London Fire Brigade Evidence - Wednesday 24th November 2021 (1/2)

Full transcript

00:00:28 hmm

00:00:32 good morning everyone welcome to today's hearing

00:00:35 hearing today we're going to continue hearing evidence from stanley cotton formerly of the

00:00:39 the london fire brigade so would you ask mr scott to come back in please thank you

00:00:50 good morning miss cotton good morning that's it let's take a seat make yourself comfortable thank you sir all right ready to carry on the hoop yes sir very good thank you good morning mr millionaire welcome good morning good morning to you good

00:01:01 good morning good morning to you good morning members of the panel good morning miss cotton good morning can we go back please to tcap0124 which we looked at yesterday at

00:01:11 one lfb403716

00:01:17 and if we go to page eight in that document

00:01:20 document you can see that there is a record of the decision to develop command decision exercises contained at the bottom of your screen there

00:01:31 there note of any key decisions made issues raised etc at tsg

00:01:37 and if you look at the first paragraph it makes reference to the babcock proposal that we looked at yesterday and it goes on in the second paragraph to say this

00:01:45 say this superseding babcock's proposal in stage three below it was not manageable to split this into separate tcaps for each incident command course as the proposal is to change and

00:01:56 course as the proposal is to change and enhance six command decision exercises cdes that will be used in all incident command courses the deadline of 20th december 2013 is current and stands for the enhancement

00:02:07 current and stands for the enhancement of six cdes following this tcap recommendations will be made for further enhancements that will be fed into the ic course review following a meeting at beckton training center on the 10th of december 2014

00:02:19 center on the 10th of december 2014 regarding the enhanced incident command training based on latino inquests rule 43 recommendations tcat124 the following points were agreed and it goes on uh and we'll look at that in a moment

00:02:31 uh and we'll look at that in a moment before we do can you just help us why was the command decision exercise number reduced from 16 down to six

00:02:42 i think as i said yesterday i wasn't directly involved in the detail of any of this i believe from what i found subsequently it was

00:02:54 what i found subsequently it was to do with the suitability of the cdes and i think once again

00:03:01 again the

00:03:02 the detailed amount of work and the length of time it would take to develop those cdes but that's just what i found out subsequently i wasn't aware of that at the time now the next block of text

00:03:13 the time now the next block of text as we go on to see on page on on page nine has some bullet points and you can see what was agreed as i've read to you about a year later in 2014 and it says

00:03:26 about a year later in 2014 and it says uh

00:03:27 uh first bullet point the high-rise building within the initial demonstration was not felt to be suitable by the lfb as the main cd to address the objectives of tcap124 this has now been changed to a cde

00:03:39 this has now been changed to a cde currently held by babcock known as blackwall tower this is a high-rise block consisting of a greater number of flaws and was felt better suited to the learning outcomes in addition to this dac graham ellis

00:03:51 in addition to this dac graham ellis felt that there was an opportunity to use a recent incident within a high-rise block which had similarities to latino house as a cde further work will be done on this by sm peter rickard who will be supplying all

00:04:02 peter rickard who will be supplying all of the necessary information to babcock regarding this incident and location as stated although the cde has been changed to blackwall tower the lfb's ideal cde is the high-rise incident

00:04:13 ideal cde is the high-rise incident identified by dac graham ellis for this training

00:04:17 training so it looks is this right that as at december 2014 there was one main cde command decision exercise namely blackwall tower initially

00:04:28 initially my question is had the decision been taken only to use one command decision exercise or was there to be one command decision exercise supported by the other five

00:04:38 five um i'm sorry i'm not aware of that decision that was taken i do know that when dac graham ellis had attended the meeting with babcocks where

00:04:49 attended the meeting with babcocks where they had had a conversation about the training inputs he told me that he had made them aware of a current a recent operational incident that he thought would be more suitable he did

00:05:01 thought would be more suitable he did share that with me and he was sharing that information with them but um that was all the detail i was aware of at the time

00:05:07 time right just going back to the foot of page eight and just picking up one or two things in your answer um you can see that there was a meeting at bechton training center on the 10th

00:05:18 at bechton training center on the 10th of december 2014 regarding the enhanced incident command training were you at that meeting no i wasn't can you explain why as uh a-c-o-a you weren't at that meeting

00:05:29 you weren't at that meeting um yes because the team who were the subject matter experts were those that met and discussed the detail of the tcap so someone from peter grove's team who i believe at that point

00:05:40 grove's team who i believe at that point was peter rickard it had been steve green

00:05:44 green and then the subject matter experts namely

00:05:49 namely mike curran from the health and safety team and neil withers from the operational review team but none of this was reported back to you no it wasn't and can you explain that why not

00:06:00 wasn't and can you explain that why not because the detailed work around the development of tcaps was something that was discussed at a board that peter groves i believe sat on but it wasn't reported back through to

00:06:11 but it wasn't reported back through to me

00:06:14 so even though is this right even though you had at least nominally responsibility as acoa for developing the command or the incident

00:06:25 developing the command or the incident command training as a result of the coroner's recommendations is this right you had no oversight no monitoring of no input into the actual training exercises developed

00:06:38 actual training exercises developed in order to meet the coroner's recommendations no that was work that was done by dse graham ellis and other members of the team dsc graham ellis was was responsible he was one of your reports wasn't he yes

00:06:49 he was one of your reports wasn't he yes he was so can you explain that why even though he was one of your reports he never reported any of this to you um he did report the subsequent issue that he had raised around the fact he wasn't satisfied with the

00:07:02 the fact he wasn't satisfied with the proposal that babcock could raise and he had suggested the more recent incident but the day-to-day detail work was i don't think on any tcap was ever overviewed by any assistant commissioner

00:07:14 overviewed by any assistant commissioner who was the um

00:07:16 um sort of in charge of the commissioning department that wasn't regular business no but then lachlan wasn't a regular business was it or the response to latino wasn't a regular business no it wasn't but this was still i mean the i

00:07:27 wasn't but this was still i mean the i was aware of the work that's being undertaken but not the detail of it was latino not sufficiently important for the brigade to depart from its regular business practice and have acs at least

00:07:39 business practice and have acs at least keep tabs from time to time on the development of the tcap intended to be responsive to the coroner's rule 43 recommendations um i had great trust and faith in my deputy assistant

00:07:50 faith in my deputy assistant commissioner who was an exceedingly experienced and professional operational officer to do that work so i did not feel the need to keep tabs on him i knew that

00:08:02 the need to keep tabs on him i knew that he would report to me if he perceived that there were any areas of concern because he was very very

00:08:11 very keen on the development right across the piece of all of the instant command courses yes is that what you might call as we've heard before elsewhere in this inquiry reporting by exception yes that

00:08:22 inquiry reporting by exception yes that is

00:08:24 is how would proper thorough adequate supervision and monitoring by an ac over a domain for which they were responsible ever work if all you did was

00:08:35 responsible ever work if all you did was delegate an activity to somebody and then trust them to get on with it i think that we have to have trust in our very professional senior officers because otherwise it would require an ac

00:08:46 because otherwise it would require an ac to

00:08:47 to do a phenomenal amount of work in scrutinizing and checking across a range of their functions that i just don't think

00:08:57 think would demonstrate any trust or belief in your members of staff who are sure who i saw on a regular basis i met with graham ellis on a daily if not weekly basis and i was aware that he

00:09:09 not weekly basis and i was aware that he would raise an issue if there was one and i have to have trust in my professional offices i don't think anybody would dispute the fact that you have to have trust in your offices who report to you

00:09:21 in your offices who report to you what i'm more interested in is keeping yourself informed so that you know what's going on in your reporting line and to some extent in your name let me give you an example if you go to page three of this

00:09:33 example if you go to page three of this document you can see the different versions of this tcap i showed this to you yesterday it starts on the 3rd of june 2013 with mike curran is the author with the first draft and it runs to the

00:09:44 with the first draft and it runs to the 10th of august 2016 with peter rickard as the author now there are a number of different versions um would it not have been

00:09:56 um would it not have been possible

00:09:57 possible and indeed sensible i would suggest at least for you to have seen these drafts as they

00:10:03 as they as they evolved even if simply for your information only by email i believe that um as i said that if there had been issues they would have been raised to me

00:10:14 been raised to me and i'd say once again it's the fact that i

00:10:18 that i you know had trust in the fact that the people who were making those amendments were working closely with subject matter experts including the people who had been

00:10:29 including the people who had been involved very closely in the lack of house investigation and therefore they were keeping an oversight on what was happening so what would happen if

00:10:40 so what would happen if the commissioner rang you up one afternoon and said uh said to you i'd i just like to understand where the incident command training exercises have got to i'm being given

00:10:50 given i've been given some stick by the uh by the assembly can i just give them something what would you'd have what would you do would you be able to look into your desk and tell him immediately or would you have to make make your own calls no i would make a call to make

00:11:02 calls no i would make a call to make sure i had the most up-to-date information and then i would return the call and give them that information i wouldn't wish to

00:11:10 wish to give the commissioner any information that i didn't believe was the most current information therefore i would always take time to check that fact um before i would report back if if um that wouldn't happen but if that had happened yes my point is that you

00:11:22 happened yes my point is that you wouldn't know yourself you'd have to do your own researches and so on down the chain until you found somebody who did know

00:11:27 know yes but it wouldn't go far down the chain i knew who the people were who were directly involved and therefore they would be able to give me that information can we go back to page nine come back onto track with this document uh you you can see

00:11:39 with this document uh you you can see i've read to you uh in the la in the first bullet point in the last few lines there there's a reference um to

00:11:48 um to a more a recent event can you see it says in addition to this

00:11:57 so four lines down in addition to this dac graham ellis felt that there was an opportunity to use a recent incident within a high-rise block which had similarities to latin house's cde

00:12:09 to latin house's cde on that um is it right that that was the whole croft house incident yes it was it was

00:12:15 was and ultimately do you recall that a cde based on holcroft house took the place of the blackwall tower cde as i understand now yes as you understand that you didn't know that then

00:12:27 that you didn't know that then i knew that that was the one they were working towards i didn't know that was going to

00:12:31 going to completely replace blackwall tower they at one point work was being done to try and prepare both of them i knew that holdcroft house was ultimately used but i wasn't sure if they were going to continue the

00:12:43 sure if they were going to continue the work on blackwall tower why not simply use the latin house fire because i think that the lacknow house fire was already subject to the lack of house training package and therefore

00:12:54 house training package and therefore they wanted to use another example to test those points because the crews would already have had the lachenal house package delivered to them so they would be familiar with the

00:13:07 them so they would be familiar with the process of the fire therefore if you wanted to test an officer's ability to respond to a situation then it's preferable to have one that's different from something they've already seen as they might

00:13:19 they've already seen as they might preempt the their response to it because they know what the answer is effectively i follow so did it work like this just help me so you had the latin house packages there were two as we've seen rolled out to station-based staff and

00:13:31 rolled out to station-based staff and senior officers in late august or from late august 2014 there's then a decision taken as it appears from this document uh during the tcap process

00:13:42 tcap process to have a decision a command decision exercise which would be an exercise is this right to test what they learned from the latino house package to test the learning against those objectives so not specifically to test

00:13:53 objectives so not specifically to test that package but to test against those seven areas of the recommendation but that and by sort of implying it would test what they'd learned from lack of house right

00:14:04 of house right now we we've been looking at numbers we saw 16 and then in the early part of this document six and then one which was blackwall then changed to holcroft house can i ask you to look at

00:14:16 holcroft house can i ask you to look at nfb

00:14:18 nfb 3033013 please

00:14:23 this is an email at the top of the screen from nourish ragbir of babcock to dave language 5th of december 2013

00:14:34 dave he says my main concern with all of this is that the deadline still stands for tcap0124 and we've promised the lfb that we would have six cdes completed

00:14:45 have six cdes completed after talking to doug my understanding is that the nfb required changes to accept victoria view if this is the case would we be better working on this and submitting the single cde or two at the most i.e

00:14:58 single cde or two at the most i.e victoria view and black wall tower on the 20th of december we need implicit agreement from the lfb this work will meet the requirements of tcap124 as it stands we could then create

00:15:10 stands we could then create 124a124b124c etc to schedule the remaining cdes now um does this tell us that the decision to slim down the number of cdes was driven by babcock's inability to

00:15:22 was driven by babcock's inability to meet the deadline the lfb's deadline from reading that um it would suggest that that was one of the factors in it i would not have seen this email it was it was internal babcock's email but that

00:15:35 was internal babcock's email but that looks like in order to meet the deadline they were going to submit some early on and then further work yes do you remember whether you or presumably not you but somebody else

00:15:47 presumably not you but somebody else within the lfb pushed back and insisted that the correct number of command decision exercises be developed um that would have happened i think that's probably why it refers to

00:15:59 that's probably why it refers to creating further exercises because that's what the agreement was of the tcap yes i mean from your knowledge can you help us whether or not the slimming down exercise from 16 to six to one and then possibly others around that

00:16:11 one and then possibly others around that was was driven by babcock's inability to meet the lfb's deadline i think that was definitely a factor yes i mean it was definitely very difficult and very time consuming

00:16:22 and very time consuming to get these training packages developed that was a major factor yes now let's look back at the tcap then um lfb403716 and let's look at page 10 in

00:16:33 lfb403716 and let's look at page 10 in that document and they're on page 10 you can see in the second paragraph the uh

00:16:42 the second paragraph there the first refers to the demonstration on the 20th of december which we saw referred to in the email and then in the second paragraph it says confirmation of the tcap being closed following the

00:16:54 the tcap being closed following the successful completion of holocroft house that should say holcroft house cde for level one incident command was agreed in 2016. the rest of the existing elements of this tcap have been incorporated into

00:17:05 of this tcap have been incorporated into the ongoing incident command course review

00:17:08 review are you able to shed any light on why the cde was restricted to level one incident commanders when the original intention was to provide exercises for all four levels of incident command

00:17:22 no i'm not aware i know that training was being developed for other levels of instant command i think that

00:17:34 think that it was deemed that the priority was to get this cd developed for level one because obviously they're the first level of instant command on the fire ground and

00:17:46 instant command on the fire ground and the first crews that would encounter the early situation so i think that was agreed as a priority in addition to which there was already an existing suite of incident command

00:17:59 an existing suite of incident command assessments that were regularly undertaken for level two and three incident commanders whereas this was quite a new development for the assessment of level one could i trouble you just to remind

00:18:10 one could i trouble you just to remind us what level one how our little one extends certainly sorry sir it's um what was um crew managers and watch managers is now leading firefighter support so station based officers basically sir

00:18:22 station based officers basically sir thank you

00:18:23 thank you on page five of this document if we go back to that please you can see there's a heading background and context and

00:18:31 and in the second paragraph it says these changes

00:18:35 changes which follows on from what he said in the first paragraph about the coroner's recommendations these changes that affect the whole range of incident command training courses needs implementing with immediate effect and

00:18:46 implementing with immediate effect and not delayed due to any other tcap or change program now peter groves told us in his evidence that it wasn't always possible to fast-track urgently needed changes to incident

00:18:57 urgently needed changes to incident command training because of largely because of babcock's limited subject matter expertise and he said that that hindered the implementation of the training program than just for our

00:19:08 training program than just for our reference purposes that's day 177 page 48

00:19:12 48 to page 49 and the same day page 55 at lines 2 to 14. um do you agree with that yes i do you do why did it take your department more than three years after the coroner's recommendations in march

00:19:23 the coroner's recommendations in march 2013 to finalize one command decision exercise august 2016 holcroft house this obviously wasn't just the work of one department or any one person

00:19:36 one department or any one person development of a tcap involves a range of different departments including mainly babcock's external training provider and peter groves his team who were very

00:19:46 were very involved in the oversight of development and the progression of tcap courses the main role of operational insurance as the commissioning department was to provide

00:19:58 commissioning department was to provide the subject matter expertise to support that development so the fact this took so long was due to a number of departments being involved but mainly due to the delay in the ability of

00:20:09 due to the delay in the ability of babcocks to develop that training

00:20:14 to your knowledge did anybody put a rocket under babcock and say to them look

00:20:20 them look normal rules don't apply here as this sentence says very clearly there must be no delay in developing these incident command programs

00:20:31 these incident command programs get on with it we can't hang around for three years yes i know that um both in conversation um i had regular meetings with my director gary reason

00:20:45 meetings with my director gary reason and he would then have meetings with his equivalent in babcock's and i absolutely know the

00:20:51 know the subject matter of this was raised on a number of occasions and conversations firm strong conversations were had about the importance of this issue

00:21:02 importance of this issue and did what was babcock's response i think that at that the director level that um gary reason used to meet with there were plenty of assurances given

00:21:13 there were plenty of assurances given and that would be prioritized but i don't think that ever really translated into the impetus that we needed to get that moving quicker

00:21:25 let's look again at the november 2013 monitoring report we saw it yesterday it's at lfb triple zero 67832 page 21 this time

00:21:41 and you can see that this one is november 2013. we looked at it yesterday we also saw the one for august that year its predecessor and the color coding as i showed you yesterday

00:21:53 coding as i showed you yesterday demonstrates that blue is an indication that an action has been completed doesn't it yes it does uh it says blue completion so we can read that now if we go to page 25

00:22:04 go to page 25 you can see uh that

00:22:07 uh that uh and we need to expand that please yes thank you you could see that the review of incident command training as against the coroner's seven recommendations is highlighted in blue

00:22:20 recommendations is highlighted in blue isn't it it is in other words complete yes

00:22:23 yes um that's what that would indicate but it clearly wasn't as i said yesterday i have

00:22:28 have no idea how that could have been mark blue because it was nowhere near complete well thank you and you did say that and and uh

00:22:36 uh that is um that is what you said but when we asked gary reason about this he said that he wasn't the one to mark the action as completed and that instead this would have been as a result of the update that was given by your

00:22:47 update that was given by your commissioning department he said that at day eight 181 page 82 17 to 83 10. are you able to comment on that or tell us whether that's right or wrong

00:22:58 that's right or wrong um i have to say i listened to the evidence i was very surprised to hear him say that because he was as aware as i was that this was nowhere near completion and this report had clearly been through

00:23:10 and this report had clearly been through odcb where we had reported that where where we were so it was nowhere near completion um i'm not in a position to understand who made the change of that color to blue because all

00:23:23 change of that color to blue because all changes of actions being completed had to be agreed through odcb so i don't know whether that was as a result of a administrative error by

00:23:36 as a result of a administrative error by someone completing it or how that happened because both gary reason and i and odcb were fully aware of the status of this action and it was nowhere near complete

00:23:47 action and it was nowhere near complete um

00:23:49 um well

00:23:50 well and you would agree i i assume that as such this was not just factually incorrect but thoroughly misleading absolutely you were on the odcb yes i was did you

00:24:03 you were on the odcb yes i was did you see this document at the time uh i didn't see a document mark complete no this is the document that would have been developed to go to the lack of house working group and i wasn't party to

00:24:15 and i wasn't party to those documents that was the update that gary reason supplied because i would have pointed out that this should not be marked complete so just to be absolutely clear you didn't see

00:24:26 didn't see this document marked blue in or after november 2013. i

00:24:32 i obviously passage of time i cannot guarantee 100 because um i can't obviously recall and i can't look back to my documents but i do know that if i had seen it mark complete i

00:24:43 that if i had seen it mark complete i would have challenged it because i was fully aware that it was nowhere near complete in fact it had barely begun can i just intervene for a moment do you happen to know who would have been responsible for

00:24:55 been responsible for the text in this document so the text i believe in this document um

00:25:02 um um would have been taken from the text of the odcb rule 43 actions and gary reason was the one who had final

00:25:13 gary reason was the one who had final sort of amendment and alteration on it that he was the one who'd been presenting it to the local house working group

00:25:20 group because

00:25:21 because some of those assurances that are in there are not ones that were supplied by my department well that's one of the reasons i was asking you because i notice in the second

00:25:32 second full paragraph starting at the end of line four is a statement that babcock has confirmed that all seven issues are covered in the existing suite of command training

00:25:45 i don't know whether you can help with what the basis for that was

00:25:50 was yes sir as i understand it and this came from the very early review that i believe babcocks did that they believed that in a manner all seven of those

00:26:02 that in a manner all seven of those issues were covered but they would need further opportunities to highlight and enhance those issues and that was the reports back they gave us from their initial review

00:26:14 us from their initial review which came back through peter groves's team

00:26:17 team but i think that then got more fully explored to discover that it wasn't they weren't satisfactorily covered by the current exis suite of training which is why there was the

00:26:28 training which is why there was the requirement to develop the new cdes well exactly because that sentence suggests that babcock was saying you don't need any more training you're getting it already

00:26:39 you're getting it already and i think that's what bob cox wanted the outcome to be because they understood how time-consuming and difficult it might be to develop new suites of training

00:26:50 suites of training all right thank you very much thank you sir yes

00:26:53 sir yes do you know miss cotton who functionally was responsible for the colouring

00:26:59 colouring who decided it should be blue and who actually pressed the blue button to say to speak um i don't know who decided it should be blue i wouldn't i i am at a loss of words to think why anybody

00:27:11 at a loss of words to think why anybody should decide it should be blue because it clearly isn't which can only lead me to believe that whoever the team were who completed the actual function of the

00:27:23 actual function of the preparing of papers and filling forms were the ones who changed it because everybody was fully aware that it wasn't complete so i genuinely don't know and i'm at a loss to suggest how that could happen because it's

00:27:34 happen because it's clearly very wrong [Music]

00:27:38 [Music] let's look at lfb 3029344

00:27:49 now this is uh dated december 2013 as you can see from the top right hand corner uh and it's a monitoring report of that month

00:28:00 month and it says it's called consolidated action plan recommendations issued to the brigade and or fire and rescue services by coroners following inquests uh

00:28:10 uh i think this is your update isn't it for the odcb

00:28:13 the odcb yes this is the uh update that my department would collate the responses from all responsible officers and submit yeah yes now can we go to page 25 please

00:28:24 yeah yes now can we go to page 25 please in this document there are other parts of it but let's look at 25. now we can see there under lfb action introduce a case study training package to incorporate learning

00:28:35 training package to incorporate learning outcomes from inquests

00:28:39 uh it says acoa you're the as the lead as you target date december 2013 uh and then uh there is if you look down the page

00:28:52 uh there is if you look down the page uh you can see uh

00:28:57 sorry i'm immediately above it i'm so sorry you need to go to the bottom of 24.

00:29:02 24. we really come back to the case study in a moment go back to 24 and uh at the bottom of 24 is review incident command training to ensure the seven points are adequately covered

00:29:13 seven points are adequately covered head hrd

00:29:15 head hrd and hrd is what human resources uh peter groves so james douglas and peter groves department right and then september 2013

00:29:27 and then september 2013 if you look at that you can see that's the target date and then if you go down to page 25 the third date in there is the 22nd of october

00:29:39 2013

00:29:42 and it says update all stakeholders have considered the training requirements in detail to address the coroner's recommendations the proposed amendments to all incident command courses have now been agreed and babcock are developing

00:29:53 been agreed and babcock are developing the first command decision exercise now we don't have another odcb update until march 2014. let's just look at that i just want to

00:30:04 let's just look at that i just want to note that let's have them two up at the same time so keep that on the screen please if you would mr documents director and let's have the one for march 2014 at lfb 3085811

00:30:23 there it is on the right hand side of your screen again that's the document just went through your hands isn't it yes yes can we please go to page 30.

00:30:37 uh and on

00:30:39 on page

00:30:41 page 30

00:30:44 yes thank you very much uh you can see again b review incident command etc and then if you turn the page to 31 it's the same item turn to 31 and see the

00:30:55 the same item turn to 31 and see the entry for the 3rd of march 2014

00:31:00 in bold it says completed babcock has confirmed that all seven issues are covered in the existing suite of command training albeit that there may be opportunities to emphasize the latin event during some inputs

00:31:11 event during some inputs additionally as part of routine business babcock are amending a number of command decision exercises to fully reflect the issues identified by the coroner now when where it says that the action

00:31:22 now when where it says that the action is completed that wasn't right was it no i think that that was reflecting the fact that babcock's had refu reviewed

00:31:34 refu reviewed the

00:31:34 the instant command inputs and had deemed that everything was covered it didn't mean that the training interventions had been completed

00:31:45 completed i think it's poorly worded i think it's poorly worded there's it went through your hands though although you may not have worded it yourself

00:31:52 yourself no it went through mine i know dcb's hands but as we've seen with a number of documents there are times when things are very poorly worded why did you allow a poorly worded

00:32:03 why did you allow a poorly worded document such as this to go to the odcb um when you knew it wasn't accurately reflecting the facts i think that it wasn't it was accurate reflecting the fact they've been through the scenarios

00:32:15 fact they've been through the scenarios and then it talks about the the fact that the number of cds are being developed and that would have been the conversation during the odcb meeting

00:32:26 conversation during the odcb meeting but i can only apologize for the poor wording um i have i don't recollect uh what happened in at that time when the words

00:32:34 words were devised and when they went through um and

00:32:38 um and i can't i genuinely the passage of time can't recall that but it's not so much the words babcock has confirmed etc it's the word completed what's what's poorly worded about a single word completed

00:32:49 worded about a single word completed when in fact what is under b was not completed because i think that is referring to the fact babcocks have reviewed the existing suite of training that's what the the

00:33:00 suite of training that's what the the completed is referring to not that the training interventions have been developed

00:33:08 right but it's not correct that this was completed was it it's not correct that it review of the incident command training to ensure the seven points are adequately covered had been completed um

00:33:19 adequately covered had been completed um in babcock's view they had been completed that exercise and had deemed that

00:33:24 that the issues were being covered and that they were going to enhance them with further training so the exercise of reviewing it in their

00:33:32 in their terms had been completed and because that as you would have seen that was allocated to hrd so that was james douglas and peter groves that would have been the wording they had taken i

00:33:43 been the wording they had taken i imagine from babcock's as an update so cox supplied updates as well to this you recall any occasion when you told

00:33:54 you recall any occasion when you told adcb that incident command exercises designed to address the problems that lachenal identified by the coroner were not complete but were in a process of very gradual development yes it was the

00:34:06 very gradual development yes it was the subject of the conversation regularly odcb and the frustrations of how very slow it was and that it was taking an inordinate amount of time to develop the training

00:34:18 amount of time to develop the training packages it was something that we talked about on a regular basis

00:34:24 but in fact given that incident command was was packaged into the incident command review course as we'll come to it couldn't possibly be the case that the review had been completed as that

00:34:37 the review had been completed as that uh

00:34:38 uh as a march 2014 given that it was a three-hour exercise and in fact was not completed even at 2016.

00:34:44 2016. so i think the review was completed we saw a document i believe it was yesterday where they'd identified a number

00:34:51 number of interventions but what wasn't completed was the training outcomes at the end of that so the

00:34:59 the and the

00:35:01 and the um outcome in 2016 wasn't the fact the review hadn't been done it was that we hadn't completed producing the different levels of training for different offices in instant command when was the review

00:35:12 in instant command when was the review completed

00:35:13 completed to the best of your knowledge i genuinely can't remember i'm sorry i think we looked at it in a document yesterday where they had been through they'd used doug massey to go through um a number of the training interventions

00:35:25 a number of the training interventions and documents so it was

00:35:29 so it was it's wording isn't it it's wording about review as opposed to the delivering of their product which was the training which was the requirement

00:35:38 let's look at the whole craft house training package which was i think a set of training materials are ultimately produced

00:35:47 produced uh in response to the incident command recommendations from the coroner that that is

00:35:52 that is bab6011 please and we can see from the front page that it is called holcroft house commander decision exercise with the subtitle developing high-rise

00:36:04 with the subtitle developing high-rise fire scenario mass evacuation persons reported with fire survival calls crew and watch manager so just pausing there this is a level one training exercise it is yes incident management

00:36:16 exercise it is yes incident management training trainer guide so this is a guide for the trainers uh now if we look at the foot of the page which you can't quite see if we can scroll down to the bottom

00:36:27 if we can scroll down to the bottom uh the issue date is marked with some hashtags

00:36:30 hashtags um do you know when it was issued no i have no idea did you or your department develop and sign this off it was this was part of tcap zero one

00:36:42 it was this was part of tcap zero one two

00:36:43 two four um

00:36:45 four um so it would have been involving the same people we were discussing earlier in the development of the training package um i'm not sure who ultimately signed it off or when it was signed off did you

00:36:56 off or when it was signed off did you ever see it before it was signed off no i don't believe i did

00:37:01 what about graham ellis yes absolutely did he ever tell you even informally that he had signed off on a command decision exercise covering these matters designed for level one

00:37:13 these matters designed for level one uh officers i remember having conversations with him about the development i don't recall whether we had the specific conversation around the issue of sign off let's go to the uh detail of the

00:37:25 let's go to the uh detail of the scenario can we start at page six please

00:37:31 and you can see what the exercise scenario is holcroft house is situated in ingrave street battersea sw11 it is a traditional concrete build high-rise block of residential flats

00:37:42 high-rise block of residential flats constructed circa unknown and is situated in the london borough of wandsworth south west london the building consists of nine floors and is approximately 110 meters by 14 meters

00:37:53 is approximately 110 meters by 14 meters there are 128 flats separated into 16 flats per floor the building is undergoing limited remedial work communal areas are being redecorated and a number of doors are

00:38:05 redecorated and a number of doors are being replaced fire crews are aware from previous calls to this address that the dry rising mains are often found to be vandalized and that lobby doors are frequently wedged open or even removed parking is

00:38:16 wedged open or even removed parking is always an issue with access to fire for fire appliances restricted or impossible the incident is initiated with a call to smoke issuing from the second floor several additional calls are received

00:38:27 several additional calls are received indicating that the fire is on the second floor on arrival it is apparent that the fire is on the fourth floor this incident increases in complexity to involve persons reported fire survival

00:38:38 involve persons reported fire survival calls significant fire growth and mass evacuation compounded by the hazards and risks associated with the remedial building works this will create significant challenges for cm and wm

00:38:49 significant challenges for cm and wm delegates

00:38:51 delegates now

00:38:52 now importance uh in the last paragraph there is not only fire survival calls but significant fire growth and mass evacuation you see those two features of this cde

00:39:05 those two features of this cde um can we then move to page 8 and look at section 1.8 on that page this is under delegate learning outcomes and

00:39:15 and you can see that the coroner's seven rule 43 incident command

00:39:20 command training recommendations and exercise injects

00:39:24 injects are

00:39:25 are said to correlate to each of the seven recommendations you see um now we'll look at some of those injects in a little bit of detail shortly

00:39:34 shortly we can find a summary of them for um assistance at page 12 we can go to that page 12 there is a table and if you study that carefully you will see two thirds of the way down that

00:39:46 see two thirds of the way down that there are

00:39:47 there are two uh first survival guidance calls uh inject

00:39:53 uh inject 53 and inject 55 yes yes and it may be that that is only one first survival guidance call one or two

00:40:07 do you accept that that was a missed opportunity to provide training on responding to what has been called multiple fsg calls in other words three or four

00:40:16 or four particularly in light of the number of fsg calls received at latino house which in total was five although there were two i think from one flat

00:40:25 flat yes so i'm i'm not sure the detail but i suspect this was accurately reflecting the events of the fire at holcroft house and the number of calls they received

00:40:36 and the number of calls they received but yes this would have been an ideal opportunity to have given

00:40:42 you know emphasis and increased number of far survival guidance calls yes

00:40:49 yes did anybody think at the time to do a comparison between the actual events of lachenal including the number of fire survival guidance calls there

00:41:00 guidance calls there and the actual events of this more recent incident holcroft house and work out whether all of the aspects of the whole craft house incident properly trained out the errors that had

00:41:12 properly trained out the errors that had been made at latinos so far as they had been identified by the coroner i'm not sure what the content of the conversation by the development team was no i don't know let's look at page 66

00:41:25 no i don't know let's look at page 66 this is the seventh inject for crew managers and watch managers you can see it says exercise reference number zero seven inject number cm stroke wm7

00:41:37 stroke wm7 and there are some performance criteria that are set out there uh some of which are

00:41:43 are decision making model dynamic risk assessment various incident command policies uh and uh

00:41:52 uh and uh item eight six three three high-rise firefighting and compartment firefighting 793 and if you look at the text it says uh holcroft house inject and then in the

00:42:03 uh holcroft house inject and then in the main paragraph having arrived at the incident received the briefing and taken over command you are in conversation with the crew manager when a man approaches you and tells you he is the council caretaker for the premises he

00:42:15 council caretaker for the premises he tells you that he believes the fire is on the fourth floor and that there is remedial work being undertaken on that floor and many others he also tells you that he has had lots of issues with vandalism here and he suspects arson

00:42:27 vandalism here and he suspects arson and if we go to page 69 three pages on you can see that the candidates are assessed there that's an assessment grid for their performance and knowledge and

00:42:38 for their performance and knowledge and if you look at the fourth item down on the list

00:42:42 the fourth red bullet or square around the bullet it says consider partial or full evacuation of block do you know whose idea it was to insert that as an inject

00:42:54 that as an inject uh no i have no idea do you remember whether there was any discussion about the insertion of partial or full evacuation of block as an inject into this exercise no i said i have no

00:43:05 this exercise no i said i have no detailed knowledge of any of the um injects or these aspects on this whole throughout the whole of this document uh right did

00:43:15 right did looking at it do you accept on his face there's nothing in this training and tell me if i'm wrong about this from your wider knowledge that there's nothing here about how a partial or full evacuation of the block would actually be achieved in practice

00:43:27 be achieved in practice no um i'm not sure what the visual inject and what they would have seen

00:43:32 seen and therefore what conversations would be had but on the face of what you read here know right and presumably because this was based on the actual event the actual incident there had been

00:43:43 actual incident there had been a partial or evacuation full evacuation of holcroft house is that right i believe there was a partial evacuation of the house here right do you know how partial in other words how significant it was um

00:43:54 it was um i i wasn't at the incident um i'm i've only become aware through reading um

00:44:00 um some preparation for this but i don't believe it was a significant part of the block that was evacuated right there's no training here on the rationale

00:44:09 rationale is there there's no training on why it is that a candidate ought to consider a full or partial evacuation as a result of being told by the caretaker that there was remedial work on the fire floor or elsewhere in the

00:44:21 on the fire floor or elsewhere in the building

00:44:22 building so this uh these sort of check boxes here aren't a training intervention these are a response to what the candidate has said so without

00:44:33 what the candidate has said so without seeing the detail of the package i wouldn't be able to suggest so that the package itself is designed to test the candidates response and give injects and this is marking whether or not they had

00:44:45 marking whether or not they had discussed that option and then the conversation would be if the candidate for instance was to say i'm now

00:44:52 i'm now considering a partial evacuation then the assessor would say what's making you consider that and they would have a conversation about it so it's not clear from here

00:45:03 so it's not clear from here what that would lead to because you'd have to see the training and have actually see the training playing out but this is an assessment to say whether or not

00:45:10 or not they um

00:45:12 they um i think and i believe that you means you know it says are you unprompted prompted or directed to actually have that so i think that if a candidate didn't suggest that they might need to do one of these things then it would require the trainer

00:45:24 things then it would require the trainer to prompt them to say have you considered and if they then didn't the trainer might say you now need to do a blc that's what the boxes mean right um

00:45:36 um just help me with this the presence of the possibility of

00:45:42 of a trainee

00:45:44 a trainee crew manager or watch manager either

00:45:48 either prompted or unprompted saying there should be partial or full evacuation of the block as of this point um

00:45:57 um com came from somewhere where did it come from do you know

00:46:03 i would think it would have come as a result of the package being developed in response to the fire at lacanal

00:46:10 lacanal right

00:46:12 right i don't know that i'm making it uh i'm making an assumption i am can you help me with whether or not this training package was influenced in its development by

00:46:23 its development by thinking about the timing the finalization and publication of gra 3.2 in february 2014. um i would only be guessing i wouldn't

00:46:34 um i would only be guessing i wouldn't know you don't no i don't sorry

00:46:39 at all events do you accept that the possibility of partial or full evacuation of this block in the circumstances of this fire was a feature or factor

00:46:51 was a feature or factor which was being tested one way or the other appropriately or inappropriately yes from what i made here yeah now if we go to page 76

00:47:08 if we go to page 76 we can see that here is another inject number 10 this time and this also is for cms and wms as opposed to either and it says this as

00:47:20 as opposed to either and it says this as incident commander is under the box as incident commander you receive information from the bridgehead that the fire is actually on the fourth floor and has spread from building debris in the communal hallway to at least one flat on the fourth floor

00:47:32 to at least one flat on the fourth floor in addition to a large quantity of debris left in the hallway apparently by the renovation contractor the flat is now 50 to light now take it from me that there's nothing else either before or after this inject

00:47:43 else either before or after this inject that refers to fire spread against the backdrop of the lack of house fire and particularly its rapid external fire spread affecting a number of flaws do you know why that is

00:47:54 of flaws do you know why that is no i don't do you accept that that was a failure by your department at the very least to train firefighters on the extent of the risk posed by weak or failed compartmentation i accept that the team that developed

00:48:06 i accept that the team that developed this should have used the um exercise as a better opportunity to explore that yes does the same apply to rapid external fire spread and the risks it poses yes it does

00:48:18 it does and the risks posed by external wall panels yes it does and in fact would you agree that this training exercise at least in those respects does not in substance meet the

00:48:29 respects does not in substance meet the coroner's seven uh incident command recommendations um

00:48:35 um i wouldn't be comfortable to say that without seeing the training package because i said i'm not familiar with the detail of it we can only see the trainer notes here as opposed to the actual

00:48:46 actual um exercise itself so i i couldn't be i wouldn't be happy to confirm that as a detail because i'm not familiar with the package i'm sorry i should just tell you we haven't

00:48:57 we haven't had from the lfb any documents other than this training guide so if there is any other material out there that you know about then we would like to see that but you can't i think identify it can you no i

00:49:09 can't i think identify it can you no i just said i think it would be if you could see and i think it would be helpful to see the training package run with the trainer giving you those um interventions to understand how that worked because uh it

00:49:20 understand how that worked because uh it wasn't something i saw in person but i think that might give you a fuller understanding i i don't have that understanding so i would be speculating about whether it did or didn't can i assume that you've never seen either at the time or in preparation to

00:49:33 either at the time or in preparation to give evidence the um that what you've called the um

00:49:39 um training package run no i haven't mr reason accepted that um holcroft house has presented to him didn't convey what we'd intended

00:49:50 him didn't convey what we'd intended in terms of fire spread nor addressed the risks of external paneling or rapid fire spread and accepted that that did not convey our response to the rule 43 for our reference purposes that's day

00:50:02 for our reference purposes that's day one eight one page one two eight nine eighteen to one two nine page twenty line twenty one do you agree with that um if uh gary reason has seen the package and believes that to be the case then i would

00:50:13 then i would trust his word as i said not being able to see the package i would find it difficult to make that statement but if gary reason has seen it and makes that statement then yes i would agree with him i understand and we are proceeding on the assumption of course

00:50:25 proceeding on the assumption of course that the lfb has given full disclosure of all relevant documents and there's nothing there so that's i'm i'm a bit lost without being able to see it as all i would say but um if gary reason agreed to that then yes thank you uh now i want to turn

00:50:37 then yes thank you uh now i want to turn to uh babcock again and the incident course

00:50:41 course review process which i referred to earlier this morning and so far we've looked at documents which suggest that the coroner's seven and seven incident command recommendations would also be fed into

00:50:52 recommendations would also be fed into babcock's initial course review of incident command training and you'll recall we looked at tcap124

00:51:01 tcap124 um which said exactly that you remember that yes i do yes and we don't need to get back to it it's just for reference purposes nfb four zero three seven one six page

00:51:10 six page eight

00:51:11 eight can we

00:51:13 can we from that basis move to lfb three zeros four three five five two

00:51:25 now um this is a document that may be familiar to some and possibly to you it is babcock's initial program course review report on incident management training i.e incident command

00:51:37 management training i.e incident command training

00:51:38 training as you can see from this document this one is dated july 2013 but the the there is a covering email with this document i should show you that lfb triple zero 73973

00:51:59 uh it's an email from doug massey to phil butler which i think is

00:52:07 what comes from babcock to the lfb uh babcock's incident command review 2013

00:52:14 2013 phil pdf glossy with photos etc doug now that's dated 27th of october 2014. that's the important point about the document

00:52:25 document um peter groves and gary reason confirmed in their evidence that there were various drafts of this document and some discussions about it between july 2013 and october 2014 when it was

00:52:36 2013 and october 2014 when it was finalized

00:52:37 finalized thus far um do you agree with that or disagree with that or don't you know yes i agree with that you agree now um go back to the document uh lfb triple zero four three five five two

00:52:50 zero four three five five two um did you see this report during its drafting stage between 2013 or even before 2013 and october 2014. um i don't believe i saw the detail i was aware

00:53:01 believe i saw the detail i was aware that the work was in progress um but i don't believe i i don't i don't recall seeing any of the drafts i may well have done i i saw the final document

00:53:11 do you know who at the lfb signed it off as acceptable that would have been someone in peter grove's team they were the interface with babcocks

00:53:22 well just help me with that someone in peter graves's team someone senior to him or at his level or junior to him i am peter groves ultimately yes would be the sign off because he was the

00:53:33 be the sign off because he was the training manager for london fire brigade right did anybody more senior to peter graves approve it before he signed it off or authorized him to sign it off um

00:53:45 off or authorized him to sign it off um i don't know that would have either been james douglas or gary reason right not you i'm taking it no i wasn't in the training world at that time that wasn't part of my department so

00:53:56 that wasn't part of my department so the course reviews were all conducted by the training interface department that peter groves ran under james douglas

00:54:09 do you remember when you first saw the final version i'm giving you the rate date range july 13th to october 14th no sorry i don't recall back then now let's look inside the report itself we find two

00:54:21 the report itself we find two perhaps i should say only two references to lack of house the first is at page 12. can we go to that and that is under the heading research finding 6.1 historical context you see

00:54:33 finding 6.1 historical context you see at the top of the screen and then two-thirds of the way down the screen you can see that there is some history do you see it says since 1991 there have been other notable events which have further influenced incident

00:54:44 which have further influenced incident management training including bethnal green july 2004 harrow court february 2005 atherstone on stir november 2007 lachl house july 2009

00:54:57 november 2007 lachl house july 2009 shirley towers 2010. and all of those are firefighter fatalities except latino yes but that's the reference there and the second reference we see the

00:55:08 and the second reference we see the lacanal is in the appendix which starts at page 30.

00:55:13 and you can see it there on your screen uh appendix stage one incident management review output document

00:55:20 document and then if you uh go on in that appendix please to page 32 you can see a row-headed political considerations you see and it says

00:55:32 considerations you see and it says corporate responsibility for managing the health and safety of employees whilst at work is a statutory requirement failure to meet and maintain these statutory obligations exposes the fire authority to the risk of legal

00:55:43 fire authority to the risk of legal action

00:55:45 and then if you turn the page or i'm sorry

00:55:50 i'm sorry for page 32 i need a little bit more there firefighting is a risk critical activity and shortcomings in incident management will not only result in service delivery failure but may lead to injury and or death with legal

00:56:01 injury and or death with legal repercussions for the individuals responsible and the fire authority

00:56:08 effective incident management training and assessment is fundamental to successfully delivering the service managing risk and ensuring the safety of fire service personnel and the community

00:56:19 personnel and the community it provides the evidence to support an individual's competence to undertake the role and then we see this current issues for consideration first bullet the outcome of the latino house inquest and

00:56:31 outcome of the latino house inquest and rule 43 letter to the lfb

00:56:36 now that's it

00:56:39 that's it there are those two references to lachen house in this document beyond what i've shown you do you agree that there's nothing in this report taking it from me that there isn't um as in october 2014

00:56:51 um as in october 2014 to indicate that the coroner's seven incident command recommendations have been substantially incorporated into or considered by the incident command course review being conducted by babcock

00:57:02 course review being conducted by babcock i'm not familiar with the page by page detail but um if you say it's not there then yes i agree

00:57:09 yeah yes i mean you i'm really asking you just to cast your mind back and recall whether what i've just put to you is something that struck you at the time other than those two references to lachenal there's nothing in the report

00:57:21 lachenal there's nothing in the report to tell the reader that the seven incident command recommendations made by the coroner have been substantially incorporated into the brigade training um i don't recall whether i had a conversation or

00:57:32 conversation or whether i consider that at the time right

00:57:34 right now mr groves accepted peter groves accepted in his evidence day 177 page 82 line 8 to 18 that the absence of any element or process for

00:57:46 element or process for as it were standing back and assessing what might be missing from this document was in his words a marked deficiency in the effectiveness of the review program do you agree

00:57:57 of the review program do you agree yes i do

00:57:58 yes i do given the prominence of the incident command course review as the process by which each of the coroner's seven incident command recommendations would be addressed by the lfb are you able to are you able to

00:58:09 the lfb are you able to are you able to explain why there's no mention of those either collectively or individually anywhere in this report um no so i wasn't part of the authoring of this report

00:58:21 authoring of this report i'm not sure what their parameters for the content of the report were so no i can't help with that i'm sorry does it and you may not be able to help with the answer to this either but as a matter of

00:58:32 answer to this either but as a matter of logic would you accept that if the coroner had picked up this report in october 2014 and read it she would not be able to find anywhere where she had she was assured that her

00:58:45 where she had she was assured that her seven recommendations had been identified and addressed and the reasons why the brigade was satisfied that the incident command learning from lachenal had been embedded into incident command

00:58:56 had been embedded into incident command policy

00:58:57 policy um if if you say there is no reference to that then yes i would agree policy process training

00:59:04 training and the like i would agree

00:59:07 so what do we look at in order to test whether what you and gary reason told the odcb

00:59:17 the odcb that the incident command recommendations would be incorporated into the babcock ic course review what do we look at to test whether that actually happened

00:59:29 i think that the i'm i'm

00:59:34 i'm i'm speculating i can't i don't know the rest of the documents the rest of the content around them from that time i'm sorry my memory doesn't serve that well far back but they i think the main aspect would have been what was

00:59:46 what was translated into the tcap as that i'd haven't i say i didn't see the previous iterations or the covering document that would have come with this and the covering report and whether or not that not that made reference to it

00:59:58 not that not that made reference to it so that without being able to see those it's quite difficult to it would merely be me speculating on where you do that um

01:00:06 um as i started with this line of questioning you'll recall that the tcap itself recorded the fact that recommendations would be made for further enhancements fed into the incident command course review and we

01:00:17 incident command course review and we also saw the updates that you provided the to the odcb as well as gary reasons monitoring reports marking these as complete which also referred to the incident command course

01:00:30 referred to the incident command course review my question really is did you ever take any steps yourself to

01:00:36 to to look for a document that assured you that the coroner's seven incident command recommendations had been fed into babcock's incident

01:00:48 had been fed into babcock's incident command course review and had been done so with a satisfactory outcome

01:00:54 outcome so that document would have been the rule 43 action plan update where the updates were provided by both babcocks the training team peace groves team

01:01:06 the training team peace groves team and the team that were developing the tcap so that's where all of our assurance was taking place around the lachenal house recommendations

01:01:24 so the answer is is that there wasn't anything i think is what you're telling me other than the tcap which is the document that shows what the training was that was being developed and the exercises themselves

01:01:36 developed and the exercises themselves and and the rule 43 update action plan which is where the updates were provided yes but the up the updates are provided to the odcb what is the objective material on which somebody coming in

01:01:47 material on which somebody coming in from outside could look at and say to themselves i am satisfied that what the odcb was told about incident command recommendations being fed into the incident command course

01:01:58 fed into the incident command course review by babcock has been satisfactorily completed i'm not sure there was a document that would have drawn those lines between those two wasn't that the kind of thing that was supposed to be at the heart of operational assurance

01:02:09 operational assurance i think that was something that was part of the

01:02:14 of the difficulties about having an outsourced training contract and the difficulties of getting an outsourced training provider to do work and to get to understand the complexities of london fire brigade i think that responsibility

01:02:26 fire brigade i think that responsibility sat with a number of departments the operational assurances department was predominantly as we talked about yesterday around the assurances of the performance of operational crews

01:02:37 performance of operational crews on the far ground we had very limited resources and therefore would not have had the ability to

01:02:44 to have somebody completely embedded in the training team assuring all of the work that was being undertaken by babcocks that would have been an ideal world unfortunately the number of

01:02:55 unfortunately the number of people that we had working in training was considerably reduced when the contract was outsourced that was part of the reason for outsourcing the contract was to reduce london fire brigade's training

01:03:07 to reduce london fire brigade's training team

01:03:09 team just the last part of that answer i i just want to examine in a little bit more detail you say that you wouldn't have had the ability to have somebody completely embedded in the training team assuring that all of

01:03:20 the training team assuring that all of the work

01:03:21 the work being undertaken by babcocks that would have been an ideal world now one can understand that if one is talking about the entirety of the brigade's training needs

01:03:33 brigade's training needs why does that apply to the very special incident command training that the coroner had recommended in the light of the latter house inquests because there was

01:03:44 because there was two there were two members the operational assurance team that gave a considerable amount of time in the development of the two t-caps in response so there was a considerable amount of

01:03:55 there was a considerable amount of operational assurance and graham ellis as well time taken to

01:04:01 taken to developing and working alongside the team that peter groves had and babcock's in the development of the training in response to those recommendations yes

01:04:12 yes but why not then put a full stop at the end of it and say we've decided that some of this at least should be fed into the incident command course review which was a much longer

01:04:23 course review which was a much longer process it was anticipated to be three years

01:04:26 years and at the end say because this is lachenal because it was inquest because it was special we are going to have somebody senior in the oa department make sure

01:04:36 make sure that what was promised to adcb actually came about why would that not happen

01:04:41 happen i think that my concern with that would be um and this is my view on it now that if we were purely to rely on those recommendations being embedded as part of the insta command course review as

01:04:52 of the insta command course review as you've just rightly said that was a very long process and i think that you know to my mind definitely and graham ellis is we wanted this work to carry on at far more pace than to wait for the roll out of the

01:05:04 than to wait for the roll out of the instant command review which would have been three years as a process and then further development of a training package so i'm not sure that the incident quran review was the answer to it

01:05:15 review was the answer to it because i think that was a very long and wieldy process but it was surely a partial answer to it because that is what the odcb was told and indeed the strategy committee

01:05:26 and indeed the strategy committee i think it was a partial answer that it was taking part in that but the main answer was to get on with the work and the matter in hand through the tcaps let's go then to the november 2013 latino house working group monitoring

01:05:38 latino house working group monitoring report this one's november 2013 we saw yesterday lfp triple zero six seven eight three

01:05:48 two uh and look if we go to page 25 there please you can see um what we looked at yesterday marked as blue we went through that what i want to show you is the final paragraph in the right

01:05:59 you is the final paragraph in the right hand column at the very bottom of the page which says as an ongoing quality assurance initiative the issues detailed in this recommendation now form a standing agenda item at the quarterly

01:06:11 standing agenda item at the quarterly incident command forum meetings held between the brigade and babcock these meetings are used to explore opportunities to further embed these incident command related issues

01:06:23 these incident command related issues into other parts of the training portfolio such as command assessments

01:06:30 and then it goes on as an additional safeguard

01:06:33 safeguard with the requirements are being further monitored at the weekly lfb babcock incident management liaison meetings which reviews the incident the issues and themes arising from operational incidents attended

01:06:44 incidents attended what were the weekly lfb straight babcock incident management liaison meetings that are referred to in that last

01:06:51 that last paragraph there i don't specifically recall there weren't a meeting i attended but from looking at that i would imagine they were a weekly update meeting between the

01:07:02 were a weekly update meeting between the lfb and potentially someone i would suggest from peter grove's team as the link with babcocks which would look and review the issues and whether someone attended from my

01:07:14 and whether someone attended from my team i can't recall without seeing um either an invite or the minutes of a meeting right would you know whether they were ministered um i have no idea we have not seen any minutes i i wasn't aware specifically of those meetings

01:07:26 aware specifically of those meetings right you weren't aware of them at all specifically i wasn't aware i i knew that there were meetings taking place i don't recall those specifically you saw this document at the time yes i did yeah so you would have known that there was a

01:07:37 so you would have known that there was a reference to these meetings yes i'm just saying i wasn't aware of the detail who was sitting on those meetings no did you ask peter groves graham ellis what are these meetings are they minuted

01:07:48 they minuted can i see a minute no i didn't why is that

01:07:51 that because graham ellis was keeping me updated whether there were any problems or issues and therefore i didn't feel the need to press further whether or not these meetings were minuted i'm not sure as they were weekly

01:08:03 i'm not sure as they were weekly meetings whether they were i know the instant command four minutes meetings were minuted because in preparation for this i've seen details of those right um well we've got no evidence

01:08:15 evidence by which i mean we have no documents which we've seen from the brigade to show that these weekly liaison meetings as they were described ever considered the coroner's seven incident command recommendations

01:08:26 recommendations or ensured that they were somehow reflected in the training we've seen nothing of that nature are you able as you sit there to tell us how those meetings resulted if at all in the coroner's recommendations being

01:08:37 the coroner's recommendations being reflected in in incident command training

01:08:41 training i'm sorry i wasn't a member of either of those meeting groups so no i can't help you with that so you can't explain to us whether or not that process did provide an additional

01:08:52 that process did provide an additional safeguard the words used there um no i'm sorry i can't i think those were gary reason's words whether he had further information on that i'm not sure right this document went through your hands but you didn't ask the questions

01:09:03 hands but you didn't ask the questions i've just asked you no i didn't why is that um i don't know because gary reason i suspect was fully

01:09:11 fully up to date as he was presenting the information to the latin house working group and he hadn't asked me the question so i assumed that i felt he was comfortable with the information he was providing

01:09:24 what was the purpose of these documents going through your hands then if they you were just going to hand them on on the assumption that everything in them was accurate i don't think the words going through the hands my team are the ones as i

01:09:36 the hands my team are the ones as i explained yesterday who collated all of the updates and these documents were then used as the discussion point for odcb to discuss what was in those

01:09:47 odcb to discuss what was in those documents and i suspect we may well have had detailed conversations and we did have detailed conversations around all of it at

01:09:54 of it at odcb so it wasn't just a case of supplying information and passing it on they were used as the conversation to discuss progress and to be subjected to questions from

01:10:06 and to be subjected to questions from the deputy commissioner and from directors uh if we go back to the bottom of page 25 please

01:10:15 25 please uh you can see that there's a reference in that last paragraph that i read to you

01:10:19 you to something called the quarterly incident command forum meetings what were those i believe those were a meeting that from reading papers in preparation for this i don't recall the setting up that

01:10:31 this i don't recall the setting up that i think either gary reason or james delgalesh

01:10:34 delgalesh asked to be established and i believe that dic graham ellis chaired those meetings and there were meetings between london fire brigade and babcock

01:10:49 i didn't attend these meetings you didn't no i wasn't a member of those meetings can we go please to lfb 00854

01:11:06 this is a report the title of which is reestablishing an incident command training forum dated 25th january 2013 for the meeting of the operational

01:11:17 for the meeting of the operational directorate's coordination board the odcb

01:11:20 odcb and the report is authored by james dalglich head of hrd as you can see

01:11:30 the

01:11:33 reference there to odcb of course is is is

01:11:36 is the body we've referred to before and as acoa at the time you would have been a member of that i was yes now let's look at the summary when the lfb had an internal training department the ac training established

01:11:48 department the ac training established an incident command training forum ictf the purpose of the forum was to seek continual improvement in training and development of all officers who undertake incident command as part of

01:11:59 undertake incident command as part of their role since first of april when the babcock international group babcock formally became the london fire brigades training provider

01:12:10 brigades training provider and the training department was disestablished this forum ceased to exist this paper proposes the creation of a new incident command forum and just just pausing there for clarity

01:12:22 and just just pausing there for clarity the first of april there is a reference to the first of april 2012 isn't it yes it is the previous year whose idea was it to reestablish the incident command training forum um it looks like it was james douglas's

01:12:36 if you look at the recommendation immediately below the summary it says that odcb note the content of this paper and approve the reestablishment of an incident command training forum chaired by operational assurance

01:12:49 by operational assurance is it right that that recommendation was accepted by odcb yes i believe so this the forum was established so yes i would say it was accepted yes and i can show you the meeting let's just look at that lfb

01:13:01 meeting let's just look at that lfb triple zero four zero six seven five let's just have page one up

01:13:12 there's the odcb meeting of the 25th of january 2013. the same date as the report we've just seen and you can see that you are present as one of the list of people there yes yes and if we

01:13:24 list of people there yes yes and if we go please to page three section five paragraph 5.3 a third of the way down the page um this is about the incident command

01:13:35 um this is about the incident command forum as you can see from the top of the page at 5-1 subject to the above the proposals were agreed as it says in 5.3 yes yes you know the action uh

01:13:47 uh i can't quite read that is it ii uh or is it h h string hr and d i think it should say i'm told it's h yes i think it should say h h r d

01:13:58 it's h yes i think it should say h h r d to progress the re-establishment of an incident command training forum so we can see that that decision was made at a meeting at which you were present yes that's correct now let's um look please uh back at the report lfb

01:14:11 look please uh back at the report lfb triple zero eight five four zero four

01:14:17 um mr chairman before i do that i'm noting the time uh yeah there's a bit of work to be done on this document it's probably appropriate to take the break now having wetted

01:14:28 break now having wetted well it sounds like it would be a good point to take the break so the scotland will stop there we'll resume please a tough fast eleven and as before please don't talk to anyone about your evidence when they're out of the room no sir

01:14:40 out of the room no sir good thank you very much

01:14:51 i'll first let him give you enough time for whatever has to be done yes yes i'll first leave

01:31:01 would you ask cotton to come back in please okay

01:31:13 all right miss cotton are you ready to carry on thank you thank you very much yes yes mr chairman thank you can we please go back to lfb 3085404

01:31:24 go back to lfb 3085404 the report of the 25th of january 2013 to the odcb reestablishing an incident command uh training forum can we go to page four in that document section five

01:31:35 page four in that document section five the forum's terms of reference

01:31:39 and you can see there that it was proposed that the icf is chaired and managed by the oa department that was your department yes yes it was yes

01:31:48 yes because there are two bullet points about why

01:31:51 about why the um first the oa department has agreed reporting protocols with odcb in respect of incident command performance and this forum would be established to support and inform these not report

01:32:03 support and inform these not report independently second bullet this forum would enable babcock to understand the issues and challenges of incident command in london and give them guidance on how best to respond to the lfb's needs this paper

01:32:14 respond to the lfb's needs this paper recognizes that the lead on incident command in the brigade is the incident management policy team within the oa department and that this team should lead this work and then uh it goes on

01:32:26 and then uh it goes on to the terms of reference uh it's it's themselves and there are six of those and you can see those if we scroll down to the bottom of page four on the screen there

01:32:37 on the screen there and i'm not going to read them all out to you you can see those but particularly picking up item

01:32:44 item one and two acting on direction given by odcb on incident command training issues and contribute to performance evidence collated through diot and the second act

01:32:55 collated through diot and the second act as conduit through which the lfb can enable babcock to understand the issues and challenges of incident command in london and provide a focused sounding board for the development of training in this competence area

01:33:07 this competence area and then you can see other things as well governing body for incident command elements of promotion and for management of the incident command exercise panel as well as other things now section 6

01:33:19 as well as other things now section 6 then goes on membership of the forum if this paper is agreed it is proposed that the following heads of service would be requested to nominate a representative operational assurance chair

01:33:31 operational assurance chair see that yes and then over the page on page five other members and you have operations prevention and performance sorry operations prevention and response

01:33:42 sorry operations prevention and response operational procedures operational resilience strategy planning and performance and then

01:33:48 and then under seven frequency of forum meetings it is proposed that the forum meet every two months at union street the frequency of this meeting would facilitate the forum feeding into both operational assurances six monthly

01:34:00 operational assurances six monthly report to odcb and informed consideration of the need for any interim reporting of contemporary issues now now um that's the document

01:34:11 now now um that's the document the inquiry asked for minutes

01:34:14 minutes of the incident command forum meetings and the lfb recently disclosed five sets of minutes spanning the period june 2013 to april 2014.

01:34:25 to april 2014. from a review of those minutes we have not noted you as having attended any of those meetings but instead graeme ellis

01:34:32 ellis or neil withers attended from operational assurance why was that um i think as it says in this document here that all the heads of departments were to nominate somebody to represent

01:34:45 were to nominate somebody to represent them and graeme ellis was chosen as the chair due to his extensive operational experience and the fact that he was the day-to-day manager and lead for the

01:34:57 day-to-day manager and lead for the incident management team right um did you receive and read the minutes of these meetings the meetings of this forum i don't believe um i did

01:35:08 of this forum i don't believe um i did but i don't recall but i remember having conversations on my one-time meetings with graham ellis about this forum

01:35:16 you don't um you don't recall so i'm not sure i understand your answer i think you do you recall having conversations uh on your in your one-to-one meetings with graham ellis about this forum yes i

01:35:28 with graham ellis about this forum yes i recall conversations because i don't recall specifically seeing the minutes of the meeting i follow did you ever ask for them

01:35:35 for them i don't recall i'm sorry um let's go back to the november 2013 house working group monitoring report lfb triple zero 67832

01:35:47 we saw this just earlier this morning before the break and if you note there on page 25

01:35:57 at the very foot of the page on the right hand side i read to you that the paragraph says as an ongoing quality assurance initiative the issues detailed in this recommendation now form a

01:36:09 in this recommendation now form a standing agenda item a standing agenda item at the quarterly incident command forum meetings held between brigade and babcock

01:36:21 it isn't clear to us looking at the agendas which agenda item that is and let's see if you can help us with that miss cotton can we go please to lfb double zero one two three six six two

01:36:40 this is the agenda for the meeting of the 19th of december 2013. open meeting apologies near from neil withers

01:36:47 withers and if you look cast your eye down um we um

01:36:52 um we um we're not clear what item in this agenda uh should cover the seven incident command recommendations can you help us with that

01:37:03 with that um for meeting the agenda then i would only be able to speculate that it could either have been covered in section potentially in section 5 under the review and the tea caps but i'm not

01:37:15 review and the tea caps but i'm not aware so i didn't attend these meetings so i'm not sure at which point but i know um it was the subject of the conversation at these meetings

01:37:24 meetings right

01:37:26 right you're speculating it might be five and but is the reason why you say it might be five is the same reason i might say that it was five namely we can read what five says indeed yes i just know it was

01:37:37 five says indeed yes i just know it was talked about from my meetings with graham ellis i'm not sure under which agenda item they specifically addressed it

01:37:44 it right

01:37:45 right uh now

01:37:47 uh now let's look at lfb double zero one two three six six zero

01:37:56 this is the meeting or the minutes for the meeting of the fifth of september 2013 and again you were not present we see that graham ellis was in the chair for the meeting

01:38:07 chair for the meeting did he usually run them do you think yes graeme ellis was the nominated chair for the meeting if we look at page two under the heading rule 43s at the top of the screen top of the page

01:38:19 at the top of the screen top of the page it says ge graham ellis informed the group that around the country a number of rule 43s have been issued dm explained that he is currently that's doug massey he is currently

01:38:30 that's doug massey he is currently carrying out work on the lfb latino house rule 43 to ensure it is incorporated into all aspects of babcock incident command training now

01:38:40 now we

01:38:41 we um

01:38:43 um given our review of the recently disclosed uh minutes of this forum this is the only mention that we've been able to identify uh where the rule 43 recommendations are referred to can you help are we right

01:38:56 referred to can you help are we right about that or do you not know i don't know i can only see what uh from the meeting that's in front of me i'm sorry i don't know the detail assuming as we must from the lfb's disclosure that the only mention of the latino rule

01:39:08 that the only mention of the latino rule 43 recommendations in the proceedings of the incident command training forum is here

01:39:15 is here do you accept that the incident command training forum sitting within your department as it did did not consider the incident command rule 43 recommendations on a regular basis

01:39:26 basis quotes as an ongoing quality assurance initiative close quotes i'm sorry i'm unable to answer that because i am not aware of the content of the conversation during the meeting

01:39:37 the conversation during the meeting and

01:39:38 and minutes and meetings aren't always accurately recorded so um because i wasn't present um i would have to speak to a colleague to find out but i'm not sure from i can see it's if you say this is the only recorded one but i

01:39:50 this is the only recorded one but i couldn't comment on the detail of those meetings

01:39:53 meetings so you you had informal discussions with graham ellis at your one to one weeklies about this did you ever ask him

01:40:02 about the standing agenda item about and about whether he was satisfied that the regular consideration of incident command at this forum was acting as a continuing quality

01:40:15 was acting as a continuing quality assurance initiative as the odcb had been told

01:40:19 been told i'm not sure i would put it in those words but i know that in my regular one-to-one meetings with graham ellis we regularly had a conversation about the updates regarding the progress

01:40:31 updates regarding the progress of

01:40:32 of the recommendations and the conversations were being had at the instant command forum right now making all allowances for the absence of the minutes and for the way in which the minutes were drafted looking at the

01:40:44 minutes were drafted looking at the documentation we've got do you accept that despite the odcb and the lack of house working group being told that the incident command training forum was looking

01:40:55 looking by way of quality assurance on a continuing basis at the coroner's seven items for incident command that wasn't in fact the case as i said before i'm unable to make that

01:41:06 before i'm unable to make that assumption because i'm not sure what meeting what conversations were had during the meeting let's then turn to the development and release of the new incident command courses in 2016 and 2017.

01:41:18 courses in 2016 and 2017. let's go back to babcock's october 2014 incident command course review report that we saw earlier please at lfb triple zero four three five five two

01:41:39 there's the first page just to remind you of the document dated 20 dated july 2013 but we know finalized in october 2014

01:41:47 2014 page 26 in that document please first paragraph under the heading recommendations section 14 and the first paragraph there says this it is a conclusion of the review

01:41:59 it is a conclusion of the review but whilst there is some scope to improve incident management training in the short term there is a greater need to adopt a more systematic and fundamental approach involving both the

01:42:10 fundamental approach involving both the lfb and babcock to maximize the benefits longer term and if we then skip the next paragraph we look at paragraph 14.1 key recommendation

01:42:21 key recommendation and it says this it is recommended that a joint lfb stroke babcock group be established to undertake a systematic and fundamental overhaul of incident management training

01:42:33 management training and then the reports goes on to set out the recommended remit of that group the joint group peter groves told us that the group was set up

01:42:44 set up uh was the incident command project board also known as the incident command program board were you a member of that board i believe i was yes right

01:42:55 believe i was yes right was the

01:42:56 was the let's call it the icpb because that's not another habit of a lifetime go by um was it previously known as the course review board i think this was a separate uh entity

01:43:08 i think this was a separate uh entity but i think the course review board as i recall

01:43:11 recall um looked at uh courses across the whole of training department this was specific to incident management so i believe they were two separate entities

01:43:21 entities two separate entities was there any commonality of membership between the two um inevitably they would have been i can't recall the specific detail of the membership of each group i'm sorry now

01:43:32 membership of each group i'm sorry now gary reason told us that he chaired the course review board which i think you've just told us is different from the incident command program board or project board icpb did you come to chair the course review

01:43:44 did you come to chair the course review board at any time i don't believe i did i believe that would have fallen to peter groves as that was the work of his department i think now it's a different group this the incident command project or

01:43:56 the incident command project or programme board you were a member of it as you told us who chaired it um i can't recall do you have a copy of the minutes i think that would help us uh well um

01:44:06 well um we might uh um we we have some and i will show they show you those in a moment but before we do let's see if we can get to the bottom of what i want to ask you about um

01:44:18 want to ask you about um peter groves told us that this board the ic project or program board met monthly um i think so if you say so the best my recollection yes um let's go to your second statement please uh lfb double zero double one

01:44:31 please uh lfb double zero double one eight two one three page ten paragraph 50.

01:44:38 and if we go to paragraph 50 in the last three lines there you say i would expect the lfb's incident command project board icpb to review the lfb's incident command

01:44:50 to review the lfb's incident command training program to manage the project of commissioning training along with ort and at 51 you say i receive regular updates regarding the implementation of

01:45:01 updates regarding the implementation of revalidation at icpb and cmb meetings the icpb was the governing board for the review of incident command training however any formal changes to lfb

01:45:13 however any formal changes to lfb policies or training had to be approved by the cmb i would also speak with peter groves and ac ellis individually at monthly meetings as they reported directly to me i've set out my recollection of these

01:45:25 i've set out my recollection of these meetings from paragraph 55 below now the first set of minutes of the icpb which is i think what you were after um we find at lfb double zero one two two

01:45:36 we find at lfb double zero one two two nine eight nine i'm not sure i can give you all of them but let's look at the first one um this is a set of minutes for the meeting of the 23rd of june

01:45:47 meeting of the 23rd of june 2015 as you see note the year 2015 and we can see that you are listed as the second person down in the list as present

01:45:58 present assistant commissioner operational assurance

01:46:01 assurance yes this is the course review board yes not the icpb oh this is this is the course review board yes they're not the incident command project board no

01:46:12 incident command project board no right

01:46:15 just looking at this document then would it be right to say that these meetings concerned

01:46:20 concerned the development of the lfb's new incident command courses i'm sorry i would have to see the detail of the meeting to recall that i um i can't remember i think the course review board covered a wide range of courses so i

01:46:32 covered a wide range of courses so i would need to see further details sorry right

01:46:36 right uh well

01:46:37 uh well let's uh

01:46:40 let's uh look and see page two

01:46:43 page two to see if this helps you page two

01:46:48 page two ba and real fire training and then at the very foot of page two incident command you see oh yes ck detailed that the incident command review had been through a process

01:47:00 review had been through a process as previously reported to determine options for a proposed solution for the initial acquisition and maintenance training programs for level one incident command

01:47:08 command this process had been replicated for levels two three and four solutions which are currently being developed then if we turn the page to page three the options relating to length of course

01:47:19 the options relating to length of course duration and indicative tu's have been submitted to project board and are tabled for further discussion at the project board meeting scheduled for the 15th of july 2015 and then there's something about costs

01:47:31 there's something about costs pg asked that jackie also be invited to the ic project board meetings to advise on commercial matters

01:47:40 it looks as if the ic project board

01:47:45 was the same as this or different from this can you help us with how they related so i think the um course review board looking at the detail of this i saw a brief mention of ba training and

01:47:57 saw a brief mention of ba training and management development so i think the course review board was the overarching board that looked at all of the courses training courses provided by babcocks and when i look at the membership there

01:48:08 and when i look at the membership there were people from strategy and development and fire safety so that would indicate it was a wide reaching membership i'm looking from what i see here the instant command project board appears to be

01:48:19 be a

01:48:19 a subsidiary or a side meeting of that to specifically discuss instant command um

01:48:28 um right you say specifically discuss incident command wasn't it all about incident command the instant command project board yes the course review board no

01:48:38 right now the course review board is different from the incident is this right the incident command course review so the instant command project board i'm sorry london fire brigade does like an acronym the icpb

01:48:50 the icpb is a board specifically to look at instant command but the course review board would make reference to that because they were discussing all courses i follow

01:49:01 i follow so

01:49:02 so this this meeting is a is a generic overall meeting looking at the course review was that a standing um a standing board yes it was when was it first established

01:49:13 established i'm not sure but i imagine on the inception of babcock taking over as the outsourced training provider uh

01:49:21 uh and when did you first join you when you became a coa um i would imagine so but i can't confirm that without seeing the minutes i would assume so

01:49:31 um right

01:49:33 right it's right to think that the incident command course review covered all levels of incident command levels one to four and eventually yes it did and we heard from peter graves that the level one incident command courses were

01:49:44 level one incident command courses were rolled out sometime between 2016 and 17 and that would fit with the tcap zero one two four we saw earlier wouldn't it so the tcap zero one two four was specific to the lack of recommendations

01:49:58 specific to the lack of recommendations but the course review for level 1 was a much wider reaching program do you remember that the level 1 incident command courses were rolled out between 2016 and 2017. um i believe so i

01:50:11 between 2016 and 2017. um i believe so i don't specifically remember the date but that that seems to accord and it's right i think that the new incident command courses which as i've just shown you from this document for levels two three and four incident

01:50:22 for levels two three and four incident commanders had not been rolled out before the grenfell tower fire in june 2017.

01:50:28 2017. um i i believed that some of them had been i think level three and four were definitely the ones that were areas concerned but i believe that level two had started to be rolled out but i can't

01:50:40 had started to be rolled out but i can't confirm that i would need to see further documentation i know there'd been a lot of work around levels one and two but there were significant difficulties being identified in levels three and four right

01:50:53 four right and well let's just see if we can pin this to a document given that you're not entirely sure and if we go please to um

01:51:01 um lfb double zero one one eight one nine five

01:51:05 five what i'm showing you is the minute of the incident command project board meeting so this is the icpb on the 22nd of august 2017 after the

01:51:16 on the 22nd of august 2017 after the grenfell tower fire two months or so afterwards uh and um you're not present but note the date you see that i do yes well if you go to

01:51:27 you see that i do yes well if you go to page um two please let's look at item four

01:51:34 uh you can see status updates babcock level one

01:51:41 level one uh is covered there level two development maintenance and group manager dm advised that the second gm pilot is due to go ahead 11th and 12th september this is

01:51:52 ahead 11th and 12th september this is 2017. sm advised that js and pf have confirmed that they will observe the course as well as mark reed who will be reviewing for the strategic arrangement workshop sm to arrange a subsequent

01:52:03 workshop sm to arrange a subsequent post-pilot meeting for the level two gm course level three now that the stakeholders have been confirmed a meeting will be booked for them from the second week of september to scope the requirements for the level three and four course

01:52:14 three and four course diaz confirmed that babcock stakeholders will be ck or ds doug massey or mark gurney level 4 development maintenance as above

01:52:24 as above it looks from that as if level 1 was in place level two and three or level two was only in the pilot phase and levels three and four

01:52:36 pilot phase and levels three and four um were still being scoped yes as of september 2017 yes yes

01:52:44 now june 2017 the month of the grenfell tower fire was just short of three years wasn't it after the lfb received babcock's finalized course review report in october 2014

01:52:57 in october 2014 yes it was and over four years after the latino house coroner's incident command recommendations in march 2013. yes it was

01:53:07 was do you accept that that time frame for the development and rollout of new incident command training which mostly occurred on your watch as acoa and director of safety and assurance was

01:53:18 director of safety and assurance was extremely slow i agree it was worse than slow it was sluggish my role as ac operational assurance i had limited impact on that

01:53:30 had limited impact on that i would regularly report to gary reason and james dale gleesh about my frustrations and my serious concerns about the lack of progress that was being made graeme ellis and i said have regular

01:53:42 graeme ellis and i said have regular conversations we met graeme ellis and i'm with members of the babcock training team to try and give them assistance so we met with doug massey to try and give him

01:53:53 met with doug massey to try and give him assistance to progress this because we were so frustrated with the lack of progress

01:53:58 progress and when i became the director of safety insurance in 2016 i again

01:54:04 i again through my meetings with peter groves as the conduit with training expressed my serious concern about the lack of progress this was one of my greatest frustrations

01:54:15 this was one of my greatest frustrations and angers the lack of ability of babcocks to be able to develop this training and it was a subject of a regular conversation at

01:54:24 at several different boards because it was unacceptable how long it took

01:54:31 it sounds as if your frustration and anger was directed at babcock is that what i take from what you've just told us yes babcocks were the training provider who was supposed to be developing the training we were providing them with subject matter

01:54:42 providing them with subject matter experts over and above the requirements of the contract on a regular basis in fact members of my team and other teams especially the operational policy team

01:54:52 team were spending an inordinate amount of time working alongside babcocks to assist to develop this training and other training and it was still taking a

01:55:02 a ridiculously long time to do the babcocks were responsible for delivery but the content was the lfp's responsibility wasn't it no the content and the development of the packages were

01:55:14 and the development of the packages were all babcock's responsibility we were merely tasked to provide subject matter experts to assist them the development of the package was entirely the responsibility of babcock as the training provider

01:55:26 we had understood from mr groves as evidence that it was the commissioning department that was to approve and give final authorization to the course contents is that not right they were working alongside it and approving it

01:55:38 working alongside it and approving it but not developing it under any circumstance we didn't we had got rid of all the teams that developed our training as a result of the outsourced training contract because the specifics of the contract were that babcocks were

01:55:49 of the contract were that babcocks were to develop the training and in fact part of their bid for the training was they were going to provide us with innovative new ways of developing and providing training and i saw very limited opportunities

01:56:01 and i saw very limited opportunities where they did that did anybody to your knowledge yourself included within the brigade ever asked themselves whether instead of simply blaming

01:56:12 whether instead of simply blaming babcock for the sluggish progress there was something they could do you could do to take back control as it were of the course content and delivery in order to speed things up

01:56:24 order to speed things up unfortunately yes this was a conversation we had but as we had signed up to a very long term contract with very specific details with an outsourced training provider it would it was something that wasn't possible to do because it was within the

01:56:36 possible to do because it was within the remits of that training contract it was a conversation that i had with gary reason and james gleash and i know it was a conversation that was discussed at commissioner's board but unfortunately at that point

01:56:47 at that point due to the requirements to outsource our training we had got rid of all of the teams that did the development of that training as part of the contract did anybody actually go back and work out why it was

01:56:59 and work out why it was that lfb had ended up in a position whereby their outsourcing arrangements had so tied their hands that they could not speedily address the lack of house coroner's recommendations in respect of

01:57:10 coroner's recommendations in respect of incident command um i'm sorry i think that's a question you would have to direct to the exist then commissioner ron dobson well that's a very helpful point but i'm asking you can you help us i would imagine they would have done but

01:57:21 i would imagine they would have done but you would have to ask ron dobson if they consider that right well ron dobson was was ron dobson kept fully abreast of the delays

01:57:29 delays and the um the problems with developing level level two level three and level four training and the slow the speed with which even level one was rolled out was he kept fully informed of all those

01:57:40 was he kept fully informed of all those things i would have imagined so i kept both gary reason and james dale glich as my line managers fully informed so i would imagine through that process they would then have informed the

01:57:51 they would then have informed the commissioner can you recall any specific occasion on which you had a conversation with gary reason about what he was telling the cmb or the cmt for that matter about the

01:58:04 or the cmt for that matter about the worse than slow in your words sluggish development of the incident command

01:58:10 command training programs no i recall talking to him on several occasions about it i don't know what the subject of the conversations he had at commission's boardwalk did he ship from what you

01:58:22 boardwalk did he ship from what you could tell did he share your anger and frustration about the speed of progress he did

01:58:29 and did you ever have a discussion with him about what he was going to tell ron dobson

01:58:34 dobson and bring it home to him about how you might be able to improve matters no i wouldn't presume to tell my line manager what he was going to tell the commissioner now we've also seen i think from documents and peter graves confirmed

01:58:46 documents and peter graves confirmed this that the incident um command review had only been partially completed and was continuing at the time of the fire and we see that in a sense from from this document uh

01:58:57 uh we've not seen any evidence that would indicate to us the inquiry that as between the coroner's recommendations in march 2013 and the date of the grenfell tower on the 14th of june 2017 that the

01:59:09 tower on the 14th of june 2017 that the rule 43 actions were in any way incorporated into or reflected in any new incident command courses can you help so they were definitely

01:59:21 so they were definitely incorporated into the tcaps for zero one five three and zero one two four which were the new training interventions directly as a result as to the detail of what was

01:59:34 as to the detail of what was put into the new general incident command training courses

01:59:38 courses i'm not sure of that level of detail right

01:59:43 in fact but in general do you accept that lfb's post latino incident command training failed to ensure that the incident commanders received full and proper training on all known operational

01:59:54 proper training on all known operational risks including rapid external fire spread and failed compartmentation no i think i couldn't agree to that statement saying they'd failed to provide all training because there were a number of different training interventions not

02:00:06 different training interventions not only through babcock's but through the training that took place regularly on fire stations through the um actual practical exercises that took place in high-rise

02:00:17 exercises that took place in high-rise blocks so there were a number of different training interventions that were taking place on a regular basis throughout london fire brigade well we've seen we've seen two of those we've seen the lack of house training package and we've

02:00:28 lack of house training package and we've seen

02:00:29 seen holcroft house i thought you'd agreed with me that there was nothing in there at least about rapid external fast spread and failed compartmentation in those two specifics yes what i'm saying is that we don't have the detail of the vast range

02:00:41 don't have the detail of the vast range of operational training that was taking place alongside that as a regular basis on fire stations as large scale operational exercises as multi-agency exercises so without

02:00:52 as multi-agency exercises so without being able to see the detail of all of those vast numbers of training interventions i couldn't agree with that i see so when you said you couldn't agree with it was that because you didn't know one way or the other no it's

02:01:03 didn't know one way or the other no it's because i believe there were a large number of training interventions that would have covered some of those issues but i don't have the detail of those to be able to make that comment right uh forgive me what is the basis on which you hold the belief that

02:01:17 which you hold the belief that notwithstanding the absence from the babcock training nonetheless station-based staff were receiving training in how to handle rapid external fire spread and failed compartmentation so on those two specific issues

02:01:29 so on those two specific issues there would have been a number of opportunities especially with the compartmentation the rapid external far spread less so but um

02:01:38 but um on the wider training issues around all of those recommendations following the lack of fire then there would have been a number of opportunities throughout training interventions that took place right across london fire brigade to

02:01:50 right across london fire brigade to address those issues yes opportunities yes were they taken care of yes absolutely through the large scale training exercises i just talked about so the regular six eight ten twelve pump exercises

02:02:02 ten twelve pump exercises um that took place where operational crews would actually run through scenarios for real in the training environment obviously without setting fires but

02:02:12 fires but and also station-based training events so that would require you to be able to access all of the individual training records and the local station borough training plans to see the detail of that

02:02:25 training plans to see the detail of that let's go to nfb three zeroes four five nine six zero please

02:02:35 this is a cfoa lga joint document london fire brigade fire pier challenge report march april 2015.

02:02:47 report march april 2015. do you remember this document um i doubt i wouldn't have been party to seeing the final document that would have been a cmb related document i remember the peer challenge taking place

02:02:59 challenge taking place you do let's go to page 12 please paragraph

02:03:02 paragraph 37

02:03:08 and the authors say this 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

02:03:20 sometimes manifests itself in some clunky complex processes sheep dip training and non-tailored renewal of competencies and training looking at the evidence we've seen so far

02:03:31 seen so far together about incident command do you do you agree that that was what was happening with the lfb's new incident command courses a desire to incorporate incorporate everything but ultimately resulting in

02:03:42 resulting in delay

02:03:44 delay um i would agree that's resulting delay i can't see the context of what they're referring to in this paragraph it would be very difficult to understand i think this is talking about the whole range of training

02:03:56 the whole range of training interventions but i would say that yes london fire brigade did have a culture of seeking the very best solutions and that did sometimes take a very long time

02:04:08 that did sometimes take a very long time let's see what gary reason told the inquiry please see if you agree with what he said day 181 page 79

02:04:17 page 79 and let's look together at lines 1 to 16.

02:04:31 he says it's really really important and it probably accounts for some of the lag in the delivery you really you really need to be careful that you're not giving one constituent

02:04:43 that you're not giving one constituent within your organization one bit of training that is consist inconsistent with another constituent that's going to come along six months later and do a different type of training but related to the same subject that that is now

02:04:54 to the same subject that that is now they're out of step that is an absolute no-no you get yourself into real problems with that so i know there's been a lot of talk about

02:05:01 about the clumsiness of this sort of process but partly it's to avoid that inconsistency and the potential confusion as you cause by having one group being trained slightly differently to another group but actually they're

02:05:12 to another group but actually they're all going to end up at the same incident and that is a recipe for disaster do you agree with that um

02:05:20 um i don't know what context that's in i'm sorry that's a wide ranging statement but i don't know what specific question you'd ask to get that would be possible to see the question yes of course let's go back to page 78 please and look at the question

02:05:33 page 78 please and look at the question i asked him at line two

02:05:36 i should just tell you gary reason gave us quite a lot of information often in one go

02:05:41 one go and therefore um the what i've just read to you was some way down in his answer but the question he was addressing was this

02:05:48 this one of the reasons from what from what you have just said in your long but nonetheless rich answer is there are lots of things that the lfe was trying to do looking back on it might it have been just simpler to focus very tightly

02:05:59 been just simpler to focus very tightly on incident command training courses in each of the seven areas rather than trying to link that into things like incident command training courses or assessment for promotion that was the context

02:06:08 context having shown you the context are you prepared to agree with what he said in the passage i've read to you forming part of the answer to that question um i don't understand how that forms part of the answer it seems a very um distant

02:06:20 the answer it seems a very um distant response to the question you asked but forgive me that will be a matter for the panel but i'm just asking you whether you agree or you disagree with his general observation which he clearly thought was relevant

02:06:32 thought was relevant i agree with the fact that it is important to be consistent in training

02:06:38 training especially in regards to risk critical training and i know one of the problems that london fire brigade has experienced um for many many years is a transition so

02:06:49 for many many years is a transition so if you change a specific part of risk critical training the ability to be able to train and prepare the organization for an effectively a switchover date for that change to happen because it is such a

02:07:00 change to happen because it is such a large organization so i would agree to that extent yes thank you let's look at your second witness statement please lfb00118213

02:07:11 page eleven

02:07:14 uh and uh i just want to look please at paragraph 52 a b and 53 um i'll read them to you you said hey there were a number of elements to the process for changing training

02:07:25 to the process for changing training under the babcock contract a training commissioning alteration process tcap would have to be submitted before any change would be made and would therefore be a significant number of tcaps in development at any one time it was

02:07:36 development at any one time it was therefore difficult to make changes quickly

02:07:38 quickly issues a raise when developing training to support the revalidation of incident commanders as babcock did not have the necessary subject experts to assist with training i recall that there was an attempt by babcock to combat this by by

02:07:50 attempt by babcock to combat this by by seconding retired lfb officers to act as subject experts in developing this training

02:07:55 training amendments to training therefore had to be considered fully and the proper process undertaken before lfb training would change and this could take some time the privatization of the lfb's

02:08:06 time the privatization of the lfb's training under the contract with babcock created inefficiencies within the lfb's training program particularly in terms of implementing changes to training babcock attended cnbs approximately every six months to discuss training i

02:08:18 every six months to discuss training i understand that ac ellis is considering the challenges faced under the babcock contract in his witness statement now you've identified a number of factors there did those factors when combined mean

02:08:31 did those factors when combined mean that there was a resistance within the nfb to undertaking a wholesale review of incident command training exclusively for the purposes of the latino coroner's rule 43 recommendations no not at all

02:08:43 rule 43 recommendations no not at all and what about the fact that babcock's recommended fundamental review of incident command was continuing was that a problem no i think that the only factors we

02:08:55 no i think that the only factors we identified here are the length of time it took to do anything

02:09:00 yes and really what i'm driving at is whether all of those difficulties which you've identified whether or not to do with babcock um

02:09:11 whether or not to do with babcock um combined in the lfb's corporate mind to provide a degree of resistance to wholesale change no i would say there was no resistance to wholesale change just the fact that

02:09:24 to wholesale change just the fact that we had identified that change brought about difficulties and complications and there were time issues involved in that um on this topic let's look at uh the

02:09:35 um on this topic let's look at uh the odcb meeting for march 2014 at lfb doubles lfb triple zero 67808 please

02:09:46 zero 67808 please this is a meeting of the odcb of the 4th of march

02:09:51 of march 2013 at union street as you can see that's the agenda there and if we look at page 2 we can see the minutes and we can see who was present and we can see that you in fact i think were not present for

02:10:03 in fact i think were not present for that but graham ellis was from operational assurance is that right yes that's correct if we go to page seven paragraph

02:10:13 paragraph 10.3

02:10:17 we can see there under the heading any other business it says this

02:10:21 says this dacoa advised that babcock training had requested that they attend the weekly ort meetings it was agreed by the board that babcock training should not attend ort meetings but that the gm incident

02:10:32 ort meetings but that the gm incident command would meet bi-weekly with a babcock training representative to discuss generic issues around incident command training do you know what had given rise to babcock's request for attendance at the

02:10:43 babcock's request for attendance at the weekly ort meetings i suspect it was because one of the members of babcock training was a retired london fire brigade officer who had been an ort officer and in fact had

02:10:55 had been an ort officer and in fact had led the ort team um and i suspect that he had suggested that but i don't know if in fact who was that person there were two there was dean johns and rick nichol to my

02:11:07 dean johns and rick nichol to my recollection rick nichol yes he was one of the babcock's trainers do you know why the board decided against babcock joining ort meetings

02:11:18 against babcock joining ort meetings i think that i'm the reason was that a number of confidential issues would be discussed at those meetings regarding performance of officers and crews at the

02:11:31 of officers and crews at the in the on the fire ground and that that would not be an appropriate meeting to have an external body at but that the key issues identified in those meetings relating to operational issues could

02:11:44 relating to operational issues could then be shared with them by the group manager in charge of the ort team uh

02:11:51 right was there a way in which you could have

02:11:54 have uh avoided or got around the issues of confidentiality just simply by redacting the names from the performance review of command or performance review of operations reports uh or in your discussions no this was a

02:12:07 uh or in your discussions no this was a verbal mainly verbal meeting where conversations were had with the ort officers about the incidents they had attended in the previous week and therefore would have heavily relied on being able to identify individual

02:12:18 on being able to identify individual teams and crews so it would not be appropriate to have an external body there right

02:12:25 was any consideration given to your knowledge about how to avoid or minimize those confidential perceived confidentiality problems and there were real confidentiality

02:12:36 and there were real confidentiality issues that i imagine would have been subject to conversation unfortunately i wasn't present here but i know that the key takeaway from that was the fact that the issues identified in relation to operational training could be shared via

02:12:49 operational training could be shared via the group manager with babcocks now you can see in the text there that the gm incident command is that group manager incident command that is yes we'd meet bi-weekly with the babcock

02:13:00 we'd meet bi-weekly with the babcock training representative to discuss generic issues around incident command training what was the problem that the odcb thought that these bi-weekly meetings would solve um i don't think there was a problem i

02:13:11 um i don't think there was a problem i think that it was more about sharing information with our training provider to give them a real flavor of the relevant and current issues that might be being

02:13:22 current issues that might be being encountered by crews in their day-to-day operational management would it not have been a good idea even allowing for the confidentiality problems to have helped babcock

02:13:34 problems to have helped babcock understand or develop an understanding and indeed some degree of subject matter expertise of incident command issues by letting them come to the ort meetings no that would have been the role for the gm incident commander to share that and

02:13:46 gm incident commander to share that and in fact the people who um were working for babcock's were fully aware of the and have an understanding they were subject matter experts as they were retired london fire brigade officers

02:13:58 retired london fire brigade officers did those bi-weekly meetings between babcock and gm incident command thereafter take place um

02:14:06 um i don't know i can imagine they would have done but i can't confirm i wouldn't have attended those right this was proposed as an oa mata by d by the dac

02:14:18 d by the dac this time graham ellis as as he was then a dac so this was within your department why don't you know whether or not the gm incident command bi-weekly meetings happened

02:14:29 happened because there would have been a inordinate range of meetings undertaken by members in my team i wasn't fully aware of the detail graeme ellis as the direct line manager of the group manager would have been the one ensuring

02:14:41 manager would have been the one ensuring those meetings took place now this is an odcb meeting minute as a member of the odcb at the time although you weren't there can we assume that you would have read the minute i would have done yes can we assume that you would have read

02:14:52 can we assume that you would have read this part of the minute yes i would have done and i would have had a conversation subsequently with graham ellis after the meeting as he attended as my deputy yeah but you still don't know as a result of reading the minute and that conversation

02:15:04 reading the minute and that conversation whether in fact these bi-weekly meetings took place i believe they did but i can't confirm because i can't see the minutes but i believe they did because graham ellis and i would have conversation about the interface with babcock training so that

02:15:16 interface with babcock training so that was the means by which that happened you say you can't see the minutes do you know whether there were minutes i have no idea sorry did you ever ask to see the minutes no i spoke to graham ellis about the issues

02:15:27 spoke to graham ellis about the issues that came up as he was the direct line manager for the group manager

02:15:35 um peter groves told us and for reference purposes this is day 177 at page 57 lines 2 to 25 and 58 93

02:15:47 and 58 93 that the tcap process was generally reviewed within the brigade as cumbersome and that he recommended to you during your time for director for safety and

02:15:58 your time for director for safety and assurance that there ought to be an external review or scrutiny of lfb's training commissioning processes but you didn't agree to that is that right no unfortunately i did hear peter groves

02:16:09 unfortunately i did hear peter groves give that evidence i would have welcomed with open arms anybody who could come and assist us because it was such a difficult process and so very cumbersome and as peter's team was the one that was

02:16:21 and as peter's team was the one that was in charge of that then he would have been able to commission that independent review without needing to get permission from me

02:16:28 from me had he brought that request to me um i would have been more than happy for him to do that because it was such a torturously slow process and delayed everything so that would

02:16:39 and delayed everything so that would have anything to assist that would have been a

02:16:41 been a um something i would have agreed to straight away you say you would have welcomed with open arms anybody who who could would come and assist you because it was a difficult process did you ever volunteer that as a suggestion

02:16:53 you ever volunteer that as a suggestion yourself

02:16:54 yourself no because um we were reliably informed that babcocks were doing everything they could to speed up the process and that peter grove's team were the ones who were responsible for

02:17:07 ones who were responsible for trying to facilitate that and to smooth it and whenever we raised issues around the delays and when i raised issues personally when i became the director of safety and assurance with

02:17:18 director of safety and assurance with the

02:17:18 the my colleague representative colleague in babcock's

02:17:22 babcock's we were regularly provided with updates that they were doing everything they could but the volume of training the lfb were requiring and the amount of tcaps was the issue

02:17:38 coming back to the point though not all training and not all tcaps were addressing coroner's recommendations were they

02:17:45 were they no absolutely not some of them were addressing other risk critical training areas some of them were addressing vast subjects like breathing apparatus training

02:17:54 training it was the the volume of those and the ability of babcocks to develop that training and provide subject matter experts across the piece that caused the day can you just help me with this there are two

02:18:06 with this there are two aspects to commissioning new training aren't there one is

02:18:11 one is the lfb side what we call the tcap process and the other is the babcock side i've got respond to the final tcaps now i quite see you've got difficulties

02:18:22 now i quite see you've got difficulties with babcocks and there may be limited amount of pressures you can bring to bear there but the suggestion that was made

02:18:31 made i think by mr graves was that the nfb side could be streamlined a bit or made more efficient did anyone look into that i believe so and i believe that peter

02:18:43 i believe so and i believe that peter groves and conversations i had with him as they were trying to make it more efficient but actually having seen the tcap process that it was um a combined from the moment the

02:18:55 it was um a combined from the moment the tcap was

02:18:57 tcap was submitted um and the development of the tcap was a process that subject matter expert from the commissioning department would the subject would be discussed they would then work closely with

02:19:09 they would then work closely with the person in peter groves team who were the ones who actually drew up the tea caps because they understood the the language want a better word of how that had to be worded and they were then already working with babcocks so before

02:19:21 already working with babcocks so before the tea caps were submitted babcocks were already included in that process so it was

02:19:28 it was it was a slow process but there wasn't deemed to be any specific way as peter groves told me of speeding that up so

02:19:36 up so i am surprised by that suggestion because if he had thought that there was someone who could have come in and assisted us then you know that would have been something very beneficial i mean did he suggest to you that

02:19:47 suggest to you that the internal lfb process was cumbersome and could perhaps be improved it was a conversation we had i recall actually saying sending that to him myself saying that

02:19:58 sending that to him myself saying that to him that i believed that it was cumbersome he told me that he believed that they had the best system that they could so

02:20:05 could so it was a difficult conversation if i'm asking him a question which he now appears to be reflecting but but i would genuinely have welcomed any external suggestion as to how we could improve that all right thank you very much thank

02:20:16 that all right thank you very much thank you so much miss cotton what about going to babcock and telling them to prioritize all the training

02:20:25 training which was a response to the lachenal coroner's rule 43 recommendations obviously there's lots of training but why not simply impose on them a prioritization

02:20:38 prioritization i'm not sure whether that was ever done by

02:20:40 by obviously when this started off it was gary reason who was the director for training whose response overall responsible who met with his counterpart i'm not sure if that conversation was ever had it would have been a good

02:20:51 ever had it would have been a good conversation but i would not have been privy to that you are right i think so far as we've seen that it didn't happen my question really is why not given that it was it not obvious

02:21:02 not obvious that if the process of developing training

02:21:06 training as a response to the latino coroner's rule 43 recommendations on incident command was being held up bogged down because of the sheer volume of other training simply to go to babcock and say

02:21:17 training simply to go to babcock and say never mind about grassland fires or whatever it was

02:21:22 it was please develop the training in response to the latin house recommendations as a priority

02:21:29 priority so the teams that would have been developing other operational aspects of training would have been a different team to that that developed operational procedures so the issue with babcocks was the

02:21:40 so the issue with babcocks was the limited number of people they had that were had any expertise in instant command

02:21:45 command to facilitate developing that training we pressed them on numerous occasions because we understood the importance of incident command and responded to those recommendations that they only had a

02:21:56 recommendations that they only had a very small team that were able with limited capability to develop those packages

02:22:03 packages did anybody look at the contract and go back to babcock and say well you need to get more people or was that a problem of the absence of a pool of smes subject matter experts as between the lfb and

02:22:15 matter experts as between the lfb and babcock i think it was a babcock's found it very difficult to attract and employ relevant subject matter expertise

02:22:27 i'd like them to turn to national operational guidance different different topic and i want to ask you specifically within that topic about the decision-making model and the decision control process

02:22:39 control process the inquiry has heard some evidence about that from dr sabrina cohen hatton during module 5. i think it's right isn't it that the decision-making model or dmm was the

02:22:50 decision-making model or dmm was the brigade's framework model for decision making

02:22:53 making at the time of the grenfell tower fire it was and it was enshrined wasn't it in nfb policy 341 it was and that was the process was it by which incident commanders were expected to

02:23:04 incident commanders were expected to make decisions at incidents yes it was now we heard from dr cohen hatton that she had carried out and published some academic research in 2015 into the

02:23:15 some academic research in 2015 into the effectiveness of the dmm and we went through dr cohatton's research in great detail during her evidence

02:23:22 evidence and i don't want to go through all that with you

02:23:25 with you uh today or any day but by way of brief overview

02:23:29 overview we heard that her research showed that most of the time incident commanders make decisions on an intuitive basis drawing on past experiences rather than in the linear analytical way suggested by the policy the dmm

02:23:42 by the policy the dmm and she told us and this is by way of background to what i'm going to ask you that while intuitive decision making is no matter is not always a bad thing the danger of training incident commanders using a

02:23:53 training incident commanders using a linear model like the dmm is that it ignores the intuitive processes that ics often used in reality in other words the dmm is not a not a real reflection of how people actually think in a real incident

02:24:07 think in a real incident she had developed something called the decision control process or dcp which

02:24:12 which in her opinion better supported the way the decisions are made by commanders in reality

02:24:18 reality now that's a bit of a background speech by way of refresher for everybody and for you it's right isn't it that the dcp the decision control process was incorporated into national operational guidance for incident command published

02:24:30 guidance for incident command published in july 2015 by the cfoa yes that's correct yes and can we take it that you were aware that the dcp was part of the 2015 national operational guidance at the

02:24:41 national operational guidance at the time yes i was yes now dr cohen hadn't explained uh her the findings of her 2015 research and a little bit more granularly that

02:24:53 and a little bit more granularly that incident commanders were more likely to carry out explicit plan formulation so explicit consideration of the implications of decision weighing options against one another and then selecting the best course of action

02:25:06 then selecting the best course of action and had better situational awareness when the dcp was applied rather than the dmm

02:25:12 dmm that's what she found now can i then show you against that background what

02:25:20 what the lfb published a few days after the publication of the national operational guidance nfb double zero one one zero six seven three

02:25:32 this is dated the 16th of july 2015 really a matter of days after i think two days after the publication of the national operational guidance on the on the 14th of july and if you go to page three

02:25:50 under organizational impact it says this the foundation for incident command the incident i'll start again the foundation for incident command document predominantly

02:26:01 incident command document predominantly details the qualities and skill requirements for incident commanders and strategic arrangements that need to be implemented regarding selection development and assessment in order to achieve command competence the contents

02:26:13 achieve command competence the contents of this document will need to be considered as part of the lfb review of command competence as the author of much of the content and lead for the lfb review this will be dealt with by dac kevin hatton learning and development

02:26:25 kevin hatton learning and development appendix one item one and then if we turn the page to page four please at the top it says and this is under the heading incident management policy at the foot

02:26:36 incident management policy at the foot of the previous page cfo simon pyling i think i should be pilling

02:26:41 pilling made it very clear the incident command conference that the decision control process does not replace the decision-making model dmm which will significantly reduce the potential impact of the guidance on nfb as it is

02:26:53 impact of the guidance on nfb as it is mentioned in and the foundation of many policies

02:26:57 policies the decision control process is an illustration of how incident commanders think and will therefore be a useful tool for selection and development but should not lead to wholesale changes in the dmm or other policies

02:27:09 the dmm or other policies however the decision controls why expectations and benefits will be incorporated into the gathering and thinking deciding area of the dmm policy appendix one item seven

02:27:23 now you say in your witness statement uh and i don't think we need to go back to it it's page seven paragraph your second statement that you don't recall who wrote this report is that still the case um i i've been led to

02:27:35 still the case um i i've been led to believe i think it was lee drawbridge potentially group manager you've been led to believe but by a review of the documents or did somebody tell you that um

02:27:44 um i think it's in somebody's statement i recall from reviewing documents right do you remember when you received well first should i ask you i should ask you do you remember reading this at the time july 2015

02:27:56 july 2015 um not specifically i remember a number of conversations with professional colleagues around the instant command aspect of nog but i don't specifically remember reading this document

02:28:09 do you remember in general when you received it whether you agreed with the statement that the decision control process was as it says an illustration of how incident commanders think

02:28:21 commanders think but that it should not lead to a wholesale change in the dmm or other policies i remember in a conversation i had with a number of senior operational colleagues that had attended the instant command conference

02:28:33 command conference that that was what cfo simon pilling had said right

02:28:40 right so you're under is this right your understanding or your view being formed at the time july 2015 doesn't come necessarily from an analysis of the words on the page here but from discussions yes it does yes i

02:28:52 but from discussions yes it does yes i see

02:28:53 see do you agree or did you agree at the time with the statement that the decision control process was not intended to replace the dmm that's what i was informed i was not at the conference myself but that was the

02:29:05 the conference myself but that was the information that was given to me by the colleagues that attended do you know who did attend um i think there were a number there was i know for definite gm drawbridge and um

02:29:17 i know for definite gm drawbridge and um drc ellis and i think two or three other senior officers attended two but i couldn't recall who they were sorry did you speak to lee drawbridge or graham ellis

02:29:25 ellis about what uh cfo piling had said at the conference um it is cfo pulling you were correct earlier um yes we had a conversation around um the the content of the

02:29:37 around um the the content of the conference and around specifically the um conversation around the decision control process uh doctor dr hen dr cohen hatton told us that the first time she had seen the

02:29:48 that the first time she had seen the provisional impact report was when it was sent to her on the 12th of august 2015 about a month later and that she'd not been consulted on its content before publication um

02:30:00 um first do you know from your own recollection whether it's correct that she had not been consulted on its content before publication uh i don't know that you don't um on the assumption that she she is

02:30:12 um on the assumption that she she is correct do you know why given dr kevin hatton's expertise in this area and her involvement in the development of the national operational guidance on this issue

02:30:21 issue um nobody within the lfb sought to consult

02:30:25 consult with her in relation to this report no i don't

02:30:29 don't they should have done shouldn't they yes it would make sense she was their subject matter expert you don't know why the nfb did not seek to involve dr cohn hatton in the formulation of the lfb's response to the

02:30:40 formulation of the lfb's response to the national operational guidance no i'm not going to

02:30:42 going to it would it would have been the obvious thing to do wouldn't it given as you say she was the subject matter expert i would have thought so yes she also told us that what is set out here on page four of the provisional

02:30:53 here on page four of the provisional impact review was in fact a misinterpretation of what cfa pilling had actually said at the incident command conference and

02:31:04 i'll just show you what she said day 185 page 46 please

02:31:27 uh if you look at that page at line 17

02:31:34 uh question

02:31:35 question simon pilling chaired the national operational guidance team's review yes do you know what he said at the incident command conference about the dcp model answer at line 23 yes i do the point he was trying to make is that

02:31:47 the point he was trying to make is that the decision control process was an evolution of the decision making model itself so it is a fundamental return the page

02:31:55 page it is a fundamental

02:31:59 can we turn the page please thank you fundamental piece of the national operational guidance but the point that he was trying to make was that it was an evolution that incorporated some aspects of the decision-making model and more

02:32:10 of the decision-making model and more helpfully would illustrate how people think as well what he wasn't suggesting was that it was simply an illustration or a picture as the paragraph latterly refers to this was a paragraph that i challenged when this report was

02:32:22 challenged when this report was circulated that's what she says

02:32:28 now can we go then in the light of that evidence to lfb double zero double one zero six seven eight

02:32:54 lfb00010678

02:32:58 yes thank you now if we go to page one at the bottom you can see if you scroll down to the bottom an email

02:33:04 email from sabrina coinhatten of the 12th of august 2015 to lead drawbridge you see that and

02:33:15 and others

02:33:17 others copied to

02:33:19 copied to among others you and graham ellis yes yes and she says thanks lee and the subject is re-ic provisional

02:33:30 and the subject is re-ic provisional impact review she says i just want to make a point of clarity around the decision control process and the dmm as i fear it might be easily misconstrued it was one of the cornerstones of the

02:33:42 it was one of the cornerstones of the new guidance and so i think it's really important that the journey is understood i appreciate there may be some resistance to this given the work that has been done around the dmm in london and i really just want to give some assurances the point that cfo pilling

02:33:55 assurances the point that cfo pilling the cfoa lead for command and the lead of the national op guidance for ic was making at the conference was that the dcp is not a new construct that replaces the dmm rather it is an

02:34:07 replaces the dmm rather it is an evolution and an improvement of the dmm it contains many of the same elements as the dmm which will mean that there is not necessarily going to be an enormous impact in some respects however it is not simply intended to be

02:34:18 however it is not simply intended to be an illustration of how people think the point he was trying to make was that the dcp is is structured is intended to support incident commanders and

02:34:29 to support incident commanders and brigades when decisions are scrutinized post incident by being more representative of how people actually make decisions having done expert witness work on behalf of cfoa in relation to incidents

02:34:40 behalf of cfoa in relation to incidents involving ff fatalities i know only too well how both barristers and the hsc will compare actions and statements to the extant guidance and how far away from reality such arguments can be

02:34:51 from reality such arguments can be this was part of the learning that went into the guidance in the case of the nog this will be the exemplar guidance that they go to and the structure of the dmm did nothing to support whereas the dcp

02:35:02 did nothing to support whereas the dcp explicitly aims to do so therefore should we deviate from this it will undoubtedly leave us in a very vulnerable position should our commander's decisions be scrutinized following an incident

02:35:14 following an incident i've read you quite a lot of that and then she goes on to say um the second part around the decision control technique it was about the research now if we then go to the top of the email

02:35:25 if we then go to the top of the email thread at the same day you we can see that you responded

02:35:32 to her

02:35:36 and you say

02:35:39 uh i think we need to meet to discuss this i'm back later next week and what you're responding to is an a private email from her to you and graham ellis sending on her wider response in which she says hi both

02:35:52 wider response in which she says hi both i didn't want to include it in the email to all but the report on the future of incident command was approved last week by the presidential board and is being published and sent to all cfos the commission is aware are the recommendations something we want to

02:36:03 recommendations something we want to consider through this working group and as i say you respond and tell her that you you need to meet and discuss it i'm back next later next week

02:36:16 now dr cohen hadn't told us that you and she did meet first is that consistent with your recollection yes it is it is she also told us that when she spoke to you she repeated her concerns and expressed her

02:36:28 repeated her concerns and expressed her disappointment that the nfb was not incorporating the dcp i don't need to show it to you but that's day 185 page 51 line 24 to 55 line 20. do you agree with her account

02:36:41 line 20. do you agree with her account of the conversation um uh we had a very detailed conversation in fact i had seen dr conhatton present on her work earlier in

02:36:53 earlier in 2015

02:36:54 2015 at a

02:36:55 at a gold command conference we both attended in scotland where we'd both been given presentations so i had seen her presentation and had seen the level of detail and the work that had taken place so i was

02:37:06 work that had taken place so i was familiar uh with the aspects of it so we did have a meeting and we had an in-depth discussion about some of the concerns that had been raised by

02:37:16 raised by the corporate management board about uh changes to incident command so yes i do recall meeting her and having her conversation yes and do you agree with her recollection or

02:37:27 do you agree with her recollection or does it accord with your recollection that she repeated her concerns and expressed her disappointment that the lfb was not incorporating the dcp by way of divergence from the nog the national operational guidance yes she

02:37:39 national operational guidance yes she did we had a very uh in-depth conversation and that's the point when we discussed the fact that although there

02:37:47 there was some initial concern about the wholesale change that the dcp would bring that we were very much supportive of the decision controls

02:37:58 much supportive of the decision controls being incorporated in the first instance into the dmm because we all recognise the absolute value of those as a method for assisting instant commanders in their

02:38:09 assisting instant commanders in their decision making

02:38:12 when she said to you that she was disappointed that the lfe was not going to incorporate the dcp can you remember what you said absolutely yes the fact that i could understand her disappointment she'd been

02:38:23 understand her disappointment she'd been very obviously heavily involved in the piece of work and was very invested in it quite rightly and had done um you know spent a lot of time in the academic research for it so i completely understood that um and i tried to

02:38:35 understood that um and i tried to explain to her that you know obviously the issue was the london fire brigade as a large entity had to agree things through the commissioners board and that they were the ones who would take the

02:38:46 they were the ones who would take the ultimate decision but that i absolutely recognised to say the value of the work and the ability of the decision controls in the first incident to

02:38:55 to it was going to be much easier to implement those um and to use those as a tool to assist instant commanders and she understood that did it concern you that dr cohn hatton

02:39:06 did it concern you that dr cohn hatton who of course you i think accept had considerable expertise on this topic and who had been involved in the production of the national operational guidance felt that the lfb was making a mistake by not incorporating the dcp into its

02:39:18 by not incorporating the dcp into its policy and its training yeah i absolutely understood that she felt that way but i felt that after we'd had the conversation she was more uh understanding of why it was an issue and that she understood how much value

02:39:29 that she understood how much value there'd be in the first instance in incorporating the decision controls i mean you've given us the impression that that what you told her was the difficulty of incorporating this because

02:39:40 difficulty of incorporating this because of the need to go to the commissioner's board to get it signed off but then so is that correct no no no the fact that not to do the sign off but the fact that

02:39:51 not to do the sign off but the fact that the we'd already had conversations um because i you know was fully aware of this training as were a number of other senior officers and there had already been conversations around um how

02:40:02 been conversations around um how difficult

02:40:03 difficult implementing such a scale change to operational instant command training would be

02:40:08 would be um and that had that conversation with gary reason as well as with graham ellis why was it in such a large scale change to operational incident command training it

02:40:20 operational incident command training it was just simply amending the policy the dmm to incorporate the dcp aspects

02:40:26 aspects absolutely amending a policy is very simple the the training that then fall out of that that would have to be designed by babcocks as a result of a tcap and then delivered to 1700 staff would be a very different matter oh

02:40:38 would be a very different matter oh does that tell us that by august 2015 you were already suffering uh from a degree of

02:40:45 degree of i'm not sure what the word would be but experience fatigue with babcock such that with your experiences from the incident command training thus far you knew it was going to be sluggish slow long difficult drawn out even to

02:40:57 long difficult drawn out even to incorporate into training dr cohen hatton's

02:41:00 hatton's suggested changes very much so

02:41:08 right were you aware that dr cohn hatton had attended the incident command conference at which cfo simon pilling had spoken yes i was you were did you discuss with her what simon pilling had actually said

02:41:19 her what simon pilling had actually said about the dcp yes we did did you discuss with her whether or not the lfe might have misinterpreted him when uh recording what it had said in its provisional impact review um i think that she and i

02:41:32 impact review um i think that she and i agreed in the conversation we had that potentially the words that cfo pilling had used were not as clear as she would have liked in order to demonstrate that point and

02:41:43 in order to demonstrate that point and they were somewhat open to interpretation is what she told me um because they they weren't as direct as she would have liked them to have been

02:41:51 been and she then could understand how both

02:41:55 both lee drawbridge and a number of other colleagues had reached that conclusion right did you actually discuss the possibility of amending the paragraph recording what simon filling had said at that conference so as to

02:42:07 had said at that conference so as to make it accurate um no i don't believe so

02:42:17 dr cohn hatton told us that you told her that the lfb would not be moving away from the dmm and that you told her there needed to be a sufficient business reason to do so that's what she said to us at day 185

02:42:29 that's what she said to us at day 185 page 53 at line 25 to 54 line 22 again i don't need to show that to you unless you want to see that but do you recall using those words business reason no that wouldn't be a term that i would use

02:42:40 that wouldn't be a term that i would use i think we probably would have had the detailed conversation around the organizational impact of changing training which would have been a large scale impact but

02:42:51 scale impact but business reason was not a term that i would have used right

02:42:55 right so

02:42:56 so what was the say i think what you're telling us in your answer there is that what you told as the reason for not moving away from the dmn was the organizational impact of changing training

02:43:07 training which would be large scale that was part of the conversation yes but definitely that would have um you know and i was trying to

02:43:14 trying to clarify that point to her i think that you know the difference in changing the training london fire brigade compared to other fire and rescue services was not only about the fact we had we're the

02:43:26 not only about the fact we had we're the only ones have an outsourced training provider but the fact that we were the largest fire and rescue service and therefore had the greatest number of staff to deliver a significant training impact too and that the conversation i think that

02:43:39 and that the conversation i think that we had earlier around the fact that you would need to ensure that all staff instant commands were fully trained on that

02:43:46 that because otherwise you could have people working to different decision making models which could cause confusion and she fully understood that because she had recently started working for london fire brigade and had experienced the

02:43:57 fire brigade and had experienced the difference in working for a very large scale organisation where training was a frustration to her because she was working in the training department yeah

02:44:05 yeah would i be right in summarizing what you've told us in this way the lfb's principal concern with incorporating the decision control process was that its implementation would be a

02:44:17 was that its implementation would be a fundamental change that would require too great an overhaul of the lfb's incident

02:44:22 incident command training and policy specifically training yeah that was definitely one of the key drivers and and i believe that in conversations that were taking place at the corporate

02:44:33 that were taking place at the corporate management board that

02:44:35 that they were very interested to see how other

02:44:39 other larger farm rescue services have managed to implement that training change and the impact that had because you know clearly that would give us an indication of what the impact would be right

02:44:51 of what the impact would be right and was it also a factor that this was at a time summer 2015 when a new suite of incident command training was nearing or supposed to be nearing rollout at least the level one commanders yes it

02:45:02 least the level one commanders yes it was and at a time when a year had gone by

02:45:06 by uh since the development and rollout of the lachenal house training package uh yes i believe so do you know who it was at the brigade who took the ultimate decision not to

02:45:18 who took the ultimate decision not to implement the dcp uh it would have been a report uh to commissions board and a decision by the board right so not ultimately your decision

02:45:26 decision no individuals would not make decisions on something critical like that it would be the subject of a report which would then go to a board for discussion as director of safety and operational assurance at the time which i think you

02:45:37 assurance at the time which i think you were by then was it was did you play any part in the decision for example did you make a recommendation to the cnb or cmt um i think i was the assistant commissioner of operational assurance at that time

02:45:49 of operational assurance at that time and therefore i would have presented the report which i believe that i appended to one of my statements so yes i would have

02:46:00 yes i would have attended cnb for that yes and the reason i say director of safety and operational assurance is because i assume that ultimately the decision was made later but in fact at the time august 2015 as you say you were

02:46:11 the time august 2015 as you say you were you're of course ac acla but yeah um you you um presented the report did you did you privately or publicly recommend

02:46:22 privately or publicly recommend what it was that the provisional impact review said no i didn't present the provisional impact review that wasn't my report i was i did present a report later i believe but um you know the the way

02:46:33 um you know the the way the the conversations i recall happened was that we had a very detailed conversation obviously the attendees at cnb a large number of them were very experienced senior operational officers

02:46:45 experienced senior operational officers so the conversation around the um the impact of london fire brigade the significant change and i had spoken to them and given them updates a detailed update on the decision controls that i felt i believe

02:46:57 decision controls that i felt i believe could

02:46:58 could enhance the dmm and that i was very keen that we could introduce those immediately and i asked for dr conhatton to work alongside

02:47:10 dr conhatton to work alongside babcocks to ensure that happened do you know when the decision was made not to incorporate the dcp by way of divergence from the national operational guidance i'm not sure exactly what was made now sorry

02:47:21 sorry um

02:47:22 um can i just ask you in that context then please to go to your second statement lfb00018213 [Music]

02:47:31 [Music] and look at page three paragraph 16 a and this is under the heading work streams in 2015-16 and you say there the

02:47:42 streams in 2015-16 and you say there the nfb was in ongoing discussions with babcock regarding the training provided under its training contract i recall that there were budgeting restrictions for training during 2016 and so work was carried out to establish which training

02:47:53 carried out to establish which training programs were to be prioritized first what were those budgeting restrictions as i recall the terms of the contract of the outsourced training contract with

02:48:04 the outsourced training contract with babcocks were that over a number of years the the

02:48:10 the the cost of the contract would be reduced

02:48:13 reduced and therefore it was um

02:48:16 um i think initially that the plan was and i wasn't partying to come to the negotiation so i'm not sure what was discussed but that there would be a big number um of a big amount of subcontract involved in

02:48:28 a big amount of subcontract involved in it there'd be far more money up front and then that cost would reduce so that the

02:48:34 the contract effectively became cheaper as i understood it therefore

02:48:38 therefore any new training requirements had to be subject to a scrutiny process to understand how they fitted in with other training requirements because there wasn't simply when london fire brigade ran its training you could

02:48:50 fire brigade ran its training you could ask for anything to be developed in any training package and they would do that but under the new processes with the outsourced training provider that couldn't happen there was something you saw earlier which was training units and

02:49:01 saw earlier which was training units and there was a reducing number of training units available sorry um

02:49:06 sorry um you referred there to a scrutiny process who was responsible for operating the scrutiny process was that babcock called lfb

02:49:15 lfb sorry i think i was speaking too fast then

02:49:21 all right

02:49:24 indeed the transcript has stopped mr chairman yes well are you able do you know what the problem is

02:49:33 does that take very long all right thank you

02:49:43 so

02:50:28 you're you've sourced it out have you well done thank you very much indeed um can you pick up that question yes i think i can mr chairman can i go back please miss cotton and ask

02:50:41 can i go back please miss cotton and ask you about

02:50:42 you about what you referred to as a scrutiny process at line 14 on the last page in the raw transcript scrutiny process um who was responsible

02:50:54 scrutiny process um who was responsible for running that scrutiny process was that the lfb or was that babcock or was that joint um it was a joint venture right

02:51:04 right and

02:51:06 and was the scrutiny process was this designed

02:51:09 designed to

02:51:10 to um

02:51:11 um ensure is this right that the

02:51:15 the cost of training was available to meet the training requirements so

02:51:20 so it was the training was provided in training units and the so the number of training units would be reducing so what the process was was to decide

02:51:32 was was to decide which training was necessary and to work on a prioritization order for training because it wasn't simply the case anymore that you could request

02:51:44 the case anymore that you could request a new development or new training as a result of a new policy or equipment or a procedure it had to go through a process to be decided upon because there was this reduction in the number of training units available

02:51:56 training units available was that always contemplated from the start of the contract

02:52:02 contract um

02:52:02 um i believe so but i wasn't part of the contract negotiation so just help me with this um is it was it the case that the way the bad contract worked was that the later on in the contract you got the less money there was available for training and therefore the more

02:52:14 training and therefore the more selective you had to be about what you asked babcock to train on as i understood it i think that the idea was that um

02:52:21 that um that they believed that training needed streamlining and that

02:52:27 and that the the plan was that babcocks would provide

02:52:31 provide in their words new and innovative ways of delivering training that would not be so

02:52:36 so resource and trainer intensive and therefore

02:52:39 therefore the effectively the training units were about

02:52:42 about developing training and delivering training and that they would be able to make that process simpler and therefore the requirement would be reduced

02:52:56 you say make the process simpler and therefore the requirement will be reduced do you mean

02:53:01 mean make the training um

02:53:06 less rich and therefore cheaper well that's one way i mean i was not part of that negotiation that agreed with that so it i found it difficult because i found it

02:53:17 i found it difficult because i found it difficult having a outsourced training provider when we had always had the ability to be able to flex and develop new training with our own internal training team but so unfortunately i wasn't aware of the

02:53:29 unfortunately i wasn't aware of the detail or part of that training negotiation to your recollection did anybody ever go to babcock and seek to amend the contract say that there was enough money available to babcock in order to

02:53:39 order to uh in order to carry into effect lfbs training needs whatever they were um

02:53:44 um i'm not sure that would be a question for the commissioner right

02:53:49 nonetheless the restrictions that we're you're referring to here in your second statement

02:53:54 statement did they play any role in the decision not to implement national operational guidance on the dcp it was more the fact of definitely

02:54:05 definitely how long the experience had been in already the development of instant command training um and the fact that introducing such a large-scale change that we recognize that would be a

02:54:17 that we recognize that would be a significant impact so i think the answer is yes because of the scale of the training changes needed in order to introduce dcp to bring it in line with national operational guidance you would run up against the budget

02:54:28 you would run up against the budget problem with with babcock and and the development and the subject matter expertise and the skills to be able to change the training so

02:54:37 so cost

02:54:38 cost absence of smes and related skills to change the training and time definitely time and the

02:54:47 the delay you mean yes right

02:54:50 let's look at your second statement then slightly different aspect of dcp please second statement page 7 paragraph 34

02:55:01 um you say there

02:55:06 that's page seven paragraph 34

02:55:12 thank you i understand that dac coin hatton had considered that the dcp should be universally adopted following the incident command nog however as i've mentioned when considering the extent to which the dcp

02:55:24 considering the extent to which the dcp should be implemented at the lfb there was concern that an e i a an equality impact assessment had not been carried out which could mean that the dcp was

02:55:36 which could mean that the dcp was inaccessible for individuals with learning difficulties and the dcp had not been tested on level three and four incident commanders there was also a concern around the extent to which dcp had been had been tested in operational

02:55:48 had been had been tested in operational situations it is also it is important that the lfb considers fully any amendment to operational policy and therefore it is prudent that we explore any implications fully before doing so

02:55:59 fully before doing so i recall that discussions took place with the commissioner ron dobson however i've been unable to recall or identify specific evidence of these discussions you raise a number of concerns in that

02:56:12 you raise a number of concerns in that passage with cotton which i just want to take in turn before i do you say that these concerns existed it's the word you use were they your concerns

02:56:23 concerns no these were shared concerns of senior operational officers and concerns in which you shared yes definitely yes now you mentioned discussions with ron dobson what was his

02:56:35 discussions with ron dobson what was his involvement if any in the decision not to implement the dcp as part of the corporate management board he would clearly well he chaired the corporate management board so he would have been involved in that

02:56:46 he would have been involved in that decision process you raised as we see from this uh this paragraph the concern that an equality impact assessment had not been carried out

02:56:54 out which i think you say meant that the dcp was inaccessible for individuals who had learning difficulties now dr cohn hatton agreed in her evidence that as a fact there had been

02:57:05 evidence that as a fact there had been no eia carried out in relation to the dcp nor indeed in relation to the national operational guidance more more generally

02:57:14 generally were you concerned about the lack of an eia in relation to any other elements of the nog national operational guidance or only in respect of the dcp oh in every uh policy that we changed in

02:57:25 oh in every uh policy that we changed in every single policy every document every report that went to corporate management board

02:57:32 board an equality impact assessment was considered and as

02:57:37 and as brought away that you know it's a legal requirement to carry that out so i asked dr conhatton very early on if she could share the details because i understood that would have happened as part of her development of

02:57:49 happened as part of her development of national operational guidance of neia and she said at that time it hadn't been completed was there any reason why you didn't you or anybody else in the brigade didn't simply ask for an eia to be

02:58:01 didn't simply ask for an eia to be carried out in relation to the dcp that that's going to happen sorry that's what i asked dr kern happened for you asked her to do it did you i she had been the one who had undertaken the research and the

02:58:12 undertaken the research and the development so it would have been impossible for someone who hadn't been involved in that to have conducted the eia without their subject matter expertise that the people involved had

02:58:23 expertise that the people involved had right

02:58:25 right so just to be clear did you ask dr cohn hatton to carry out an eia

02:58:30 an eia i asked if one had been conducted and if she could provide me with one in relation to the instant command nog who would be responsible within the brigade for carrying out an eia on this

02:58:42 brigade for carrying out an eia on this aspect of the national operational guidance

02:58:45 guidance so um

02:58:46 so um my understanding was that any national operational guidance should be published with an eia um so that would be the national operational guidance team who had designed the training of the

02:58:57 who had designed the training of the designed policy and who was so the national operational guidance team where did this team sit in the brigade so so in london fire brigade uh housed national operational guidance it was a

02:59:08 national operational guidance it was a national uh body um so each um each guidance that was reviewed and developed would come with an eia so in this case

02:59:19 would come with an eia so in this case it would have been the team that developed the incident command nog which dr cone happened was a part of and cfo simon pilling and a number of others

02:59:33 right and just help me in which director let's start with directorate did that team sit so the overall management of the nog team

02:59:44 team was done nationally by sifo and the nfcc we london fire brigade housed the nog team in london fire brigade and it sat in the strategy and policies susan

02:59:55 and policies susan bunce's team which sat under at that time i believe um sue button oh right i see so not the operational team and not uh your team no

03:00:07 team and not uh your team no i see

03:00:09 so it would be sue buttons directorate and the and the services or groups within her team that would have been responsible for carrying out the eia no sorry i'm probably not making myself very clear no they so the new the

03:00:21 very clear no they so the new the national operational guidance was the sort of body of it was housed in london fire brigade but it was made up of teams of people from all around the country from different farm rescue services

03:00:32 services as dr cohen hatton was part of that team at the time she didn't work for london fire brigade and when that new training was

03:00:38 was new policies were developed by those national teams that's when the eia should have taken place yes what i'm really trying to work out is who

03:00:47 is who was responsible for carrying out the eia in respect of any change coming from the national operational guidance and you mentioned a team yet so dr cohn hatton i would have

03:00:58 yet so dr cohn hatton i would have expected her to have provided an eia with that piece of work so she would have expected her to do it carrying her or the team yes that she was working i think across purposes here um

03:01:09 think across purposes here um if i've understood you correctly the national operation guidance team is independent of london fire brigade but sits in an office provided by london fire brigade that's correct sir what mr

03:01:20 fire brigade that's correct sir what mr millett would like you to tell us is

03:01:23 is who within london fire brigade would have been responsible for carrying out an eia

03:01:29 an eia if it had decided to adopt the dcp into its policies i get the question sir so um once it had been adopted into a london fire brigade policy that would be conducted by the

03:01:42 policy that would be conducted by the team that owned that policy in london fire brigade so in this case it would have been operational assurance but before it came in as a policy to be adopted when it was the guidance that should have come with an eia as part of

03:01:54 should have come with an eia as part of the publication of the guidance yeah and i understand that but it didn't no it didn't know and therefore i asked dr conhatton

03:02:01 conhatton if she could provide that for me right right but in her capacity is this right as a member of the nog team rather than as an employee of the lfb yes that's correct

03:02:14 yes that's correct and what does she tell you in response um she said to me that hadn't been done and she would look at it it hadn't been done and she would look at it and what did you say to her that thank you

03:02:25 that thank you and it never came uh i answered it did come i think in twin late in 2016 2017 i think under steve actor um i believe that dr cohn hatton spoke to

03:02:37 believe that dr cohn hatton spoke to professor honey who she had worked with which was some year 18 months later and then

03:02:43 then that information was provided yes thank you very much uh mr chairman is that a convenient moment yes we will come back to this topic after lunch i'm afraid right well that's a good point anyway thank you very much well i think we'll break now so we can all have some lunch

03:02:55 break now so we can all have some lunch with cotton we'll come back at five past two please and again please don't talk to anyone about your evidence while you're out of the room thank you thank you very much

03:03:14 thank you mr millet five past two please