think you used the word earlier burdensome so i was certainly
02:16:06 burdensome so i was certainly aware that that was the case
02:16:09 i think the answer to my question is no indeed
02:16:21 um continuing with your statement please on page seven can we go to uh
02:16:26 uh line one um it's actually the very foot of
02:16:29 of the previous page but i'll give you the first two words i'm also it says reminded
02:16:33 reminded that many of the reports considered by odcb seemed seem to demonstrate that it was hard to make some lessons learned as some issues repeatedly presented themselves back to us i mentioned this because i think it's
02:16:44 us i mentioned this because i think it's important to recognize that whilst there was a genuine desire of the lfb for continuous improvement that hurdles were encountered which impacted on whether we could always produce the desired effect
02:16:55 could always produce the desired effect when you say hurdles were encountered encountered can you tell us what you mean there what were they well that we would see reports come back to odcb which said for example
02:17:09 we addressed this issue of messages from incidents six months ago or 12 months ago but what we're picking up from uh our observations and from the database is there's still a problem with
02:17:21 database is there's still a problem with messages from incidents they're either not happening or they're not happening quickly enough or they're not happening in the format that they should happen in um
02:17:29 um so that that's what i meant
02:17:33 i mean what what were the issues that would repeatedly present themselves uh messages from incidents uh came to odcb often concerned about as i've said
02:17:47 odcb often concerned about as i've said whether they were sent quickly enough whether they were in the right format
02:17:52 etc
02:17:55 other examples um
02:18:02 compartment firefighting could have been on that list
02:18:09 sorry i feel that i know this list really clearly but i'm struggling to recall it at this precise moment i do know this list really clearly um i've been back through all of the operational news and
02:18:22 operational news and so certainly messages from incidents i mean don't you've given us a fair flavor sorry pre-planning uh came up um pre-planning
02:18:33 pre-planning uh sighting of appliances yes um there were probably eight to ten topics which made an appearance each
02:18:43 each on more than three occasions in operational news over the five five or so years that i was involved yes now on the examples you've given us just now so compartment firefighting messages from incidents pre-planning sighting of appliances at
02:18:55 pre-planning sighting of appliances at incidents all of those were within the lfb's control weren't they they're not dependent on a third party they're not dependent on government no you're correct yes yes yes and and therefore why is it not the case that a
02:19:07 therefore why is it not the case that a meeting of senior operational officers of the lfb and the ods as such the odcb could not overcome them uh because it
02:19:18 uh because it because it's not how big organizations work mr millet so we were talking about trying to get 400 different workplaces four watches 100 fire stations we're talking about
02:19:30 100 fire stations we're talking about trying to get 400 different workplaces to
02:19:34 to all conform you know
02:19:37 you know to
02:19:38 to a policy intention and a training intention
02:19:42 intention and it wasn't always successful just sometimes sometimes it was the same people who failed over and over and then that
02:19:53 failed over and over and then that needed to be dealt with on that basis sometimes it was you know 10 different people over
02:20:01 ten different incidents over a six month period failed on messages from incidents um so there were there were lots of variations on why those issues presented themselves
02:20:15 why those issues presented themselves but i think you do have to think about london fire brigade as being 400 different workplaces and it's
02:20:21 and it's it's simply not well
02:20:25 well i mean
02:20:26 i mean maybe
02:20:29 i don't know uh maybe some organizations are successful in getting 400 of their outlets to perform uniformly into their standards
02:20:40 perform uniformly into their standards um but
02:20:42 um but i guess in the case of many organizations they're doing it in a single environment day after day but we're talking about 400 different workplaces 400 different watches going to random random different
02:20:55 going to random random different incidents all over london seeing different things experiencing different things having to make different responses and they didn't all get it uniformly right all of the time and that was a challenge
02:21:06 challenge and
02:21:07 and many of these things were a challenge and we had to keep working on them and then you had staff turn over and then at the same time as we were trying to maintain what i've referred to i think as traditional operational competence
02:21:19 as traditional operational competence we were pumping lots of new things into the organization so i'll try not to be too long but you know london fire brigade when i left in 2015 was radically different to the london
02:21:30 was radically different to the london fire brigade it was in 2001. it was completely different 77 changed it enormously you know dozens and dozens of new appliances came into service with many many more
02:21:42 into service with many many more we call them attributes but with many more specialisms and the brigade had to accommodate all of that and then it had to accommodate the risk of marauding terrorism for example and
02:21:54 of marauding terrorism for example and it was always having to change in response to events so we have this enormous
02:22:02 enormous responsibility or burden of new risks to introduce to the brigade and to train people for and in parallel the maintenance of what i call traditional
02:22:14 maintenance of what i call traditional competence and and it was a challenge and there's no point in me saying it wasn't a challenge because it was and sometimes it went really well and you know sometimes it remained a challenge for many many years
02:22:26 challenge for many many years um
02:22:28 um you say your statement here i quote
02:22:33 i quote uh that there was a genuine desire of the lfe for continuous improvement that hurdles were encountered which impacted on whether we could always produce the desired effect and you've given us a long
02:22:42 long list of reasons for that but did you ever consider or did the odc be as a body ever consider that the system you had
02:22:53 the system you had uh was ineffective well if yes we did or could be improved so i go on to say here i've said you know we were genuinely committed to continuous improvement and
02:23:05 committed to continuous improvement and i go on to say evidence of this desire is contained in self-assessment published in january 2015. so you've taken us to the document which was as it were the follow-up to the document which is part of my evidence so my evidence is
02:23:18 is part of my evidence so my evidence is the self-assessment which was prepared while i was with london fire brigade but i wasn't involved in the final in
02:23:25 final in in the document that you've produced but in that document are four pages on operational competence where we completely expose ourselves to the period we they
02:23:37 the period we they uh completely exposed themselves to the peer review team and said look these are all the things we do but tell us if there are better ways of doing it where you know we're genuinely open to learn um and we didn't do that
02:23:50 open to learn um and we didn't do that because we had to do that as part of the process so there were lines of inquiry as they called them which were mandated as part of that assessment process but the piece on operational competence we offered to them we didn't have to do
02:24:02 we offered to them we didn't have to do that we decided to do that because we were open to other perspectives about whether there were better ways of confronting this
02:24:13 were better ways of confronting this problem that you know you didn't always see
02:24:16 see the operational competence that you wanted in practice but did nobody ever think that there was something about the lfb as an institution that was peculiarly resistant
02:24:26 resistant to change which would have meant that these hurdles could be overcome uh do you mean compared with other fire brigades or other organizations just as a matter of efficacy on its own
02:24:38 a matter of efficacy on its own merits
02:24:40 merits um
02:24:43 um no i don't no i don't think that um no i don't uh
02:24:51 you know i i think about what's happening in maternity services in this country and some of the terrible terrible things we've seen in maternity services all over the country really scandalous things about women and babies
02:25:02 scandalous things about women and babies dying in childbirth and you know maternity services that defy understanding and
02:25:09 and and i'm very i'm obviously very unhappy about that but but i'd but i do take from it that other organizations too other services too you know have sometimes have
02:25:20 sometimes have very real challenges in improving their services and improving their organizations and
02:25:27 and you know i i don't want to convey to you either that we were complacent about it or that we were cocky about it i don't think we were either of those two things i i i think we were trying really hard to do the best we could
02:25:39 to do the best we could and
02:25:40 and i think the people who were involved in that the senior management team you know were a talented group of people and if they'd been um you know if they'd been better or other things that we could do i think we'd
02:25:52 things that we could do i think we'd have been talking about that um that's sorry a long answer but an important one for me uh because you're probing this question of you know
02:26:03 you know how
02:26:04 how how reflective were we about what we were doing and whether it was working and whether there were better ways of doing it and and i genuinely feel we were reflective about it we may not have got it right we obviously didn't get it
02:26:15 got it right we obviously didn't get it right in you know in in some respects in important respects in tragic respects but
02:26:22 but i i don't believe that we were not reflective about these issues did there ever come a time during your tenure as deputy commissioner when it occurred to you
02:26:33 when it occurred to you that the structures and processes at the lfb within which you were operating
02:26:39 operating were inefficient clunky slow and over process driven which meant that your objectives could not be secured did that ever occur to you
02:27:02 some of the answer is yes but it's it's not a straightforward answer
02:27:07 answer mr millet uh ron dobson used to say in my annual appraisals you know you need to go a bit slower rita um you know uh that was in my annual appraisals i you know i was
02:27:20 my annual appraisals i you know i was i'm not was just speaking about me but you know maybe i was always trying to get somewhere in a hurry and you know didn't do enough to he would say you know maybe sometimes you need to carry people with you you know and that means
02:27:31 people with you you know and that means you
02:27:31 you you slow down a tiny bit um
02:27:42 i'm not really asking you
02:27:47 sometimes it was too clunky and sometimes it was necessarily where it was
02:27:52 was it was not a straightforward it's not a straightforward organization it's you know it's more complicated than it than it looks um i feel
02:28:01 i feel um on the basis of what we've discussed so far about odcb and deota's processes and bodies um i'm going to ask you three three questions and see if you agree with them
02:28:12 questions and see if you agree with them i'm going to rather four i think first do you agree that the scope of the odcb's work was in essence to look at past incidents and training events and identify
02:28:24 and training events and identify learning points for the future yes yes do you agree that the diat process fundamentally relied upon the proactiveness of individual officers on the ground to
02:28:35 individual officers on the ground to feed back information up the chain
02:28:40 leaving aside single big events like la canal
02:28:46 well the diop process also included the feedback from operational procedures department and training department however organised um that was also part of the diop
02:28:58 um that was also part of the diop process so not just the incidents but the
02:29:01 the aspects of the action taken to follow it up but yes do you agree that in the context of a
02:29:08 a diminishing number of incidents that the diat sources were an increasingly narrow pool of learning opportunities uh i agree that it was an increasingly reducing pool
02:29:20 reducing pool and would you also agree that the odcb's primary training output namely operational news articles and the accompanying packages uh
02:29:30 uh also relied on individual officers being proactive
02:29:37 proactive yes yes
02:29:41 now i'm going to turn to a new topic which is fire safety and just start with that topic with some general general questions
02:29:53 with some general general questions we've established i think that the lfb's fire safety department fell within your directorate yes yes and during your time as deputy commissioner i think it's right that assistant commissioner steve turek was the lfb's head of fire safety
02:30:07 turek was the lfb's head of fire safety for most but not all of the period yes right um now uh could you just help me when was he not
02:30:16 certainly for my last four to six months uh the ac fire safety was neil orbell uh ac neil orbell um
02:30:29 uh ac neil orbell um and
02:30:30 and the
02:30:32 the there were a number of periods where steve was absent and i i simply can't remember whether we had an acting ac on those occasions or not
02:30:41 not because
02:30:43 because and they covered months rather than as it were weeks now can we look at your statement your first statement please and go to page six and let's look together at paragraph 19.
02:30:59 and you say uh
02:31:02 uh in the first line there one of my objectives was to make sure that the that the investigation findings had more impact on the work of the lfb and so from march 2013 i asked for
02:31:14 and so from march 2013 i asked for relevant fire investigation findings to be included in the reports to adcb in addition and at the same meeting i asked for information about control room activity to be included
02:31:26 um what had prompted that
02:31:30 that that i've read you there to be one of your objectives uh
02:31:34 uh reading the fire investigation reports so the fire investigation team i can't i can't somebody else will be able to tell you what the specific criteria was for
02:31:45 criteria was for the incidents that the fire investigation team would attend um so there was a scheme but i can't recount the details of it here today um but the fire investigation team would
02:31:56 um but the fire investigation team would then
02:31:57 then produce a written report and copies of all of those written reports
02:32:04 reports came to my office and i read them all well there's the sais no that's a different thing uh sais are senior accident investigation reports so they're focused upon
02:32:16 they're focused upon uh injuries to firefighters as part of the health and safety structure right
02:32:23 right now um
02:32:29 uh what did you hope would come from the odcb's regular consideration of fire investigation findings uh well they weren't they weren't considering all of the
02:32:41 they weren't considering all of the findings of the fire investigation activity um so there was some kind of filtering that went on in operational assurance the liaison between operational assurance and the
02:32:52 between operational assurance and the fire investigation team but i
02:32:55 but i from reading all of the investigation reports which i which i did they provided insights into
02:33:07 insights into uh details which to my mind had not been uh
02:33:14 uh had not been surfaced as well as they could have been previously um so
02:33:20 um so this this could be that in an individual dwelling fire for example uh
02:33:26 uh they'd been a house and sorry this is a real example there'd been a house extension maybe 20 years before and somebody had died in a fire as a result of smoke inhalation
02:33:37 result of smoke inhalation on in their bedroom upstairs and the fire investigation team uh discovered as part of their investigation that there was a breach of compartmentation even in a domestic um a domestic dwelling like
02:33:49 a domestic um a domestic dwelling like that
02:33:50 that but things like breaches of compartmentation smoke
02:33:55 smoke smoke ventilation systems a whole range of
02:33:59 of fire safety feature failures were often identified in fire investigation reports i can't say for certain i just don't know whether that was specifically a purpose
02:34:10 whether that was specifically a purpose of fire investigation reports i feel rather bad now that i don't know that but but as a matter of fact i don't but they provided uh additional insights and they were detailed and useful insights into
02:34:23 detailed and useful insights into what was happening in fires um and given that part of the objective of odcb was to make firefighters aware of
02:34:32 of new risks or commonly found risks or or such like um there was there was a natural synergy there i felt right what just just help me what did the odcb do from march 13 with the
02:34:44 the odcb do from march 13 with the information gleaned from all of these fire investigation reports it was receiving well it wasn't receiving all of the fire investigation reports so it was
02:34:53 was right i think were boiled into the impd reports as i recall and that was my next question in what form did the the findings from firing from relevant fire investigation
02:35:04 firing from relevant fire investigation reports come to you um
02:35:10 uh i don't know that i can very clearly answer that at a distance um you had an impd report uh earlier
02:35:22 you had an impd report uh earlier and in the index that referred to fire investigation findings
02:35:28 it would have been [Music]
02:35:32 [Music] a summary or a round up of [Music]
02:35:37 [Music] issues that the fire investigation team in consultation with the operational assurance team felt were notable enough to be drawn to the attention of odcb
02:35:49 to be drawn to the attention of odcb and the fire investigation team sat where in the fire safety department that's under your directorate yes uh but the operational assurance team
02:36:00 uh but the operational assurance team sat under mr reasons that's right yes yes i see yeah so they would have had to have talked to each other and decided what went into a single report they would who how was that done you know can you help can you help us with the
02:36:11 you help can you help us with the process of that oh
02:36:18 they i don't know i imagine they met right talked about things right
02:36:24 right and
02:36:25 and did the inclusion of this information from relevant fire investigation findings
02:36:32 findings have the the result you desired uh so i think i've said here i asked that to happen in march 2013 so um
02:36:43 um so if i asked for it in march it probably didn't start happening until later in 2013 so uh i don't think he just had a sufficient gestation period
02:36:54 sufficient gestation period for me to be able to answer that right okay um let's turn to a document um now
02:37:01 um now we know that the latino house fire happened in july 2009 and we know that that was a significant event for the lfb's fire safety department we will look at that in detail before we do i want to ask you a few questions about a
02:37:14 want to ask you a few questions about a document from december 2010 at inq 301
02:37:20 if we can just have that up please
02:37:29 and it's entitled fire safety in london fire risks in london's tall and timber frame buildings december 2010 uh now just just for your um
02:37:43 uh now just just for your um your reference uh this was discussed at the odcb uh in august 20 2009 an earlier version of this i think which predates your
02:37:54 of this i think which predates your appointment but um
02:37:57 but um if we
02:37:58 if we look at the report itself and perhaps you want to turn down a page or two do you recall seeing this uh i do recall having seen it yes do you remember the circumstances in which you saw it
02:38:11 it was an investigation by the london assembly
02:38:16 assembly i think i may even attended one or more of the london assembly meetings as director of corporate services
02:38:23 services probably to do with i don't know data or information but i'm not certain about that i think i did attend
02:38:29 attend uh one or more meetings of the assembly uh an investigation by the assembly into um
02:38:37 um something within as it were our remit wasn't it was an unusual thing now we're going to come back to this report shortly but before i do i want to take an excursion outside it to look at some surrounding documents can we go first please to lfb two zeros
02:38:50 can we go first please to lfb two zeros one zero one nine seven five
02:38:56 um this is a document from february 2010 so the beginning of that year that the
02:39:04 that the london assembly planning and housing committee
02:39:08 committee wrote to ron dobson you see that yes he was the then commissioner and if you look at paragraph two of the letter it says the purpose of the investigation is to help ensure that the risks and occurrence of fires in tall and
02:39:19 occurrence of fires in tall and timber-framed buildings in london both during construction and after completion are reduced and therefore writing to request your help with this investigation you see that yes uh and uh it signed on
02:39:31 you see that yes uh and uh it signed on page three by jenny jones assembly member
02:39:34 member uh and the letter went on to set out the terms of reference uh for the investigation and the questions for the lfb
02:39:42 lfb um
02:39:44 um first was was this the investigation that led to the report that we looked at a moment ago dated december 2010 i think that's likely can we then go to lfb double zero one zero one nine seven four
02:39:56 zero one nine seven four this is an email chain uh from february 2010 and uh the topic was london assembly scrutiny committee as you can see from the first email there can we go to the
02:40:07 the first email there can we go to the bottom of page one and over to page two at the very bottom of page one you'll see an email from steve turek to you and ron dobson of the 10th of february 2010 at 10 40 in the morning and if you turn
02:40:18 at 10 40 in the morning and if you turn the page he says this he says i have just received this for completion and return i will get it completed then discuss before any final submission you see that and then immediately above that
02:40:30 see that and then immediately above that um if you go back to page one uh
02:40:34 one uh uh sue marshall tells steve turek you and ron dobson just to let you know the commission has received the letter attached to and i think sue marshall was the personal assistant
02:40:46 the personal assistant to um ron dobson is that right yes yes uh uh now um she attaches the same well she attaches i'll show you a letter uh nfb double zero one zero nine seven five
02:41:00 zero one zero nine seven five it's the same it's the same letter um
02:41:03 um now can we go back to the email chain and go to the top of the page we go to the top of the page
02:41:11 we can scroll up um steve this is from you uh to steve turek copy to ron dobson and um others
02:41:21 um others steve i know that you will feel we've done this work once for navin's briefing but this means that it's time to do it all again and a bit more we will need to make
02:41:30 make a detailed submission based on this invitation it might be helpful to see if colleagues beyond sfr have a contribution to make and so i will copy this to obvious colleagues for them to consider the matter
02:41:41 consider the matter now first what were you referring to when you referred to the work for navin's briefing uh
02:41:48 uh navin shah was
02:41:50 was at one time or for a period of time leader of the labour group on the uh on the authority um
02:42:04 uh on the authority um i don't think i don't think navin was ever chair of the authority but he was certainly leader of the labour group what was the work done uh navin
02:42:15 navin navin was also an architect uh my background he was interested in this issue of timber framed buildings um and navin
02:42:27 um and navin uh i gathered from this must have asked us for a briefing and so there'd been a number of very notable fires in
02:42:36 fires in probably all in 2010 but maybe in 2009 i don't think any of them had been in navin's constituency but i'm not sure but navino's leader of the labour group will have asked officers for a briefing
02:42:47 will have asked officers for a briefing which we will have provided and i guess that my reading of the letter from jenny jones i think you said was
02:42:57 was that you know we covered some of the grand in the briefing that we prepared for nothing but we needed to we needed to now do more so there's a briefing for navin sharp it was created that's what it looks like
02:43:08 was created that's what it looks like yes right
02:43:10 yes right you know we often produce briefings for navigation we produce a briefing for any member who asked for it on any topic was that did that briefing involve tall buildings
02:43:20 buildings and particularly far spread into all buildings or was it limited to timber-framed buildings i can't be sure mr miller my my recollection is that this started out as being about timber framed and turned
02:43:31 being about timber framed and turned into
02:43:32 into tall and timber-framed but i i can't i can't tell you more than that with any authority now you can see to whom you've copied this email yes um and you've said in your email
02:43:45 and you've said in your email um it might be helpful to see if colleagues beyond sfr uh have a contribution to make um why did you think that they that these particular people might have a
02:43:56 these particular people might have a contribution that they could make because of the responsibilities of their roles
02:44:03 right i'm not going to go through each of them but um
02:44:09 did did they have particular insight into tall buildings dry spread in tool buildings
02:44:15 buildings do they have insulin well sorry they're they're a real mixed bag i'm afraid so david atkinson was the clerk to the authority at that
02:44:27 was the clerk to the authority at that time so that's why he was copied in he needed to know he needed to know we were interacting with the assembly on this um i can't remember whether if at that time dave brown and andy hickmott were
02:44:40 time dave brown and andy hickmott were sharing um what was sometimes known as service delivery but at other times was known as operations prevention and response so i think there was a time where we had a north south split
02:44:52 north south split and so they were as it were equivalent assistant commissioners and because they were assistant commissioners responsible for fire stations and other things
02:45:04 fire stations and other things it certainly seemed at least conceivable to me that they might well have a contribution to make now um
02:45:13 if we go to the next document i'm mindful of the time mr chairman um i'll think i'll probably do this one and then
02:45:20 then and then
02:45:21 and then ask for the break lfb triple zero eight six four one one
02:45:33 this is an email from you to steve turek dated 3rd of march 2010
02:45:40 and you can see that you say steve here is a version with all of the changes would you give it a thorough review please
02:45:48 uh now
02:45:50 now this is a response i think to the planning and housing committee um perhaps you don't recall it i'll show you the attachment it's at nfb triple zero eight six four one two
02:46:17 lfb triple zero eight six four one two
02:46:28 so
02:46:42 well i don't know it seems to be reluctant
02:46:45 reluctant to make an appearance
02:46:49 ah here it comes right uh
02:46:58 that is a draft letter yeah
02:47:00 yeah which i think you attached to this email just can you confirm that oh uh
02:47:06 oh uh i can't confirm it but i think it's very you know
02:47:09 you know uh it's likely right
02:47:12 right do you know who else was involved in drafting the lfb's response to the planning and housing committee
02:47:20 my experience from working london fire brigade would suggest that probably half a dozen people were right so some people were involved in the substance and some people were more involved in the vocabulary and
02:47:32 involved in the vocabulary and the layout and uh whether it was generally uh
02:47:38 uh whether it was generally uh
02:47:42 uh suitable for a non-specialist audience so the
02:47:47 so the people people will have contributed on the basis of different considerations well perhaps we'll we'll visit the um response in more detail and the submission that came after it tomorrow
02:47:59 submission that came after it tomorrow um
02:48:00 um rather than persist with this document at this hour mr chairman is that a convenient moment i think it is yes mr miller thank you well mr dexter we're going to stop at that point and um i'm afraid i'm going to have to
02:48:11 and um i'm afraid i'm going to have to ask you to come back tomorrow i should have thanked you this morning actually for making yourself available today at all because i think we originally asked you to come tomorrow didn't we but we're grateful to you for
02:48:22 didn't we but we're grateful to you for filling in a gap today so thank you very much anyway we'll we'll resume please at 10 o'clock tomorrow and again please don't talk to anyone about your evidence or
02:48:33 talk to anyone about your evidence or anything
02:48:33 anything relating to it over the break all right thank you good thank you very much indeed
02:48:38 indeed the usher please thank you
02:48:48 thank you mr miller so 10 o'clock tomorrow please yes thank you
02:49:00 you