Evidence session examining the London Fire Brigade's response to the Grenfell Tower fire, including operational decisions, command structure, and lessons learned.
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# Source: Local audio transcription (no YouTube captions available)
00:00:30 Yes, would you ask Ms Cotton to come back in please?
00:00:32 All right, Ms Cotton, ready to carry on?
00:00:45 Yes, sir.
00:00:45 Thank you very much.
00:00:46 Yes, sir.
00:00:47 Thank you, Mr Chairman. Ms Cotton, can we go back to the DCP that we were looking at before the
00:00:52 lunch break? In relation to your specific concern that the DCP may be inaccessible for individuals
00:00:57 with learning difficulties, we heard from Dr. Keween Hatton that she was unaware of any empirical
00:01:02 basis for your concern and that her understanding was that you had shown the DCP to a colleague who
00:01:07 at first look found it confusing. Is that correct? Not in its entirety. So obviously with any new
00:01:16 policy, it was important to ensure if we were to deliver training to our operational crews that if
00:01:23 there was going to be any difficulty in people understanding or in different learning styles,
00:01:30 that we would be able to find a way to adapt that training to sort of cater for that. When I had
00:01:36 first seen the DCP, I had had a conversation with a number of professional colleagues who I was aware
00:01:44 were suffering from dyslexia and a number of those, so about five or six of them, had said
00:01:52 on first viewing it, they found it complicated to understand because it was not sort of as it were
00:01:59 in the line and it was a different approach. So it was just my concern that if we were to introduce
00:02:05 it and to deliver that training, that we would have to make sure that there would be the ability
00:02:10 to adapt it so that we could ensure that all of the operational colleagues could fully understand
00:02:16 it. Right. Was that not so with many, if not all, policies published by the LFB? Every policy would
00:02:24 undergo an equality impact assessment. It would depend on the nature of the content of that policy.
00:02:30 Some people obviously have different learning styles according to different things, some people
00:02:34 it's diagrams, or some people it's writing, for some people it's methods of communication. So it
00:02:38 was ensuring that all of those were covered. Right. But that wasn't of itself, was it, an obstruction
00:02:44 to proceeding with the DCP as a policy? No, not at all. No. We also heard that Dr. Cohen-Hatton had
00:02:49 discussed that issue with Professor Honey, with whom she'd carried out the research. You referred
00:02:54 to his work and indeed himself in your evidence before lunch. And she told us that he, Professor
00:03:01 Honey, had consulted specialists in neurodiversity and dyslexia at Cardiff University. And she told
00:03:08 us that her understanding of their view, with which she agreed, was that the DCM would actually
00:03:13 be beneficial for those with dyslexia rather than inhibitory, because it provided scaffolding,
00:03:21 is the word she used, to support decision making. Were you aware of that view at the time?
00:03:27 No, I believe that wasn't until 2017 that she had that information. So I believe she shared that with
00:03:35 the then Director of Safety and Assurance, Steve Apter. Steve Apter. Were you not involved with
00:03:39 that discussion by that stage, presumably because you were Commissioner? No, I wasn't.
00:03:43 I see. Did you hear about that view at the time? I believe not whether it was that time or some
00:03:50 time later. Mr. Apter did share that with me. You also refer, I think, to a concern that the
00:03:56 DCP had not been tested on level three and four incident commanders. Is that right?
00:04:01 Yes, that's correct. Right. Dr. Cohen-Hatton told us that that concern had never in fact been
00:04:05 directly discussed with her. Is that right? No. Quite early on, when I had a conversation
00:04:12 about her research, she said that the team that had done the research were hoping to get further
00:04:17 funding from CFOA to carry out that research on level three and four incident commanders,
00:04:23 but it was funding dependent. Funding dependent. I mean, her view was that it wasn't a good reason
00:04:28 for rejecting the DCP, because level three incidents are very like levels one and two incidents,
00:04:33 and the results are broadly extrapolatable, they're generalisable. Level four more strategic,
00:04:40 and the elements were covered in any case, as she told us. Would you agree with that?
00:04:43 No, I think that level three and four are fundamentally quite different to level one and
00:04:47 two, and because she had expressed to me that the work was going to be carried out, we were very
00:04:52 interested in seeing the results of that work on more senior officers. Did you discuss with anybody
00:04:59 the fact that the DCP had not been tested on level three and four commanders as a reason for
00:05:05 rejecting the DCP? That was discussed with a number of other factors, with the corporate
00:05:11 management board, with a range of the other things we talked about earlier, as considerations as to
00:05:18 whether or not to adopt the DCP in its entirety at that moment. Right, did you think to discuss
00:05:24 that with Dr. Cairn Houghton herself? Yes, I had discussed that with her. You did, you say you did?
00:05:28 Yes, absolutely. And you also say that there was concern around the extent to which the DCP had
00:05:33 been tested in operational situations. What did you mean by that? So as I understood it from the
00:05:39 way Dr. Cairn Houghton explained it, they had undertaken a number of studies of operational crews
00:05:46 by fitting with body cams and then afterwards interviewing them to discuss the way they had
00:05:52 reached decisions. And then in a simulated environment, a number of officers were
00:05:59 tested using the DMM and the DCP. Dr. Cairn Houghton then explained that what was going to happen next
00:06:05 was once it had been embedded that they would do a further piece of work to look at how well
00:06:11 that was embedded in the operational arena going forward as a method of evaluation and we'd be
00:06:16 very interested in seeing that outcome. Were you aware of Dr. Cairn Houghton's research,
00:06:22 which consisted of precisely that? I think you've just explained it to us, namely the
00:06:30 testing and analysing of decision making at operational incidents. Yes, and that was all
00:06:37 as I understood it when she explained it to me. The actual testing was in a simulated environment
00:06:41 rather than at operational incidents, although they'd gathered information prior at operational
00:06:45 incidents, the actual process while they tested it, because they needed to be able to repeat the
00:06:50 same scenarios and therefore you could only do that at a simulated event, albeit realistic in
00:06:56 real venues, not just by computer simulation. Right, I mean in your statement you're expressing
00:07:03 concern or you're reflecting concern about the extent to which DCP had been tested in
00:07:07 operational scenarios. My question is were you aware of the conclusion of her research,
00:07:13 namely that incident commanders were more likely to be goal-orientated and have better situational
00:07:18 awareness when the DCP was applied as opposed to when the DMM was used? Yes, I was aware that was
00:07:24 the finding that as a result of the academic research she had done and testing in the simulated
00:07:29 environments. In addition to the reasons referred to at paragraph 34 of your statement, which we've
00:07:35 just looked at, can I ask you about some further possible reasons which have been raised? Can we
00:07:42 go to Graham Ellis's statement please at LFB 00118230?
00:07:58 And if we go to page 7 in that statement, paragraph 34,
00:08:02 he says, I recall discussions that took place regarding the IC NOG and the decision control
00:08:10 elements in particular with AC Cotton, Adrian Bevan, LFB head of health and safety, and GM
00:08:16 Drawbridge, as well as many other LFB officers. We collectively considered the decision controls
00:08:21 as stated in the NOG, being that decision controls are a rapid mental review exercise that asks,
00:08:28 a rapid mental review exercise that asks, why am I doing this? What do I think will happen?
00:08:33 Is the benefit proportionate to the risk? The consensus view during discussions was that LFB
00:08:39 incident commanders were already being trained to complete those rapid mental checks under the
00:08:44 existing DMM. Incident command training had always included critical challenge to decision making,
00:08:50 but also explicitly encouraged incident commanders to constantly check, reconsider, and amend their
00:08:56 plan with due consideration to benefit versus risk. Do you agree first that incident commanders
00:09:02 were already being trained to complete these, as he calls it, rapid mental checks? I think that
00:09:09 DSC Ellis's view is that the incident command training and a number of scenarios, the injects
00:09:17 and the questions that were asked were encouraging and educating incident commanders to do that,
00:09:24 and although that if you look at the DMM in its sort of linear approach, it is in boxes and it
00:09:32 doesn't always look that way. I think that the conversations and the training that took place
00:09:37 supplemented that, but I do agree that during the conversation we had that we discussed the absolute
00:09:45 benefit of the decision controls to enhance that process of critical thinking and incident commanders.
00:09:52 Was the fact that incident commanders were already being trained to complete,
00:09:57 as he calls it, these rapid mental checks a factor in the decision not to implement the DCP?
00:10:03 I think it was one of the consideration factors that CMB discussed as well, that the enhanced
00:10:11 enhancement of the DMM with the decision controls was seen as a way of sort of almost having a hybrid
00:10:19 version of it, which would not be such a fundamental change that would require a huge training impact, yes.
00:10:28 Did you discuss with Dr Cohen-Hatton the view that the existing training and the existing model
00:10:34 already incorporated the necessary elements of the DCP as a reason for it not being adopted?
00:10:41 I don't remember the specific detail. Dr Cohen-Hatton and I had several conversations around
00:10:47 the adoption of the DCP versus the DMM. I can't recall the exact detail of those now.
00:10:54 If that was a factor, as you I think agree that it was, do you agree that it would have been
00:10:59 prudent to do so, given her expertise, and at least then to tease out from her why it was she
00:11:05 thought that the existing training didn't cover what she thought it should cover?
00:11:10 I think at that time that Dr Cohen-Hatton hadn't seen much of London Fire Brigade's existing
00:11:18 training. I don't think she had been in London Fire Brigade very long at that point, so it would
00:11:22 have been difficult for her to have commented on existing instant command training, but we definitely
00:11:27 had a conversation about the benefits the decision controls would bring, which is why she was asked to
00:11:34 present them to Babcock and work closely with them to integrate them into the existing training.
00:11:39 Now we've seen that DAC Lee Drawbridge was of the opinion that the only time the DMM,
00:11:44 the decision-making model, did not work was when it wasn't applied properly. Was that a view you
00:11:50 shared? I think it's more nuanced than that. I think that it's very, I could not point to a time
00:11:58 where I felt that an instant commander was directly criticised for not using the DMM and
00:12:08 therefore not making decisions. We used the DMM at the performance review of command and went
00:12:14 through the steps in it, so it was used not only as a briefing tool, as a decision-making tool,
00:12:20 but as a debriefing tool at the PRCs, and I think at that point you could tease out whether or not
00:12:27 there were aspects that instant commanders had not adhered to. For instance, did an instant commander
00:12:33 gather all available information about the risks they might be facing and then if you perceived
00:12:38 they hadn't that would be the conversation that would happen. Right, you say it's more nuanced,
00:12:43 maybe to see if I can get at it slightly differently. Dr Cone-Hatton addressed this
00:12:48 view, the, if I can call it the Drawbridge view, that the only time the DMM wasn't right was when
00:12:53 it was worked wrongly, and she told us at day 182 pages 81 and 82 that that view was inconsistent
00:13:02 with her academic findings and research and her own operational experience while at the LFB itself,
00:13:09 as she was from February 2015, and indeed her own experience as head of ORT after June 2017.
00:13:16 That's what she told us. Can you comment on that? Would you agree with it? I think at the time when
00:13:22 we had this conversation, so this was in, I believe it was around June 2015 we were talking about this,
00:13:29 Dr Cone-Hatton had not long joined London Fire Brigade and actually at that point had not been
00:13:34 out operationally because when we have new officers come into London from another fire
00:13:39 and rescue service we spend a period of time so they can familiarise themselves with London
00:13:44 policies and procedures and do some shadowing. So I don't think at that point she would have been
00:13:49 commenting on London's operational sort of response because she hadn't been sort of in contact with
00:13:56 that at that moment in time. No, but she had been hadn't she in and after June 2017 when she became
00:14:01 head of ORT. By that stage she had gained enough experience at the LFB and was still of that view.
00:14:08 So can you account for that? Yes, by then she would have had operational experience
00:14:13 with London Fire Brigade. Yes, and therefore given that experience and her academic work which she'd
00:14:18 done in 2015, she was of the view that the drawbridge view was not consistent with her
00:14:25 work and experience and given that she rejected it. What is your view about that? What is your
00:14:37 evidence about that? Well clearly I'm not an academic and I wouldn't seek to challenge Dr
00:14:41 Cone-Hatton's academic review because it was a very thorough review and I don't think after that
00:14:48 time we had further conversations around it so I'm not sure what her views were but I understood
00:14:54 that she did not agree with the drawbridge. Did you ever discuss Dr Cone-Hatton's rejection
00:15:03 of the drawbridge opinion with her at any time? Not in 2017, no. Would have been prudent to do
00:15:11 so would it not? I think by that time in 2017 the conversations that were had around the DCP were
00:15:20 being had with Steve Apter who she was working with so I don't think we had further conversations
00:15:25 around it. Would you accept that properly considered none of the possible reasons that we've examined
00:15:31 both before and after the lunch break justified the decision not to implement the DCP particularly
00:15:37 in the light of the detailed research that Dr Cone-Hatton had carried out both with the problems
00:15:42 of the DMM and the improvements which could result or would result empirically identified
00:15:47 from adoption of the DCP? I think that is more complex picture for London Fire Brigade and I
00:15:53 think that the areas that we discussed before lunch and I identified in the difficulty and the
00:15:59 complexity around bringing such a significant change to London Fire Brigade, instant command
00:16:07 training to training 1700 officers in a quite different and new way, those were difficulties
00:16:16 and those were the reasons why that at that time we discussed adopting the hybrid version of
00:16:22 including the decision controls. It's right isn't it that the brigade was the only fire and rescue
00:16:28 services in the country not to have implemented the DCP as part of the national operational
00:16:33 guidance? That's correct. And that was a point noted wasn't it, you may know this, by the
00:16:38 inspectorate as an area for improvement both in its 2019 and its 2021 reports. I'm not familiar
00:16:44 with the 2021 report but yes definitely the 2019 report. Yes and I'll give the reference
00:16:51 for that, the 2019 is at INQ30A's 14796 page 21, second paragraph from the bottom for those who
00:16:58 want to look at it but you would agree with that. Now you were still commissioner I think just about
00:17:04 at the end of 2019 when the 2019 report was published, did it come as a surprise to you to
00:17:09 learn that the LFB was the only outlier in that regard? No I think I was aware of that. You were
00:17:15 already aware. Can I turn to cladding and external fire spread and I want specifically to look at the
00:17:23 institutional knowledge of the brigade of fires involving rapid external fire spread, cladding,
00:17:31 facades, modern methods of construction and the training on those matters. Now we've already
00:17:37 explored your involvement as AC for operational assurance in distilling the lessons from Lackin
00:17:42 into training, can I pick the timeline up in 2014 and in doing that go please to LFB00084762.
00:17:57 This is an email between Graham Ellis and Rita Dexter on the 11th of March 2014 subject
00:18:04 potential rekindling Wardour Street and then there's the incident number given there. We looked
00:18:11 at this with Rita Dexter and she gave evidence and what he says if you go to page three
00:18:22 is in the email of the 11th of March earlier on that day
00:18:27 if you go please to I'm sorry it starts at the bottom of page two my fault I apologize if you go
00:18:33 to the bottom of page two this is this is where this particular chain starts for for my purposes
00:18:40 he says this not wishing to insult your intelligence if you already knew this but King's
00:18:44 ban quotes unquote referred to in this report is the proprietary name for foil backed insulation
00:18:49 board used in modern construction to improve insulation and meet the requirements of the
00:18:54 to improve insulation and meet building regs it is the same as celotex eco therm extra therm
00:19:00 and a range of other major proprietary insulation slabs it generally looks like this and is used
00:19:06 behind plasterboard below floorboards stroke floor sheets and in roof lining the thickness can vary
00:19:11 from 25 millimeters to 150 millimeters and if you turn the page you can just see there's a
00:19:18 photograph there of a piece of king span insulation and three paragraphs down from that he says this
00:19:26 perhaps we can empower our commanders perhaps we need to empower our commanders with the knowledge
00:19:31 that if they can reasonably justify any cutting away we will support them in any claims for damage
00:19:37 done it all comes back to training and ensuring that cbt's and guidance documents are reinforced
00:19:43 by regular practical demonstrations using modern building materials that does not happen as far as
00:19:49 i'm aware the days when a significant minority of our operational workforce was still skilled
00:19:55 trade persons with working knowledge of building construction have long gone did dac ellis as your
00:20:03 deputy and a direct reporter this time raise these issues with you and this was part of an
00:20:09 ongoing conversation around what we termed highly insulated buildings it had become
00:20:18 increasingly apparent that in order to be not only economically viable but environmentally friendly
00:20:24 more and more buildings were being built with insulation panels in them that not only retained
00:20:31 the heat inside the building so that it was more efficient to heat but prevented you know drafts
00:20:37 etc coming in and this was causing a number of issues for firefighters in the operational arena
00:20:45 highlighted tragically by the fire in athelon stour in warwickshire where four firefighters
00:20:50 lost their lives in a vegetable packing factory that was had a lot of this material and what it
00:21:00 served to not demonstrate any external sign of fire when in fact there was a very extensive
00:21:07 fire burning inside the building and unfortunately the crews had gone into the building not being
00:21:12 aware of the severity of the fire and four of those had lost their lives i'm going to cut you
00:21:17 off there i think you may have finished the answer we're going to look at the november 2007 athelon
00:21:23 fire and its aftermath shortly my question was i think a shorter one did dac graham ellis as
00:21:32 your deputy and direct report raise these issues with you at this time yes he did he did how long
00:21:38 had these issues been on the radar of dac ellis or your operational assurance department by this
00:21:44 time this is march 2014 i would think at least since 2007 since athelon stour right
00:21:51 uh and what about his view that cbt's and guidance needed to be reinforced as he put it by
00:21:58 regular practical demonstrations using modern building materials had he raised that with you
00:22:02 in his discussions with you i'm not sure about that i think he would have discussed training but
00:22:08 i'm not sure exactly what he means by regular practical demonstrations well you don't know what
00:22:15 he means by that is it not is it not obvious from the ordinary words he is using sorry in
00:22:21 the context that i don't know whether he means showing operational firefighters a piece of thermal
00:22:27 installation or whether he means going to a building and demonstrating how it was being used or
00:22:32 whether he means showing that in a fire context so there's a number of ways of practical demonstration
00:22:38 to take place yes i see had he raised that with you no i don't think so so you wouldn't have had
00:22:43 an opportunity to ask him what he meant no no clearly um had you yourself raised this question
00:22:49 about training and demonstrations of one kind or another on building modern building materials
00:22:56 with others in the brigade whether the odcb or the training department or gary reason so i think
00:23:03 this was at the time when we were discussing um the um findings from the athelon stour fire where
00:23:10 this was a component so yes we would have been having the conversation in conjunction with that
00:23:15 yes um let's skip up the chain then to page one where we started and here is a a subsequent email
00:23:23 from dac lister rita dexter 11th of march same day 2014 uh later in the day in fact quite late
00:23:31 at night on that day and if you look at the third paragraph in the email he says this by now
00:23:37 babcock training should have a rig at training venues where they can demonstrate how fire can
00:23:42 spread undetected through voids or shafts and a selection of modern building materials such as
00:23:48 king span which they can show to students to highlight the dangers associated with concealed
00:23:54 fire spread it wouldn't even have to be a full-size rig even a glorified wendy house would do the
00:24:00 trick this will become more critical if we move to reinstate recruit training
00:24:06 did dac l is raise that question with you in other words getting babcock to train
00:24:13 through practical demonstrations on a whether a full-size rig a half-size rig or a glorified
00:24:20 wendy house i don't recall a specific conversation um on that matter right did uh i'm assuming then
00:24:29 neither rita dexter nor gary reason came to you with this this didn't filter down to you
00:24:34 no i think this um became um a subject of conversation at odcb
00:24:42 in the talking about um these building materials um i don't know if the conversation around having a
00:24:50 a rig at the training venues was subject to that conversation
00:24:55 um well we'll look at that shortly i think um before we do let's um let's proceed with the
00:24:59 story later into 2014 and what i think you referred earlier uh as the highly insulated
00:25:06 buildings training package can we go to lfb double zero one two one one two five please
00:25:16 email from gary reason to you dac ellis and adrian bevan
00:25:21 as we can see uh and danny and graham please find attached the final report detailing the lessons
00:25:27 learned from the athelstan on sturt incident warwickshire frs is keen that other brigades
00:25:31 are made aware of the content of the report so i have attached the learning points detailed
00:25:36 in the main report that runs to over 80 pages nb the full report can be accessed on the wfrs
00:25:45 can be accessed on the wfrs website and that's warwickshire fire and rescue service
00:25:52 not surprisingly you will see many parallels without with issues that have emerged from other
00:25:57 incidents such as harrow court shirley towers lacanel at our own sai outcomes from my own review
00:26:05 i think that we are already cited and progressing many of the issues detailed in the report
00:26:09 however you will see from the extracts from the bre global report pages 75 to 77 refers
00:26:17 that there are some themes that may be worthy of inclusion in future impd reports to odcb
00:26:24 let me know what you think and whether you feel we have adequately addressed
00:26:27 all of the key operational related issues detailed in the report
00:26:31 so now to be clear we've just discussed this the the athelstan on stir fire november 2007 was as
00:26:40 you say a fire in a vegetable packing warehouse where there was fire spread beyond the compartment
00:26:46 of origin wasn't there yes and that involves sandwich panels in the sense of insulated panels
00:26:51 designed for refrigeration within the building that's correct now let's look at the extracts
00:26:57 that gary reason attaches to his email to you those are at lfb double zero one two one one two six
00:27:14 and i should just say for everyone's record that the full report which we don't need to see
00:27:19 is at inq 30s 14765 so that that is the main document but here are the extracts and if you
00:27:29 look at the extracts this is the learning points document published or issued by the warwickshire
00:27:36 foreign rescue service and if we go to page three in this document there is a heading fire safety
00:27:43 building construction knowledge the top of the page and it says this post incident
00:27:50 incident investigation highlighted that some of the fire safety features of the warehouse were
00:27:54 incomplete and some of these features influenced fire development there was also a lack of
00:28:00 understanding of modern methods of building construction by many of the operational crews
00:28:04 the learning point is that operational crews should be able to recognize the fire safety features
00:28:10 and wider construction methods used in modern building to identify potential hazards and safety
00:28:15 features and then it goes on with identification of sandwich panels the presence of sandwich panels
00:28:22 in the part of the building affected was not widely recognized at the incident the three types
00:28:27 of construction used in the premises had been clad with the same material of the same color which
00:28:32 made recognition in the dark problematic the national guidance available highlighted the need
00:28:37 to identify the presence of sandwich panels although it did not provide guidance on method
00:28:41 of identification the learning point is that national guidance should clarify a consistent
00:28:47 and practical method for identifying the presence and type of sandwich panels used within buildings
00:28:52 see also national ventilation work unfinished overleaf now these kinds of learning points even
00:28:59 from incidents involving other fire and rescue services were central were they not to the work
00:29:05 of your operational assurance department they were did you or your team give consideration to
00:29:10 the learning point that i've shown you that operational personnel should be able to recognize
00:29:15 fire safety features and other modern construction methods and materials yes we did you did what did
00:29:21 you do as a result of that consideration so as a result of that the operational policy department
00:29:30 um were tasked with producing a training package on fires and highly insulated buildings
00:29:41 which was a training package that was designed to identify to cruise not only that the sandwich
00:29:48 panels as i mentioned earlier could hide the true nature of fire inside a building but that they
00:29:57 that fire might travel between them and equally the information that was referenced previously
00:30:04 in dsc alice's email that it may not be easy to identify that there is still fire trapped within
00:30:11 those panels when he talks about rekindling and cutting away the importance of actually being
00:30:16 able to identify that there could be fire contained within them now you've jumped ahead i think to
00:30:22 where we end up or maybe end up on the way which is a training package just to be clear is that
00:30:28 the training package produced as a result of an article in operational news in december 2015
00:30:35 called highly insulated buildings and rapid fire growth yes that's the one so the nature of that
00:30:40 would have been that after that the email from gary reason that graham ellis as part of the
00:30:47 diet would have presented information around that for consideration of an operational news item
00:30:55 and then a subsequent training package yes but i think you've summarized very well some of the
00:30:59 detailed documents are going to show you but let's take it in stages before i go to that can i just
00:31:05 ask you about the second learning point in the extract i read to you namely that national
00:31:09 guidance should clarify a consistent and practical method for identifying the presence and type of
00:31:14 sandwich panels used within buildings was consideration given as to how the lfb could
00:31:20 provide guidance to its crews on that point and i think the point they're making there is that the
00:31:25 expectation was that the national operational guidance team should produce a piece a document
00:31:33 and a piece of research around that which would then be promulgated to all fire and rescue services
00:31:38 to develop training from so that was addressed at what the cfa way was it that would be yes
00:31:43 now let's look back at the email the covering email again just to pick up the reference in it
00:31:53 lfb double zero one two double one two five where he refers specifically to the extracts from the
00:32:01 bre global report you see he says that and he says that some themes may be worthy of inclusion in
00:32:09 future impd reports to odcb now if we go to the extracts themselves which he attached we will find
00:32:19 those at lfb double zero one two one one two six at page 12 so it's within the learning points
00:32:29 document and there it is bre global report paragraph 17.1 highly insulated buildings
00:32:37 and it says this highly insulated buildings are becoming increasingly popular
00:32:41 as a means of reducing the energy consumption of buildings bre global sustainability experts
00:32:47 are heavily involved in the development and certification of highly insulated buildings
00:32:52 of all sizes ranging from domestic properties through to commercial offices industrial buildings
00:32:57 and warehouses the popularity of these buildings is driven by the sustainability agenda which
00:33:04 currently carries far more interest in the construction industry and is currently achieving
00:33:08 far more rapid development than fire the fire safety agenda as the level of insulation afforded
00:33:15 to buildings increases two factors pertaining to the fire are affected and then he explains what
00:33:21 they are and if you go down then to the next page and the next heading paragraph 17.2 rapid fire
00:33:29 growth he says this or it says this partly as a side effect of the increased insulation afforded
00:33:35 to buildings but also as a result of changing materials present in and around buildings rapid
00:33:40 fire growth is becoming increasingly common during the course of carrying out the reconstructions
00:33:46 it was noted that modern fire and rescue service training involves the use of simulator units these
00:33:52 units often show firefighter trainees fires that burn at a steady rate for a considerable period
00:33:58 of time they do not show a fire growing suddenly from a relatively small well-contained fire
00:34:04 to a fire that is engulfing an entire compartment and extending beyond the boundaries of the
00:34:10 compartment as a result trainees are not necessarily taught how to identify signs and symptoms
00:34:16 of impending sudden fire growth and how to respond to these signs and symptoms
00:34:22 Now Gary Reason told us when he came to give evidence that it was that information
00:34:27 in 17.2 in particular that he considered worthy of inclusion in future IMPD reports to the ODCB
00:34:35 my question for you is did you did you direct your team to pick up that issue and make sure
00:34:40 that it was reflected in the next IMPD report for the ODCB?
00:34:44 Yes that's what I was referring to earlier that that was the report that then came to ODCB where
00:34:49 the conversation was had around highly insulated buildings
00:34:52 so yes is the answer to that question but let's look and see how that plays out
00:34:56 can we please then go to the response to the email that Gary Reason sent from DAC Graham Ellis at
00:35:01 lfb 00088107 if you look at the second email down on that page it's 12th of November 2014
00:35:13 same day and he copies you in as he does Adrian Bevan and he says this sir I think you are right
00:35:21 in saying that many of the identified lessons have been considered and actioned by the LFB
00:35:26 the need for improved and more frequent operational and command training is something that we will
00:35:31 hopefully address further through the ongoing review of IC training they have clearly identified
00:35:36 the need for more frequent and enhanced training as operational exposure of the LFB and the need
00:35:41 for more advanced training as operational exposure of staff decreases a few initial observations are
00:35:47 that we can sit we should consider an ops news article of highly insulated buildings
00:35:52 we are already seeing examples of compartment fires in modern well insulated properties
00:35:57 the challenges associated with firefighting in such premises will no doubt continue to test us
00:36:02 given the unprecedented increase in the development of modern high-rise premises across London
00:36:08 and in the email above that if we can see that together Graham Ellis writes to you and Adrian Bevan
00:36:13 a few days later later in the month 27th of November 2014 as follows we have shortlisted fires
00:36:22 in highly insulated buildings quotes on quotes on the wish list for the next main ops news
00:36:28 and better and more frequent incident command training is being addressed via the review of ICT
00:36:33 I think you were referring to that weren't you in your answer now we will we will come on to look
00:36:39 in a moment at the highly insulated buildings ops news article and its associated training but
00:36:45 before we do that it looks from this email as if this was not a new problem and was already known
00:36:50 to your department would that be fair yes so it was making itself present in a number of different
00:36:57 areas we had experienced a large number of building fires that were
00:37:05 timber frame buildings that were being insulated with these sandwich panels and we'd had a number
00:37:11 of very high profile fires where before the external matter was put the external face was
00:37:18 put in the building they had fires and they burnt very rapidly because there was no protection
00:37:23 afforded to them so we'd seen two or three 20 and 30 pump fires in these buildings under construction
00:37:31 and then a number of other issues with things like sandwich panels in warehouses just pausing there
00:37:38 you say we've had a number of very high profile fires where before the external face was put on
00:37:45 the building had fires and they burned very rapidly what was the material that was burning
00:37:51 in those fires the insulation panels and the wood from the timber frame cladding right
00:37:57 and can you remember a particular type of insulation what whether it was pir pur a brand
00:38:03 no i'm sorry i'm not aware of that
00:38:07 now given that the lfb was seeing examples as it said of fires and these kinds of premises and
00:38:14 the unprecedented increase as the words that are used by graham ellis in the development of
00:38:19 modern high-rise buildings is it right that the lfb had sufficient evidence of a trend
00:38:24 in its corporate knowledge so as to justify it being fed through the lfb's diat process and
00:38:30 through the odcb into training yes that's what graham ellis is referring to here yes i'm just
00:38:36 taking it in stages but that so you agree with what i've put to you yes i do yes now before we
00:38:40 leave this email did you yourself take any additional steps or instruct anybody within your
00:38:45 department to take any additional steps to investigate the lessons
00:38:50 to be learned from the atherstone on the stuart incident so these graham ellis had
00:38:58 as he said looked at the other issues as was asked by gary reason and identified that they
00:39:04 were being addressed in other areas of our training and that the incident command was being
00:39:09 addressed in the incident command review so it was this specific issue that was the area of concern
00:39:14 so was the decision to take the highly insulated buildings ops news article to the odcb deemed
00:39:21 at least by you to be a sufficient response to the problem identified in the bre report on
00:39:28 atherstone yes yes thank you now let's go to the odc b minutes next lb lfb triple zero four zero
00:39:36 six one nine please
00:39:40 this takes us to march 2015 and this is the minute of the board's meeting on the 16th of march 2015
00:39:47 we can see from that you were present i think we've looked at this yesterday because we looked at
00:39:55 parts of it but if you go please down to the attendees we can see that you were there as the
00:40:00 fourth attendee as a coa if you look at item three on the same page for which we will need
00:40:06 to scroll down you'll see impd sixth monthly report july to december the hoop to discuss the
00:40:15 issues relating to highly insulated buildings and rapid fire growth on page two with the hohs
00:40:22 hoop is i think peter cowell isn't it that's correct ahead of operational procedures and hohs
00:40:29 was adrian bevin health and safety yes that's correct yes as we know i think adrian bevin
00:40:34 reported to you he's is yes now we have a copy of the six monthly impd report for that time
00:40:40 march 2015 that is at lfb triple zero eight four three nine five can we please go to that
00:40:52 uh you can see that it's called the operational directorate's coordination board date march 2015
00:40:58 report by dac g ellis and the report title as we can see there is the incident monitoring six
00:41:03 monthly reports can i take it that you would have read that yes at the time uh do you remember
00:41:09 whether this report was discussed at this at the odcb meeting the minutes for which we've just seen
00:41:14 yes it would have been yes if we go to page four of this report
00:41:20 you can see that it says there's a heading um proposed articles for operational news
00:41:25 30 december 2015 and then at the very bottom of the page you can see item two highly insulated
00:41:32 buildings and rapid fire growth and then if we turn the page please to page five at the top of
00:41:36 page five it says this recent reports from across the uk fire sector have highlighted the specific
00:41:42 dangers associated with fighting fires in highly insulated buildings as the level of insulation
00:41:47 afforded in modern buildings increases two factors pertaining to fire are affected the ability of
00:41:53 such buildings to contain heat increases this means that less energy is required to heat a room
00:41:58 to the point where flash ever might occur and the temperatures that can be achieved during a fire
00:42:03 are increased the external indicators that a fire is occurring are reduced highly insulated buildings
00:42:10 need to be well sealed gaps or cracks in the building envelope allow heat to leak out reducing
00:42:15 thermal efficiency and reducing their environmental performance as a result of steps taken to reduce
00:42:21 heat loss and seal gaps less smoke from a fire will be able to exit the building to be seen by
00:42:27 passes by all members of the fire service attending an incident rapid fire growth it continues is
00:42:34 becoming an increasingly common feature in highly insulated buildings studies have shown that
00:42:40 firefighters have often been unprepared for such rapid fire growth and as a result of not used
00:42:45 effective firefighting tactics compartment fire behavior training in simulator units has contributed
00:42:52 towards this lack of preparedness in that the fire in these units rarely extends past the compartment
00:42:58 of origin and therefore firefighters are not necessarily taught how to identify signs and
00:43:04 symptoms of impending sudden fire growth and there's a recommendation which we'll come back to
00:43:12 uh in a moment on the basis of this document thus far do you accept that the lack of preparedness
00:43:19 on the part of firefighters for fires spreading beyond the compartment of origin was a key
00:43:24 concern for your department yes in this respect in that um i think that the fact that the
00:43:31 that method of insulation contained any visible signs of fire um outside meant that fire could
00:43:39 meant that fire could spread inside those buildings um and that firefighters were
00:43:45 not necessarily prepared to be going into a building where there was such a well-developed
00:43:49 fire that could have spent spread beyond the compartment of origin and there had been no
00:43:54 external signs of it yes and indeed the second part of this which is that firefighters were not
00:43:59 necessarily taught how to identify signs and symptoms of impending sudden fire growth so
00:44:04 it's the second aspect of the similar problem yes definitely and i think that they're right that the
00:44:09 simulated units that unfortunately were very popular for fire behavior training
00:44:16 not least of all we had the problem in london because of emissions where you weren't allowed to
00:44:23 do the type of demonstration that used to take place meant that the training was quite restricted
00:44:29 in that manner now it was right wasn't it that according to dac ellis the lfb firefighters were
00:44:38 not properly trained or prepared for what to look for by way of symptoms of impending sudden
00:44:44 fire great perhaps for the reasons you've identified but that was correct wasn't it
00:44:47 yeah they weren't necessarily as prepared as they could be um they had some training but not
00:44:51 to the extent where that we would like them to have had i put it this way is there anything in
00:44:56 the paragraph that first paragraph on that page that you disagree with no there isn't no now when
00:45:01 your department came to realize that that that all of this was the case did it not then immediately
00:45:07 strike you that the lfb's post-laconal training clearly had not as the coroner had recommended
00:45:14 prepared crews in those matters now i don't think that line was drawn because this was talking about
00:45:21 this was as we've talked about result of the astor and stout fire which was a fire in a warehouse
00:45:27 and the conversations we were having here were around sandwich panels and the ability of those to
00:45:34 insulate fire and have no visible fire signs which was a very different set of circumstances
00:45:39 than the fire at lacanel which was obviously a very visible external fire spread and the internal
00:45:46 spread of the fire was due to modification in the building well you'll recall and we if we need to
00:45:54 we can go back to it but the coroner had recommended that crews be prepared or consideration be given
00:45:59 preparing crews to and i'm quoting anticipate that a fire might behave in a manner inconsistent
00:46:04 with the compartmentation principle you'll remember i read that to you yes i'll do the
00:46:08 recommendations looking at the second part of this paragraph starting with the words rapid fire growth
00:46:15 and ending with the words therefore firefighters are not necessarily taught how to identify signs
00:46:21 and symptoms of impending sudden fire growth does that not or did that not strike you at the time
00:46:28 as as revealing the possibility at least that the lfb's post lacanel training had not covered that
00:46:36 issue no because this is actually a different issue so when they're talking about impending
00:46:41 sudden fire growth earlier on in the bre report it talked about the fact that because the rooms
00:46:47 are insulated then it takes far less heat and build up to develop the fire to flash over and
00:46:54 it's looking at that that's what the sudden fire growth is that firefighters need to be able to
00:46:59 identify the signs and symptoms of a flash over which is when a fire is contained and then you
00:47:04 open the door to extinguish the fire and it can then spread out of the compartment which is quite
00:47:10 a different set of circumstances than that which was the training at lacanel the point for well i'm
00:47:15 not sure i understand that let me try this slightly differently if you look at the last four lines
00:47:20 of this report and this is a report in the odcb so it's absolutely right in the in the lfb's
00:47:27 knowledge it says this compartment fire behavior training in simulator units has contributed
00:47:33 towards this lack of preparedness in that the fire in these units rarely extends past the compartment
00:47:38 of origin etc yes did that not tell you that the lfb's post lacanel training had not taken on board
00:47:46 the coroner's recommendation back in 2013 to anticipate that a fire might behave in a manner
00:47:51 inconsistent with the compartmentation principle no because this is specifically talking about
00:47:56 training and simulator units so that as an entity i agree would not give firefighters the ability
00:48:02 to recognize fire spread beyond the compartment of origin because the container is one compartment
00:48:08 are you saying that this was a this was a um focused in a problem related only to simulator
00:48:16 units but there was plenty of other fire behavior training that that demonstrated or taught
00:48:22 firefighters to anticipate that a fire might behave in a manner inconsistent with the
00:48:26 compartmentation principle and so this aspect specific aspect of training did not teach them
00:48:31 that and was a very limited aspect of delivering training i think that we were all struggling in
00:48:37 the uk fire service with real fire training as we called it and the ability to deliver that to
00:48:42 firefighters i think that you know as a number of people have discussed there is no better training
00:48:48 than real life real fire training and there wasn't sufficient of that across the uk fire service for
00:48:55 anybody and i think that the advent of the growing increasing use of insulated material
00:49:03 had led to a problem with our ability to train firefighters to be prepared but
00:49:08 that was not the same aspect about training firefighters to understand fire leading a
00:49:14 compartment of origin by in a normal block that wasn't a highly insulated block it was a
00:49:20 quite a different matter it's quite difficult to explain but it's a quite a different
00:49:24 set of circumstances than that in a highly insulated contained building
00:49:30 i'm struggling i'm afraid that may be my fault let me just try it again one more time slightly
00:49:34 differently um the the last part of this paragraph paragraph about rapid fire growth
00:49:41 says what it says it says and then goes on to say compartment fire behavior training
00:49:45 in simulator units has contributed towards this lack of preparedness are you saying that that was
00:49:50 the only problem and if one ignored the simulator units problem in fact crews were regularly being
00:49:56 fully and satisfactorily trained about behavior of fire beyond the compartment of origin i would
00:50:01 definitely not say fully and satisfactorily i think the adequacy of real fire training was definitely
00:50:08 lacking but the the simulator units were one of the key problems simulator units one of the key
00:50:14 problems and presumably not properly counterbalanced by adequate training on fire spread beyond the
00:50:19 compartment of origin in any other respect not in real fire training no i think it was purely in
00:50:24 theoretical input because of the constraints of the real fire training unit did you do anything
00:50:29 in response to what dac graham ellis was saying here in this part of the report so this report
00:50:35 was to go to odcb where we would have the conversation we had the conversation with all
00:50:39 colleagues um and the decision was taken that the operational policy department who owned
00:50:46 all the firefighting policy and tactics would develop a training package right did you take
00:50:52 any steps to liaise with the training department or babcock in that respect no this was a dac
00:50:57 ac peter cowops department that was the commissioning department for this training
00:51:02 why because it was a firefighting policy which were all owned by operational policy under peter cowop
00:51:09 was it not also an incident ground policy which fell under your no no no it all sat within peter
00:51:17 cowop's world right but nonetheless it's your report ellis who's bringing this essentially
00:51:24 through you to the odcb no yes and the reason for that is that as part of the operational assurance
00:51:30 horizon scanning we would bring recommendations as we discussed from other fire and rescue services
00:51:36 which would then feed in as part of the diop process the result of which would be
00:51:41 ops news reports and developments of training packages by the relevant department who owned them
00:51:47 right do you know whether what is said here by graham ellis was then raised as a matter of
00:51:52 significant concern and earmarked as something to be addressed in training as a matter of urgency
00:51:57 so this was then at the odcb taken on by peter cowop as operational policy to develop that
00:52:05 and i know that graham ellis had a number of conversations with peter cowop when he was
00:52:12 developing this training package right did you ever have cause given what graham ellis is saying
00:52:17 here to consider whether crews needed to revisit the training that they had had in response to
00:52:22 lacanel notwithstanding that they had already had some training no because this was a different
00:52:29 issue around the insulation material and the obviously the the risk to the firefighters from
00:52:36 going into a fire compartment where they couldn't see that there was a fully developed fire inside
00:52:40 right and you say it was a different issue i think i'm challenging you on that perhaps too
00:52:48 gently and it wasn't a different issue was it was the same issue because it's all to do with
00:52:51 training firefighters about what to do and what to look for in circumstances where there is a risk
00:52:56 that the fire will spread beyond the compartment of origin and that was a lacanel point so i agree
00:53:01 with you it's about training firefighters but the the the issue that is being discussed here was
00:53:07 around the fact that the insulation of these buildings meant that the fire could develop
00:53:12 inside a building without any external sign whereas obviously at lacanel it was very obvious
00:53:17 that the fire was developing the building and spreading so yes the aspect of training
00:53:22 firefighters to recognize fire could extend beyond the compartment of origin but this was
00:53:27 specifically around the fact that fires would develop and be undetected and that firefighters
00:53:32 could be at risk or lose their life as they tragically did at athelon stowell by entering
00:53:38 a building where they were unaware that a rapidly developing fire was in progress
00:53:44 so your so i've got your evidence on this you're saying that this issue was really nothing to do
00:53:49 with lacanel because this was all about unseen fire spread because of the circumstances in which
00:53:53 the compartment came to be insulated that was the origin of this from athelon stowell yes
00:53:58 whereas in fact lacanel was also about unseen fire spread through voids so what's the difference
00:54:04 so lacanel very obvious ex uh fire spread they could see that the building from the moment their
00:54:09 ride was on fire because it was very visible so they knew that the fire was inside the building
00:54:14 um fires like athelon stowell the crews turned up and were unaware that there was a fire present
00:54:19 in the building that was the difference yes fire spread um through compartments is something
00:54:25 firefighters need to be trained on but the i'm saying that the origin of this piece of training
00:54:29 was due to fires that were not visible from outside
00:54:36 let's go to the uh report again at page five which is now the recommendation put forward by dac ellis
00:54:45 uh underneath the passage i've been asking you about and he says odcb is requested to consider
00:54:49 an obs news article on highly insulated buildings and the dangers of rapid fire spread
00:54:55 odcb is further requested to consider a proposal for a training solution to address the issues
00:55:01 highlighted the training intervention should give firefighters an awareness of the increase
00:55:07 in the number of highly insulated buildings under construction in london and provide examples of
00:55:12 the construction techniques and materials used the training solution should also highlight the
00:55:17 dangers associated with firefighting in such buildings and outline how to identify signs and
00:55:23 symptoms of rapid fire growth and firefighting tactics that should be should be deployed to
00:55:28 contain and extinguish such fires now uh that that's uh to put it very bluntly um entirely
00:55:39 applicable to what happened at grenfell isn't it um i feel i may be not explaining myself very well
00:55:48 the aspect of training firefighters to identify signs and symptoms of rapid fire growth and
00:55:54 firefighting tactics absolutely but the issue here is about understanding the fact that
00:56:00 firefighters could enter a building that was highly insulated and they would have no awareness
00:56:06 that the fire was taking place inside and therefore they could be at risk from entering a compartment
00:56:12 where a sudden rapid fire growth occurred by the introduction of oxygen by them opening the door
00:56:17 into that compartment and they could be subject of a flash over which would then mean that
00:56:21 compartment would become compromised and the fire would spread beyond that compartment
00:56:26 so that's also a vital piece of training to keep firefighters safe yes that i understand like what
00:56:31 i'm really suggesting to you is that you've become rather enmeshed in the original specific
00:56:36 context but not actually looking at the breadth of the recommendation that came out of it it's
00:56:41 right isn't it that the recommendation that came out of it wasn't limited to making firefighters
00:56:47 alert to the possibility that there was unseen fire spread within the compartment it went much
00:56:51 more widely didn't it as we can see yes so it's why it is about the um the fact that lots more
00:56:58 buildings are being built with highly insulated material and that can cause rapid fire spread it's
00:57:03 a wide ranging area but the the risks associated at that time were to do with the risk to firefighters
00:57:10 following the death of four of our colleagues can i just um see if we can clarify this a little bit
00:57:16 listening to your answers i have the impression that your understanding of the fire at
00:57:23 Athelston was that it the building contained a number of compartments created by the use of
00:57:31 insulated boards and therefore the individual compartments within the building could contain
00:57:41 a fire whose presence was not apparent until perhaps you opened the door and went in and then
00:57:48 the introduction of oxygen could create a very rapid well flash over perhaps is it is that your
00:57:55 understanding of the situation that occurred there yes whereas it might be said that the problem at
00:58:03 Grenfell was not the existence of an undetected fire but the occurrence of fire in the external
00:58:14 envelope of the building because the materials would support a very rapidly developing fire
00:58:21 visible as it was on the outside yes that's correct sir yeah right thank you but in light
00:58:27 of that distinction that the chairman has helped you draw would you accept that the recommendation
00:58:33 here which we can see on the screen covered both of those eventualities yes it covered the
00:58:39 fact the firefighters needs to be trained to be aware of those issues yes yes thank you
00:58:43 now peter groves told us that the development of an operational news article and a training package
00:58:48 was a sign of a topic's importance do you agree with that yes yes and do you recall whether the
00:58:53 importance of this topic was actually discussed at this odcb meeting yes it would have been right
00:58:59 do you remember what was said um no i imagine we would have had a conversation around the fact that
00:59:06 this had generated the result of loss of life of four firefighters and the significance of that
00:59:11 information and how important it was to ensure that our crews were trained to recognise the
00:59:19 signs and symptoms of that yes then let's then turn to the minutes of the next odcb meeting which
00:59:25 happened in june 2015 that's at lfb three zeros four zero six four seven
00:59:35 there it is on the screen 15th of june 2015 we can see uh that you were not there
00:59:41 because your name is absent from the list of attendees peter cowp is there adrienne bevan is
00:59:47 also there as head of health and safety for ac danny cotton yes yes so did you depute him to turn
00:59:54 up at this meeting on your behalf um adrienne bevan was a standing member of the odcb but he would
01:00:00 have attended this uh nominally for me as well as i my apologies are shown yeah did you provide him
01:00:05 either with notes or some kind of oral update to prepare him for that meeting uh no because he
01:00:11 would have been at previous meetings to understand uh and he would have seen the meeting minutes
01:00:15 right did he feed back details of this meeting to you afterwards he would have done yes right you
01:00:21 say he would have done because that was his habitual practice and you have no reason to think he would
01:00:24 have departed from it indeed yes um can we look at item four please at the very foot of page one
01:00:31 uh it says there agreement of operational news themes the hoop that's peter cowp
01:00:39 reported that after discussion with oa which i think must have been adrienne bevan for present
01:00:43 purposes an article was to be prepared and issued regarding ventilation issues and materials of
01:00:48 construction this was considered relevant rather than specifically subjecting the issues relating
01:00:54 to highly insulated buildings and rapid fire growth agreed to come to a decision to remove
01:00:59 and rapid fire growth agreed to continue with existing themes now is it right that you and
01:01:04 peter cowp uh who was the head of operational procedures had decided uh that the article
01:01:11 should focus on ventilation and materials of construction rather than on rapid fire spread
01:01:17 no i didn't have a conversation with peter cowp about that did uh right let me try differently
01:01:22 did the hoop and someone in oa have that discussion um i recall graham ellis speaking to
01:01:29 peter cowp and being very insistent um that the um article and the training should cover
01:01:38 the matter as we had discussed it originally um and that it should cover all aspects uh of
01:01:44 the recommendation that dac ellis had made uh does that tell us that
01:01:52 well what was the up what was the upshot of that discussion um so graham ellis pressed the point
01:01:57 with uh peter cowp that that was his belief that that was what the um article was to cover um
01:02:03 peter cowp as the head of operational assurance and therefore the owner of the policy and therefore
01:02:09 the new news article and the subsequent training um was fully aware of graham's views on it
01:02:17 and then he was the one who was responsible with his team for taking that forward do you know why
01:02:22 as it appears from this minute at least peter cup decided on that narrower focus for the
01:02:26 operational news article rather than on rapid fire spread symptoms of impending sudden fire
01:02:33 growth or firefighters not being prepared for fire spread beyond the compartment of origin
01:02:37 no i'm not i don't know why i know that graham ellis had a detailed conversation with him about
01:02:42 it did that mean that the article as then proposed hereafter didn't actually address the concern
01:02:48 raised in the impd report namely that firefighters were not adequately prepared for fires which
01:02:53 spread rapidly beyond the compartment of origin um have you got the specific um article that was
01:02:59 in the ops news to refresh my memory please yes do you want to see that yes please thank you
01:03:04 before i go to that are you able to answer my question without it no sorry you're not
01:03:11 it's lfb triple zero six one four eight two
01:03:16 this is 30th of january 2016
01:03:22 and there's the front page and you can see the date in the top right hand corner
01:03:27 uh if we go please to page five you can see what what is said fires in highly insulated buildings
01:03:35 now there's quite a lot of this i want to show you not least because i think it will help you
01:03:39 answer my question so bear with me um modern methods of construction have developed significantly
01:03:44 over recent decades to improve the energy efficiency of buildings developments in building
01:03:50 construction insulating materials and building techniques have led to increasingly well sealed
01:03:55 buildings and compartments such advances have influenced fire behavior in a number of significant
01:03:59 ways developments in fire resistant material and prevention measures have reduced the number of
01:04:05 fires attended by fire and rescue services however modern methods of construction and
01:04:10 extensive use of compartment insulation can now have a significant impact on fire behavior
01:04:15 specifically and in the first bullet point the ability of highly insulated buildings to contain
01:04:21 a rise in temperature this means that less energy is required to heat a room to the point where
01:04:25 flash over might occur and the temperatures that can be achieved during a compartment fire
01:04:31 are higher when compared with traditionally built buildings the external indicators of the fire may
01:04:36 be reduced highly insulated buildings are well sealed and as a consequence less smoke and fire
01:04:41 will be visible to passers-by or members of the fire service arriving at an incident crews need
01:04:46 to be aware that it is not just new builds that contain modern construction and insulation
01:04:51 technology when older building are refurbished they are often retrospectively fitted with
01:04:56 insulation and compartments will be sealed to increase energy efficiency identifying the exact
01:05:01 nature of construction and internal technologies from the exterior of a building remains a difficult
01:05:06 task for crews at operational incidents and then there's an example given of a march 2015 fire at
01:05:12 a travel lodge hotel in east london and picking it up halfway down that column it says mindful of
01:05:20 the nature of construction and the fact that an intense fire had remained contained in the
01:05:25 compartment the incident commander i.c. quickly developed a safe tactical plan with crews
01:05:29 demonstrating excellent firefighting techniques in the way they dealt with the fire crews anticipated
01:05:34 a well-developed and intense compartment fire and ensured that everyone was evacuated from the fire
01:05:38 floor before making a safe compartment entry with an appropriate weight of attack
01:05:43 and then there's some technical report reportage there about what they did national operational
01:05:48 guidance project nag has worked closely with the building research establishment to create a body
01:05:52 of research about building construction building types and firefighting facilities this information
01:05:57 is available on the national operational guidance website and the research is the website for
01:06:03 research is given there so that's the article i've read it to you almost in its entirety
01:06:11 just looking at it would you agree that far from illuminating an over-reliance on
01:06:17 compartmentation and a failure to anticipate rapid fire spread this article instead encourages
01:06:22 and reinforces traditional training on compartmentation firefighting tactics
01:06:26 I think the aspect it does pick up is the recognition of the fact that insulated compartments
01:06:34 can contain an intense fire that if you open the compartment of origin could then result
01:06:40 in that rapid fire growth so when it talks about the example in the travel lodge it quite rightly
01:06:46 suggests that the crews made sure that everyone was safely out of the potential risk area so if
01:06:52 the fire had extended beyond the compartment of origin then it wouldn't put anyone in harm's way
01:06:58 and it also tackled the issue of fires using appropriate a firefight using appropriate
01:07:03 firefighting tactics to deal with that potential rapid spread of fire it does cover that area
01:07:14 it covers that area but it doesn't cover everything does it it doesn't cover
01:07:18 the anticipation of sudden impending rapid fire spread or spread beyond the compartment of origin
01:07:25 i think it does cover the rapid fire spread because that's what's articulating in the
01:07:30 travelodge example but i agree it does not cover the spread beyond the compartment of origin
01:07:36 no it deals with intense compartment fires which are unseen and sudden and surprising perhaps but
01:07:42 not the full breadth of the recommendation no it doesn't know why is that um whether that was
01:07:48 due to be picked up in the training package which will be on the back page um i imagine that that
01:07:53 was going to go into more detail reinforcement of traditional training on compartmentation
01:07:58 firefighting is precisely what the impd report warned against isn't it
01:08:04 um in a way yes yes and yet the middle paragraph there about the travelodge incident
01:08:10 is quite congratulatory isn't it um i think that uh makes reference to the fact that it was um
01:08:17 exactly an example of a fire that was contained within um a building with insulation uh and that
01:08:24 firefighters anticipated uh an intense compartment fire that could spread beyond the compartment of
01:08:30 origin and therefore evacuated everyone from the floor so i think it did recognize those factors
01:08:35 if i was to pick this up as a firefighter what would i learn from the travelodge hotel experience
01:08:40 has reported there other than that the incident commander quickly developed a safe tactical plan
01:08:45 and the crews demonstrated excellent firefighting techniques i think that you would read the fact
01:08:50 that modern methods of construction meant that there were premises that had highly insulated
01:08:55 compartments in them where you might not see or recognize external indicators of fire
01:09:01 and that those buildings were able to contain a rise in temperature and the flash over could occur
01:09:06 and that the crews attending this fire had prevented that flash over and fire spread occurring
01:09:11 by developing a tactical plan to prevent that and to keep the members of the public and everyone
01:09:17 else safe yes well i can see that it might raise awareness of the risks but it doesn't train anybody
01:09:22 on how to deal with them does it the purpose of ops news articles weren't training they were
01:09:27 information pieces the training then came attached as a on the back page as we saw yesterday
01:09:32 you would have had sight of and is this right and approved this article before it was published in
01:09:36 operational news i wouldn't have approved this article no this was approved by um acp to cow up
01:09:42 did anybody to your knowledge ever go to those responsible for producing operational news and
01:09:47 say this is far too narrow this does not cover the recommendation made to the odcb
01:09:53 back in march 2015 or in june 2015 i'm not sure if peter cow had that conversation with gary reason
01:09:59 or anyone else i wasn't aware of that let's go to the final page of this operational news issue
01:10:04 please page eight you can see a list of the training associated with each of the articles
01:10:11 and if we look at the third row down it says fires in highly insulated buildings
01:10:16 and we have two uh by now familiar policies seven nine three compartment firefighting
01:10:22 article policy and then there's a training package high rise firefighting pn 633 and then highly
01:10:28 insulated buildings computer-based training package cbt and that's on big learning now peter groves
01:10:34 told us that that cbt package like the others was developed and signed off but not released because
01:10:39 of it issues namely the difficulty with local stations being able to play videos embedded within
01:10:46 the training packages and i'm summarizing his evidence but he that was what he said at day 177
01:10:52 page 74 to to uh page 181 there's quite a lot of it um do you agree with that yes i do you do do
01:11:00 you know why it was therefore that the operational news article referred to a cbt package that didn't
01:11:06 exist um i um i believe at the time that assurances were being given that uh that
01:11:14 it would be able to be used on fire stations right why was there no indication in this article that
01:11:19 the cbt package had been delayed but was forthcoming i'm not sure right peter groves also told us that
01:11:26 he remember discussing with the commissioning department which was your department as he said
01:11:31 the possibility of disseminating this training package without the videos but that was rejected
01:11:36 by your department on the basis that the video components helped to take the individual through
01:11:41 learning and if they didn't get that then there could be just as much of a risk as not doing
01:11:45 something rather a lot of the mouthful of this evidence but do you agree with that
01:11:49 no the we weren't the commissioning department we were the ones who'd taken the article to ops
01:11:53 news but because it was a firefighting policy and a firefighting piece of training that belonged to
01:11:59 peter cow up i know that graham ellis would have been very keen on ensuring the full training package
01:12:06 was available in order to articulate the point that he'd made previously that crews were unaware
01:12:12 of what some of these materials looked like and a package without the video and therefore the picture
01:12:18 evidence would have been a lower quality training and wouldn't have demonstrated those components
01:12:25 to the crews
01:12:40 do you accept that it would have been beneficial for crews to have received this package at least
01:12:45 in some form so that they were aware of the dangers and risks of impending sudden fire growth
01:12:51 and fire spread beyond the compartment of origin posed by modern materials and methods of construction
01:12:57 not least given the unprecedented increase in their usage across london yes it would have been
01:13:01 yes and what was it in the videos that was so fundamental that meant that the packages
01:13:06 couldn't be released without them i'm not sure i wasn't involved in the development of the training
01:13:11 package but mr chen and i've got one or two more questions on this before we come to the t cap
01:13:17 i can just i wouldn't finish them can i just yes um peter groves also told us that the lfb had
01:13:22 solved the problem for other training packages by sending the videos to stations on a cd or other
01:13:27 medium but that wasn't suggested for this package or there could have been do you know why that
01:13:32 wasn't considered why that workaround wasn't considered for these packages uh no that would
01:13:37 have been for peter groves to suggest as an idea as the um the interface with babcock's training
01:13:43 that would have been useful if we've been able to do that do you accept that while any of those
01:13:47 methods may not have been optimal they're not have been the best thing they would it would at
01:13:51 least have meant that crews would have had some kind of training which your department at least
01:13:55 knew to be risk critical yes that would have been and instead by the time of the granville tower
01:13:59 fire nearly two years later that training had simply not been rolled out to crews at all
01:14:05 yes that's uh it would have been better for them to have that information i agree
01:14:10 mr chairman is that convenient yes thank you very much we'll have a break now we'll come back please
01:14:16 at 25 to 4 and again please don't talk to anyone about your evidence or anything related to it
01:14:22 over the break thank you sir all right thank you very much thank you very much 25 to 4 please
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01:32:21 would you ask miss cotton to come back in please
01:32:33 all right scott and ready to carry on yes sir thank you yes yes yes mr chairman the t cap
01:32:39 is cotton lfb 0010 2213
01:32:48 this is t cap 0 212 which we can see from the first page is entitled ops news 30 highly insulated
01:32:56 buildings and if we go to page three we can see that in the version control grid version 0.1 was
01:33:04 created on the 14th of october 2015 by nick markwell agreed draft for submission to babcock and
01:33:13 version 0.2 which is which is this was created on the 10th of october 2019 also by nick markwell
01:33:21 final draft for closed down c explanation in section 11.1 now taking it slowly can we go please to page
01:33:28 four box 1.2 name of commissioning officer and their department dac graham ellis operational
01:33:37 assurance now dac wayne brown so at the time of the initiation in october 2015 it's right that it was
01:33:43 graham ellis wasn't it um i think it was assigned graham ellis because of the ops news article
01:33:48 and then obviously subsequently passed to dac wayne brown do you know when no i have no idea
01:33:55 but at all at all events do you agree with me that the commissioning officer
01:33:59 was dac graham ellis of your department yes because the ops news article was related to him
01:34:06 but the content of the training would fall under peter cow up because of the fact that he owned
01:34:14 all of the policies in relation to firefighting policies and therefore subsequently any training
01:34:22 material that would fall from those and the name of the client and their department is dave brown
01:34:29 director of operations now andy row director of operations that would be in 2019 yes that's
01:34:35 correct at the bottom of page four you can see there's background and context you'll need to
01:34:41 scroll down it says this the key thrust of the ops news article 30 and package is that fs should be
01:34:47 aware of the implication on their firefighting tactics of the increasing use of highly insulated
01:34:53 sealed compartments fire development in these compartments and the hazards associated with
01:34:57 modern methods of construction the article and package should highlight a number of key concerns
01:35:02 and developments relating to modern methods of construction and signpost the new stroke improved
01:35:07 more than modern methods of construction cbt package the emphasis in the cbt package should
01:35:12 be on the implications modern methods of construction for firefighting tactics this should be in greater
01:35:17 depth than currently exist in the training package it is not sufficient to talk about rapid
01:35:23 fire spread and or unusual fire spread through voids straight cavities etc now mr groves told
01:35:31 us that that text there would have been provided by nick markwell in consultation with your
01:35:36 department as the commissioning department do you agree i think it would probably have been in
01:35:42 conjunction with tom goodall from operational policy who was listed further up who was in
01:35:48 charge of the firefighting section of operational policy i expect that graham ellis would have
01:35:55 worked in conjunction with them and i also saw lee drawbridge listed in there as well so
01:36:00 i think that would have been as it were a combined effort of those people right now you've picked on
01:36:06 something that i didn't show you so i'm assuming that your familiarity with that is from your
01:36:10 preparation but let's go back to page four to pick up what it is that you've seen this is under
01:36:15 paragraph 1.4 t cap stakeholder group members and we see tom goodall and lead rawbridge identified
01:36:23 there yes yes that's right i'm just like to say i have never seen this document i read that as you
01:36:28 put that up on the screen before i read those two names oh i see okay well that was very fast but
01:36:33 anyway there they are tom goodall and lead rawbridge lead rawbridge ops assurance yes yes that's
01:36:39 correct so also your department yes as part of the stakeholder group that would have been important
01:36:43 yes uh what makes you so sure that the text of the background and context that i've just read to you
01:36:53 at the foot of page four was provided not by nick markwell in consultation with your department
01:37:00 but in consultation with tom goodall no sorry to reiterate i think it was probably a combination of
01:37:05 but tom goodall was the group manager in charge of all of the firefighting policies for operational
01:37:11 procedures and this would therefore sit within him but i am pretty sure that lead drawbridge
01:37:16 would have provided assistance as well thank you now let's move ahead to uh well before we do that
01:37:21 the final sentence there if we can just have that back on the screen sorry we've lost it but page
01:37:25 five last sentence there it is not sufficient that spelled out didn't it that the current training
01:37:31 packages were not sufficiently addressing that topic i would say so yes i say this is the first
01:37:36 time i've seen this uh t cap yes now let's move ahead to page seven see see how far we get with
01:37:41 it box 4.1 what do you want this training to achieve and your department wrote the following
01:37:47 or rather it was written the following cbt package has referenced the following
01:37:52 first bullet point background for the development of increasingly well sealed compartments
01:37:55 global drivers for reduced co2 emissions and energy composite conservation conservation etc
01:38:01 technologies that are used to make this happen celtx which i think should be celotex king span
01:38:07 etc triple glazing aluminium ceiling tapes passive house rating building specific fixed
01:38:13 installations and other technological solutions this sort of technology is being retrofitted
01:38:19 in old buildings under development so not just found in new builds this sort of technology is
01:38:24 highly interdependent if one aspect fails it can undermine the entire design solution
01:38:31 signpost the bre research and the no g guidance as a resource both for operational staff but also
01:38:37 writers of training and policy and then this specific firefighting strategies to address the
01:38:44 hazards associated with high compartment fuel loading and temperature associated with modern
01:38:49 building contents we get less compartment fires but when they happen they are hotter and more
01:38:54 vigorous and they can be different to an old victorian semi that might traditionally have been
01:38:58 our bread and butter what a perfect response should look like consideration of ventilation path
01:39:04 weight of attack pro jet covering jets cruise external safety officer monitoring and communicating
01:39:11 window straight compartment failure and effects crews can anticipate on the compartment fire
01:39:16 conditions now looking a little bit more closely at the third from last bullet point in that list
01:39:23 signpost the bre research and the no g guidance as a resource for both for operational staff but
01:39:29 also writers of training and policy do you recall what that bre research and no g guidance was
01:39:37 no as i say i'm not familiar with this document so i'm i'm not familiar with the
01:39:41 research they're talking about and and which national operational guidance that would have been
01:39:48 group manager tom goodall as he worked in the operational policy where the guidance would have
01:39:53 been translated into london fargo policy right um you didn't see this t cap at the time as we can
01:39:59 see yet it was commissioned by graham ellis um i think as i said i explained i think initially his
01:40:05 name was put on it because the ops news article neither graham ellis nor lee drawbridge wrote the
01:40:10 content of this um i can tell by the style and by some of the phrases used which is not something
01:40:16 either of those officers would have put in the expression traditionally would have been our
01:40:20 bread and butter would not be a sentence that either of those two would use whose sentence was
01:40:25 it i have no idea but it's not the style and um type of context that either of those two would
01:40:33 use in a report right well on the footing then that this is a document you didn't see at the time
01:40:40 and had apparently no input into um let's see how you go the the bre research and no g guidance you
01:40:48 can't help us with can i show you a document and see if you could help with it lfb triple zero two four one seven four
01:41:01 this is something called the bre national operational guidance program fires in the
01:41:07 built environment knowledge and information and it's a very long document it runs to some 191 pages
01:41:13 uh have you ever seen this before no i haven't you've never seen this before no i haven't right
01:41:20 well you may come back to it in due course but again perhaps shortly do you know if this guidance
01:41:27 even though you haven't seen it before was shared with firefighters and writers of training and
01:41:30 policy i have no idea no idea um let's get back to the t cap form then please at page seven
01:41:36 lfb double zero one zero two two one three page seven at the foot of the page paragraphs two
01:41:44 four point two and four point three
01:41:48 lfb double zero one zero two two one three
01:41:57 uh
01:42:03 we can see from the foot of the page at four point two and four point three uh who do we need to train
01:42:08 four point two firefighters watch managers watch officer led cbt package station managers group
01:42:14 managers self-study package four point three when do we need this training cbt package to be delivered
01:42:20 in december 2015 you can see that and that would coincide wouldn't it with the release of operational
01:42:27 news 30 in january 2016 yes it would that was the idea why was that training limited to levels
01:42:33 one and two incident commanders as we see i have no idea sorry i wasn't party to this right would
01:42:40 you have expected this self-study package to be provided to all senior staff of all levels
01:42:47 i would expect it to be accessible on the brigades intranet for any officers to study yes yes now the
01:42:54 t caps progression was in fact discussed at the odcb do you remember that uh no i don't recall
01:43:00 that let's go to lfb triple zero four zero seven one one this is the odcb meeting for the 31st of
01:43:07 march 2016 and we can see that you were in attendance there as the second named attendee
01:43:14 down in the list and that was after your promotion to director of safety and assurance on the 1st of
01:43:19 december 2015 wasn't it yes it was if we go to page two you can see in there that under item 4a
01:43:27 there is an item dynamic and intelligent operational training and procedures update and that if you look
01:43:33 at roman numeral three it says this fire in highly insulated buildings is a computer cbt package
01:43:40 which has been developed but not gone live yet due to it issues it was confirmed that the it solution
01:43:45 lays with the lfb and it was hoped that these issues would be resolved with the it rollout
01:43:49 that is expected to begin in may and you can see from the right hand column that the action there
01:43:56 is assigned to dos and a see that i do yes uh that was you wasn't it yes but i think just to be clear
01:44:07 there are a number of actions uh detailed there um and so some of those would have been specific
01:44:13 to individual people so that what they should have done was to put the names against each of the roman
01:44:20 bullet points to say who that was assigned to well uh all right um it looks as if and this is the way
01:44:29 i read it but this is wrong that that assignation sorry the allocation uh to those um three or four
01:44:38 individuals for officers dosa hota and um br stroke dmo stroke hfs apply to all of those
01:44:51 um i'm not sure that it did but um we would have all had some responsibility in um i was we were
01:44:57 aware about the issues around the it and those were then being escalated to the head of it
01:45:04 um who worked for sue budden because uh it was taking an extraordinary long time to attempt to
01:45:11 resolve this issue and we kept being promised that the solution was imminent right um just for our
01:45:18 assistance which of these roman numerals what uh were allocated to you for action and i couldn't
01:45:25 tell from him i can see uh the roman numeral four actually has uh um my name there at the bottom
01:45:33 but the others i couldn't be specific it was not a terribly clever way of uh allocating actions on
01:45:39 the grounds of the fact that it'd be better if it'd been specific but i know that i definitely um
01:45:44 had a conversation with um sue budden who in which the department the it department sat
01:45:51 about my frustration on the issues right um now as one of the three directors by this time what
01:45:57 steps did you take to rectify the problem uh by speaking directly to sue budden who was the
01:46:03 director in which the it department sat right now this is of course march 2016 given the
01:46:08 significant impact on training packages can you tell us why the it issues which had originally
01:46:13 been identified in 2014 were not treated as a priority or handled with more expedition
01:46:19 they were treated as a priority but um unfortunately i'm not familiar with it
01:46:25 um
01:46:33 to be produced that was as much as i could do because i'm so i'm not familiar with it
01:46:38 and just by pressing the issue with the director responsible was my role at that time can you help
01:46:45 with this question that these it issues were insurmountable or non-insurmountable
01:46:51 i'm sorry i don't understand let me try it there was a bad question do you accept that these it
01:46:55 issues were not insurmountable they could have been surmounted if we'd had an it fix yes absolutely
01:47:00 yes and they're not withstanding that these basic it issues denied crews important training
01:47:05 yes they did now let's look at the contents of the highly insulated buildings package
01:47:11 uh can we go first to the watch based package which is a b.a.b. six zeros one six
01:47:17 um this is dated the 21st of may 2019 so this is almost two years after the granville tower fire
01:47:25 itself but you i think uh were still commissioner at this stage yes i was yes yes and we can see
01:47:33 the packages aims and objectives at page three if we go to that
01:47:36 uh and you can see a slide and underneath the slide text aim and objective standard information
01:47:42 aim to increase awareness of highly insulated compartments and associated operational
01:47:47 considerations objectives describe how highly insulated compartments impact on firefighting
01:47:53 techniques and strategies and how they impact on fire safety and safety and safety and safety
01:48:01 insulated compartments impact on firefighting techniques and strategies
01:48:06 and then summarize how this technology may fail and the related hazards explain the risks of
01:48:11 increased fire loading in relation to modern building contents outline what best practice
01:48:16 should look like at an incident with a highly insulated compartment list the technology and
01:48:22 building techniques used in construction to reduce co2 emissions and improve energy conservation
01:48:28 but that's what the aim was if we go to page seven we can see as part of a series of slides
01:48:34 on modern methods of construction a slide on thermal insulation boards
01:48:41 uh and that has a an image above it uh and the text says increasingly used in construction
01:48:51 as a core panel system for internal structures and into external cladding often the boards are
01:48:57 constructed of polyurethane pur or polyisocyanurate pir and are covered with an aluminium foil facing
01:49:05 modern methods of construction to create environmentally efficient buildings
01:49:09 a range of specialized building materials have been developed that's what it says uh the only
01:49:17 video we've been able to identify in this package appears to be associated with a series of slides
01:49:22 which start at page 15 and if we go through pages 15 16 17 and 18 can we do that you can see 15
01:49:31 modern day fire development 16
01:49:38 fire loading 17 fire loading 2 18
01:49:47 fire loading 3 and just looking at that would you agree that that is demonstrating that the cbt
01:49:52 package is playing a video of the difference in the time it takes to reach flash over as between
01:49:59 modern rooms on the one hand and older or legacy rooms on the other uh yes it appears to i'm not
01:50:05 familiar with this uh do you agree that that video is was not essential to disseminating
01:50:12 to disseminating information about modern construction methods and insulation materials
01:50:17 and the risks they pose um if that's the only video then yes i agree yes and actually even
01:50:23 the contents of the video could have been easily explained by a text or even still images yes they
01:50:29 could have been so do you agree that the decision not to release this package without its inessential
01:50:33 video content lacked any proper justification um if that was the original video that was embedded
01:50:39 or whether this has been updated and a different video embedded i i wasn't aware of the content so
01:50:45 if that was the only video then yes now we hold a copy of the training guide which accompanies this
01:50:50 watch based package at bab 6038 can we please can we please go to that
01:51:01 and it's called training guide highly insulated buildings e-learning watch manager led and if
01:51:06 you look at the bottom of the screen you can see um it's a doc ref babcock lesson template
01:51:15 and the authors of jonathan blow and divina latang do you know them no i've never heard of them
01:51:25 if we go to page 20 we can see the text
01:51:27 next
01:51:32 unseen fire spread read the following text to the watch the effectiveness of compartmentation
01:51:39 relies on good workmanship at installation and it being in a good state of repair failure to seal
01:51:45 gaps and voids reduces the fire stopping element of construction and can contribute to the unseen
01:51:50 spread of smoke stroke fire from one compartment to another the increased use of thermal insulation
01:51:56 boards can add to these problems as they are seen as less as a less effective fire barrier
01:52:00 than traditional materials the material they are constructed from can degrade and release
01:52:06 flammable and toxic gas the insulation properties of the material may make it difficult to track
01:52:12 fire spread uh the senior officer packages at bab 709 i don't propose to to take you to it because
01:52:21 it has similar contact content and only contains the the video i've shown you already just looking
01:52:27 at that do you agree that this training was essential for crews to understand the risks
01:52:32 facing them in the modern built environment yes as part of a training package definitely and do
01:52:38 you accept that in not releasing it or otherwise disseminating its contents down to station-based
01:52:43 staff at the very least that was a significant failure by the operational assurance department
01:52:48 um no because the operational assurance department weren't responsible at that time for releasing
01:52:52 this training i agree that not sharing that training with operational crews was um a risk
01:52:59 to crews because we weren't keeping informed about these modern methods of construction
01:53:04 do you accept that in not releasing this package that was a very significant failure uh by somebody
01:53:11 it was a significant failure yes by whom i'm not sure at this time who was responsible for
01:53:16 releasing the training package i'm sorry well we know where the t cap assigned its origins your
01:53:24 department and also tom goodell and lee drawbridge lee broad drawbridge being within your department
01:53:30 and that was um back in uh 2015 uh and 2016 what changed between the two years between then and
01:53:41 2019 um so dr sabrina cohen hatton was in charge of the operational review team the
01:53:48 instant command team i also believe peter critchell was in charge so there were a
01:53:52 number of different offices in charge of that team and also in charge of the operational policy team
01:53:57 and probably the teams working in peter grove so that's why i find it hard to identify
01:54:02 which individuals had been responsible during that time in those posts right well let's get
01:54:08 back in time then i've shown you the package that was eventually rolled out in 2019 let's get back
01:54:13 in time to 2016 and the 31st of march 2016 lfb 00088900 this is the same date as the odcb meeting
01:54:27 this is the training package document and it's set it's called dynamic and intelligent operational
01:54:32 training update says diot babcock 31st march 2016 do you remember uh this diot report being
01:54:40 circulated at the meeting not specifically no but it but you can remember you can't disagree
01:54:47 that it would have been i suppose no if it's on the minutes and this agenda yes it would have been
01:54:51 if we look at paragraph 1.1 of the report uh it says this report identifies how training interventions
01:54:58 have been reviewed and amended in line with the requirements of operational news 30
01:55:03 any amendments to training interventions have been subject to the training commissioning and
01:55:07 alterations process t cap the updates that were necessitated by operational news on fires in
01:55:14 highly insulated buildings we can find set out at set out at page four let's just go to page four
01:55:20 now on page four you can see that changes were identified for a b and c
01:55:37 firefighter development the importance of recognizing different types of buildings and
01:55:41 the hazards associated with these is reinforced through ffd training this subject is also supported
01:55:46 by e-learning packages and training notes building construction and firefighting in buildings you see
01:55:51 that i do yes and then if you go down to the third paragraph on this page incident command
01:55:59 incident scenarios are being created for the rollout of the new ic training across levels one to
01:56:03 three the injects for a range of these scenarios will include hazards and signs associated with
01:56:09 highly insulated buildings the content of the article will be raised by trainers during the
01:56:13 delivery of current incident command training we've seen no evidence to indicate that the
01:56:19 lessons underlying the highly insulated buildings package were worked into the new incident command
01:56:23 training packages or or that injects were developed specifically dealing with those issues
01:56:30 do you know whether they were uh no i'm not sure i've not um seen the full suite of incident
01:56:36 command training packages and the detail behind them to be able to confirm that do you know what
01:56:42 work was done on this uh no i'm unaware this would have been work that babcox would have been
01:56:48 undertaking to include that in the training they were developing right do you remember you may
01:56:54 not but when watch manager dowden who was the initial incident commander at granfell gave
01:57:00 evidence at part one of the inquiry he said that he didn't recall receiving training on looking out
01:57:04 for early unexpected failure of internal compartmentation or the impact of building
01:57:10 materials and contents on fire spread that was day nine at pages 41 and 42 for those who want
01:57:17 to get back to their transcripts in the light of his evidence do you accept that the new incident
01:57:23 command courses did not adequately incorporate or replicate the content of the highly insulated
01:57:29 buildings training package i can't confirm that because that would have assumed that
01:57:36 mike dowden had been subject to that training package and i wasn't aware if he had
01:57:40 as i said i haven't i haven't seen the content of those so i would be able to confirm or deny that
01:57:45 i'm sorry i don't know the detail of them right can i then turn to the national operational guidance
01:57:54 on fires in the built environment which is a similar topic do you remember that in 2014 while
01:57:59 you were ac operational assurance the national operational guidance program published a document
01:58:05 called fires in the built environment not specifically no right lfb 000 24174
01:58:16 we looked at this a moment ago and i said i'd come back to it and i think you didn't recall it
01:58:20 um it's that document there um now uh this document consists of some knowledge sheets
01:58:29 and i just want to see how much of this you can help us with can we go to page 25
01:58:36 this is on the subject of cladding you see i do yeah external wall finish cladding uh now
01:58:43 before i go into the detail you say this is a document you've never seen before are you able
01:58:48 to explain why that given that this is a 2014 document you as head of operational assurance
01:58:57 didn't see this document um it wasn't commonplace for um the national operational guidance documents
01:59:07 to be um read by everybody because this was used to translate into training
01:59:14 and policy for london fire brigade so the national operational guidance was issued
01:59:18 and there was a department which sat within peace cowops department that translated national
01:59:24 operational guidance into london fire brigade policy which would then be disseminated why was
01:59:29 that not of interest to the operational assurance department i'm not saying it wasn't of interest
01:59:33 i'm saying that that was the way the policy works so we wouldn't necessarily have had the
01:59:37 national operational guidance shared with us yes i'm just trying to understand why this document
01:59:42 would have bypassed you was it not your department's concern to make sure that key health and safety
01:59:49 risks uh whether to firefighters or to members of the public which were incorporated in national
01:59:56 operational guidance was seen by your department no because these would have been seen by the
02:00:01 operational policy department who wrote london fire brigade's operational policy that would then
02:00:05 translate into the workings of london fire brigade and how that was disseminated to firefighters to
02:00:11 ensure that firefighters and members of public were made safe right just miss cotton just remind
02:00:17 me what did your department do so operational assurance was responsible for monitoring performance
02:00:22 of operational activities on the fire ground and through the use of the operational review team
02:00:29 to feedback on those and also to provide information via the diop process to odcb to allow
02:00:36 operational news articles to be developed yes yes um operational activities on the fire ground so
02:00:43 in a nutshell say that we're clear because of some of the evidence we've heard today i just
02:00:46 want to be crystal clear about what your job was uh as a coa was to make sure that operations on
02:00:54 the fire ground were up were reasonably adequate if i could put it that way yeah better than that i
02:01:00 would hope all right better than that did that not mean that you would have to know and understand
02:01:07 what training people on the fire ground were getting in order for them to be able to perform
02:01:12 in accordance with the better than adequate standards you expected of them so the role of
02:01:17 the operational review team would be to review the performance of firefighters and officers on
02:01:21 the fire ground against london fire brigade policy so very much the policies that have been
02:01:26 developed by london fire brigade they would be aware of those and they would monitor the
02:01:30 performance of the crews against those are you saying that national operational guidance was
02:01:37 irrelevant to your job unless and until it was incorporated effectively domesticated into london
02:01:43 fire brigade policy it wasn't irrelevant but london fire brigade the operational assurance team
02:01:50 would work to london fire brigade policies which were developed from national operational guidance
02:01:54 by the operational policy team so that in making assessments assuring to use the word of the title
02:02:02 of your department the performance of those on the incident ground at any incident you are not
02:02:07 concerned to look at national standards only lfb's policy and training nothing else now i was fully
02:02:13 aware that the operational policy team were the ones who were reviewing the national guidance and
02:02:17 then incorporating that into london fire brigade policy which is what we trained london firefighters
02:02:23 to and therefore we would assess them against and your role when it came to training was to
02:02:28 make sure that the training fitted with what you understood to be the role of the firefighter on
02:02:35 the fire ground no we had no role in assuring the training that was done by peter groves team
02:02:42 and the training department and independent assurance and then the training on fire stations
02:02:46 that took place was assured by dave brown's training officers the trios and then the triple
02:02:53 sos who were subsequent team that went and monitored their training i didn't ask you about
02:02:57 whether you had a role in assuring the training what i'm really seeking to understand is what your
02:03:02 role was in relation to training at all we didn't have a role in relation to training and yet you
02:03:07 were the commissioning department in so many of the t caps that we've seen in only the ones relating
02:03:11 to instant command well and in relation to the to this package which i said was because of the
02:03:19 initially to do with the operation news 30 and it was then transferred to the operational policy
02:03:23 department who were the owners of the policy and therefore were developing the training
02:03:29 let's look at page 25 a little bit in a little bit more detailed then description external
02:03:34 cladding is commonly a non-structural material or assembly that is used to cover structural surfaces
02:03:40 on the outside of the building for aesthetic reasons insulation or to provide protection
02:03:43 from weather and climate and then under the heading general considerations in the box below
02:03:50 there's a list of cladding materials set out prefaced by the sentence cladding may be combustible
02:03:56 or non-combustible depending on the material used the following materials are typically used to
02:04:02 provide external cladding applied to the face of the building envelopes and then there's a list of
02:04:07 starting with clay then we have concrete thin stone metal steel which says steel stainless
02:04:14 steel copper bronze and aluminium are generally used in sheet form for cladding to walls as
02:04:19 profiled metal sheeting metal panelling aluminium and steel profiled cladding
02:04:26 and then you can see from the rest of the bullet points below that how that material
02:04:30 and insulation would be installed in the system and what the installation material might consist of
02:04:36 and then if you turn the page
02:04:43 it says cladding systems may also require an insulation material which is typically fixed to
02:04:48 the supporting structure using a combination of mechanical fixings both plastics and steel
02:04:53 adhesives and in some cases railing systems on uneven surfaces for general refurbishment
02:04:58 or masonry based systems a single product is typically applied to the supporting structure
02:05:03 using a combination of mechanical and or adhesive based systems on uneven or lightweight frame
02:05:08 systems that require a cavity between the insulation layer and the sheathing boards
02:05:13 railing systems are typically applied insulation insulating materials typically used in external
02:05:19 cladding systems fall into the following groups and then you can see non-combustible as the first
02:05:25 thermo setting as the second and that refers to polyurethane foam pur poly iso cyanurate
02:05:32 foam pir and phenolic foam and you can see that then it goes on at the end these products are
02:05:39 often faced with materials such as glass fiber or aluminium foil and then finally
02:05:47 it goes on to say after that list in the paragraph if we scroll down a little bit below
02:05:55 the the bullet points as follows the fire performance of minor items such as breather
02:06:00 membrane brains vapor barriers and gaskets also needs to be considered in isolation they may not
02:06:05 pose a fire risk but when used over large surface areas in multi-story dwellings they have the
02:06:11 potential to contribute to fire spread on or through the system by offering a route to bypass
02:06:17 fire prevention measures such as fire breaks and cavity closers and then if you go to page 27 you
02:06:24 can see that there are two types of two types of rain screen cladding system there ventilated
02:06:32 and unventilated but if you look at the bottom of that on the right hand side under inherent hazards
02:06:41 if we scroll down it says the potential for external fire spread with combustible cladding
02:06:46 systems hidden fire spread behind cladding this can lead to a second seat of fire if the fire
02:06:51 spreads upper cavity and breaks out higher up the structure falling debris may present a hazard to
02:06:58 people outside of the building or cause downward fire spread and if you look a little bit above
02:07:03 that you can see that in the context of a ventilated cladding system in the last paragraph
02:07:09 or pronouncement paragraph falling combustible cladding may cause fire spread to floors below
02:07:14 the original or primary seat of fire cladding which has plastic or aluminium components may
02:07:20 also produce molten droplets when exposed to fire which may drip onto people or objects below
02:07:26 the failure of cladding may leave the underlying structure of the building exposed this may aid
02:07:30 firefighters in the identification of the structural elements and materials used within the building
02:07:35 but may also leave the structure more exposed to the fire now that's an awful lot there
02:07:43 uh and is that something um that as of 14 was well known within the lfb and when i say that i mean
02:07:55 everything i've just read to you um no unfortunately i don't think it was why is that um i'm i don't know
02:08:02 that would have been a document that i said their operational policy team would have referred to
02:08:09 in the development of their policy um i was not aware but clearly in the national operational
02:08:13 guidance the number of areas are highlighted there that i don't think were translated into
02:08:19 either training or information that was given to firefighters yes and do you accept that as of 2014
02:08:27 there were materials available to fire and rescue services nationally including the
02:08:31 london fire brigade through the national operational guidance program that forewarned the lfb of what
02:08:37 cladding was and the fire risks that it posed um yes this document clearly states that yes and
02:08:43 that as head of operational assurance which encompassed the brigades health and safety
02:08:48 department at the very least do you accept that your department should have been alive to alive
02:08:53 to and implementing that guidance um no unfortunately as i said that guidance and the translation of
02:08:58 that into policy sat within the operational policy department therefore we would not have
02:09:03 been involved in this even though related to health and safety yes that's correct
02:09:10 leaving aside whose fault within the lfb it was do you accept that in failing to issue any form
02:09:16 of policy or training that covered cladding the brigade was at fault in failing to follow and
02:09:21 implement national guidance yes i do and and a failure in its health and safety responsibilities
02:09:28 both towards crews and to members of the public yes i do looking at page 86 please at this
02:09:35 document this is a knowledge sheet on means of escape in buildings higher than 18 meters but
02:09:41 under 30 meters as you can see from the very top of the screen uh and uh it goes on to express
02:09:49 general considerations and below that it has inherent benefits and inherent hazards
02:09:54 uh under inherent benefits it says increased fire resistance additional provisions to assist
02:10:00 firefighters provisions should be in place to limit external fire spread from the building
02:10:05 and then the third element of inherent hazards says firefighters should be aware of facade failures
02:10:12 and the potential for exposed edges of the building at height again do you accept that this was
02:10:18 forewarning all fire and rescue services including the lfb of the need to prepare
02:10:24 firefighters for facade failures yes it is and the failure to do so was a failure adequately
02:10:30 to implement national guidance yes it was yes can i then turn to the question of international fires
02:10:38 uh can we start with lfb 3024114 please
02:10:51 this is an email if you look at the second email down from peter cow up to russ timpson
02:11:00 copied to a number of people including you date of the 22nd of february 2015
02:11:05 subject high-rise fire in dubai dear russ you will no doubt be aware of the above and i was
02:11:11 wondering whether through the good offices of the international tall building fire safety
02:11:15 network you could put me in touch with some relevant individuals who would have been involved
02:11:19 in and or might have firsthand knowledge of this incident although lfb has recently invested
02:11:25 significant effort to improve our high-rise firefighting techniques and procedures we are
02:11:31 never complacent and it is hard to imagine that an incident on this scale won't bring forward some
02:11:37 lessons learned quotes unquote my focus would be any quotes new unquote issues associated with
02:11:43 firefighting operations and in particular to identify whether this incident highlighted any
02:11:48 command procedural or tactical issues which are not already which are not already covered in
02:11:54 the
02:12:07 then if you skip to the bottom peter carp says in addition my colleague assistant commissioner
02:12:12 neil orbell will be interested in any prevention or protection issues arising from this incident
02:12:17 so i would be also i would also be grateful if you would you could bear this in mind when suggesting
02:12:22 any contacts which you are able to offer first what was the international tall building network
02:12:28 can you tell us i've not heard of it before do you know what came of this email
02:12:34 no i'm not aware i don't i'm not whether whether i saw any reply to it or not why was it sent to
02:12:39 you do you think um peter cow up had a habit of copying a lot of people in on his emails for
02:12:44 information um and i think it would have been for that purpose did your operational assurance
02:12:49 department take any steps to obtain further details of the incident um no because i think
02:12:53 uh as covered by their peter cow up um who obviously was the um holder of the policies
02:13:00 in relation to firefighting there was clearly chasing that information and also had usefully
02:13:05 copied neil orbell as the assistant commissioner for fire safety and because they would obviously
02:13:11 have a key interest in that as well so it was being covered by the two departments who would be
02:13:16 taking that up indeed but can we proceed on the basis that he thought it was relevant because
02:13:22 your department covered health and safety and therefore he thought it was something that you
02:13:26 should know about i think he thought we should know about it because it was a an incident of
02:13:31 interest yes yes and therefore as an incident of interest were you not interested oh absolutely and
02:13:39 but i could see quite clearly that the people who would take the relevant action to progress any of
02:13:45 those issues were the ones that were being highlighted in this email by peter cow up
02:13:49 including himself and neil orbell did you yourself give any consideration to whether there was any
02:13:55 learning or operational assurance to be gleaned from that incident uh no i know that if peter
02:13:59 cow up had found any he would have shared that with us right is it because it was international
02:14:06 that you didn't think there was much to learn no not at all i mean i think that um graham alice as
02:14:11 well was very interested in international fires so it wasn't the fact there would be nothing to
02:14:16 learn um it was the fact that i knew the right people were uh involved in this email to pick
02:14:22 up the information may you say graham alice was very interested in international fires
02:14:26 had your directorate or the operational assurance department under your leadership between march
02:14:32 2012 and december 2015 been made aware of any other international or indeed domestic cladding
02:14:38 or facade fires um i think that we've been made aware of other fires i can't recall the specific
02:14:43 details but um graham alice uh where he was aware of them would share information you don't recall
02:14:50 any uh not off the top of my head sorry let's go to lfb 000 24217 this is an email chain from january
02:15:00 2016 almost a year later and the subject matter of the email chain is do by fire
02:15:09 uh and if you go to the email at the foot of page one you can see it's from graham graham alice
02:15:19 to lee drawbridge martin freeman copy to you and tony byles do by fire yes yes but tony byles
02:15:29 uh he's a name we may come across at some later stage but he was a long serving um firefighter
02:15:36 wasn't he yes he was he was a senior officer in the national resilience team he was and in fact
02:15:42 am i right in saying that he was actually incident commander at uh the adair house fire i'm not sure
02:15:49 oh you're not sure all right um we will come back to him in due course um but looking at the email
02:15:56 it says fyi interesting article about flammable polyurethane and aluminium building cladding
02:16:03 involved in the do by fire and he provides a link to an article on a site called if sec global
02:16:09 you see that yes i can um we'll look at the article in a moment but just before we do can
02:16:15 we look at the middle email uh sent on the 7th of january 2016 at 1507 just above it
02:16:23 tony byles and tony byles there is a group manager national resilience as you've said
02:16:28 and he says always knew clause 12.7 would be used somewhere by someone
02:16:33 relied on it heavily throughout my career regards tb um what's that about um i think
02:16:40 unfortunately that's tony byles having a private joke about something i'm not sure what clause
02:16:46 12.7 is but um he was very good friends with graham ellis um it didn't detract in any way
02:16:53 for the fact we had a conversation actually around uh this fire because graham ellis was signed up the
02:16:58 if sec notifications um but i think that was just tony making a comment and then i made a comment in
02:17:05 response to that so it wasn't a relevant piece of information i have no idea what clause 12.7 is
02:17:09 that tony was referring to but it was just a flippant comment i believe well you you've
02:17:14 dropped a hill a little bit in the in the in the um process of question and answer um first of all
02:17:20 i think as you've just told us you didn't understand what he meant by clause point seven
02:17:24 why didn't you ask him because i i knew by the tone of that that he was um being flippant
02:17:30 being flippant about what i don't know but i knew he was being flippant i knew tony well he was
02:17:35 good friends with graham and i knew that he was being flippant about clause 12.7 whatever that
02:17:40 was so i knew he wasn't referring to it in a um context of something he worked on or relied on
02:17:46 heavily throughout his career but were you not curious to know what he meant he clearly thought
02:17:50 it was important no he didn't he was being flippant i think and i'm i know that from a
02:17:55 conversation i've had subsequently with graham ellis about it did you look at the article yes i did
02:18:01 you could have told them from the article that this was a enormous external external cladding fire
02:18:07 yes and therefore um flippancy may have been regarded perhaps as out of place but tony
02:18:13 bars was certainly getting at something serious wasn't he um so we did have a conversation
02:18:17 between graham ellis lee drawbridge um and other colleagues around this fire um as a result of that
02:18:25 um tony bars wouldn't have been there because he was actually seconded out of london fire brigade
02:18:29 at that time working for national resilience but the colleagues in operational assurance did
02:18:34 have a conversation following viewing that video yes i take it from what you said just a moment to
02:18:41 go about 12.7 uh that you didn't think at the time that that was a reference to approved document b
02:18:48 guidance paragraph 12.7 no i didn't uh did you know at the time that that was the very paragraph
02:18:54 which had the requirement for insulation products used in the external walls of buildings over 18
02:18:59 meters to be of limited combustibility no i didn't in the top email that you send back
02:19:06 the same day a few minutes later i'm surprised it's taken them so long to reference such a key
02:19:11 piece of information what do you mean by that it was a response to tony bar's flippant comment
02:19:17 well i know but what did you mean by it um it was just a response to that there meant nothing by it
02:19:21 but what was the key piece of information that you were referring to i'm not sure i have no
02:19:25 recollection of that was it adb 12.7 i don't know i have no idea looking at the email run
02:19:32 from someone who wasn't involved in it at the time that is a fair reading of it doesn't it
02:19:38 if you didn't understand the context and the people involved in it yes possibly but i know
02:19:42 it wasn't because i know that tony bars would not have been familiar with approved document b
02:19:49 from the roles he'd conducted in london fire brigade any more than i was because i'd never
02:19:54 been a fire safety officer right um well let's look at the article which may provide a clue
02:19:58 that is at inq 3014890 and the article is entitled fatalities will happen sooner or later warns fire
02:20:12 safety expert after dubai blaze resurrects fears over flammable cladding and there is a photograph
02:20:18 of the new year's eve fire at the dubai hotel there the torch and you can see that there is
02:20:28 quite a lot of text below the picture uh the fire and it says this um the fire that engulfed a 63
02:20:36 story dubai hotel on new year's eve is a harbinger of fatalities to come a leading fire safety expert
02:20:41 has warned the fire which rapidly engulfed the address hotel's exterior sorry the address not
02:20:47 the torch the address hotel's exterior shortly before midnight is the third such blazes in many
02:20:52 years resurrecting fears about the prevalence of highly combustible materials among skyscrapers
02:20:56 across the uae 16 people suffered minor injuries in the latest blaze although there were no
02:21:02 fatalities a fire safety consultant with gloss door based cwb fire safety has warned that there
02:21:07 will be fatalities sooner or later speaking to the daily telegraph phil barry estimated that up to
02:21:13 70 percent of dubai's high-rise buildings could be clad in polyurethane and aluminium composite
02:21:18 cladding a highly flammable material used routinely during dubai's building boom the material was only
02:21:24 outlawed in the emirate in 2013 the basic rule is that outside any building over 13 meters which is
02:21:31 as high as any fire truck ladder can reach must be made of non-combustible materials because you
02:21:36 cannot fight the fire he said large numbers of buildings in the uae do not meet that standard
02:21:41 and then if you look at the foot of the page if you look at the foot of the page you can see it
02:21:46 says tall british buildings have been required to comply with british safety standard bs 476
02:21:52 which meets the class nought standard stipulating no surface spread of flames
02:21:57 since regulations were changed in the aftermath of the 1973 summerland holiday park fire on the
02:22:03 isle of man on the isle of man which killed 50 people and injured eight seriously
02:22:09 um now um can we take it i've read you quite a lot of that but can we take it that your directorate
02:22:16 and you particularly uh were well aware of this fire yes we were did you give any consideration
02:22:23 at that point around a year following the previous email we looked at to directing the operational
02:22:29 assurance department to revisit the international fires perhaps graham ellis in particular given his
02:22:35 interest to investigate why these fires were occurring and whether there was anything for
02:22:39 the lfb to learn from them or be prepared or take from them for preparation purposes
02:22:45 i think i do recall a conversation i had with graham ellis and other colleagues other senior
02:22:52 officers in different departments and i think the thrust of the conversation was that we were very
02:22:57 glad that in the united kingdom we had building regulations and bridge safety standards that would
02:23:04 not allow products such as this to be applied to buildings um it was i remember watching the fire
02:23:10 as it happened and you know seeing how rapidly it spread um and then reading this it was you
02:23:16 know very worrying that 70 percent of dubai's high-rise buildings were covered in it but the
02:23:21 bit at the bottom was the bit that i believe that um you know everyone thought that british
02:23:28 buildings complied with the fact that there would be no surface spread of flames so whilst we could
02:23:34 see that was happening overseas i think the issue that we raised was the fact that we were very glad
02:23:38 that we had far better protection in the united kingdom to not allow building materials such as
02:23:44 that to be used on buildings did anybody take any steps within the lfb to obtain details of this
02:23:49 incident the address fire for example to see what materials had in fact been used and whether a
02:23:55 similar incident could occur in london um i'm not sure they did um whether the fire safety department
02:24:02 who would have been the ones um who related to building construction materials would have done
02:24:07 that i'm not sure but i'm not aware and if you look at the bottom of the page which i think you
02:24:19 you are interested in we can see the reference to british standard 476
02:24:24 but a little bit above it it identifies the fact that although there is a basic rule in the uae
02:24:31 for non-combustibility of buildings over 30 meters large numbers of buildings in the uae do not meet
02:24:36 that standard why was that different from the position in london and i ask that because
02:24:43 polyurethane and cladding were materials as we've seen identified in the highly insulated
02:24:48 building cbt package um because i believe as it says at the bottom that tall british buildings
02:24:54 were required to comply with the british safety standard that they were not in the uae
02:24:58 and therefore there should be no surface spread of flames on any building that complies with bs 476
02:25:06 clearly those standards didn't apply in dubai at the time of this article in email january 2016
02:25:13 so 18 months or so before the grandville tower fire was it the view or the attitude of the london
02:25:18 fire brigade that an incident such as the address fire in dubai simply couldn't happen in this
02:25:24 country because of our regulatory regime i think it was a view that was held nationally by the
02:25:32 british fire service that no fire like this should ever be able to happen because we had british
02:25:37 safety standards and building compliance that should prevent any of this happening yes
02:25:43 what about the risk of non-compliance the risk that the regulations in question may not have
02:25:47 been complied with in the case of any given building that was a risk i'm not sure if that
02:25:52 was a risk that was ever identified or brought to anyone's attention but clearly there is
02:25:57 always a risk of non-compliance but i don't think that we had seen example in sort of something of
02:26:03 this case where that had happened and if we had then it wasn't shared widely
02:26:11 mr chairman i'm in the middle of a line of examination but i'm not going to finish it
02:26:14 before 4 30 not least because we're beyond 4 30 you've probably got a little further to go
02:26:19 with this too haven't you a little bit yes i do well it's an uncomfortable place to leave this
02:26:24 hanging but unless you want to sit for another 10 or 15 minutes to finish it off i think we're
02:26:29 not in trouble with no not in the slightest not at all i would think that this cotton's probably
02:26:34 had a long enough day already and maybe others have as well so i'm sorry to break you at a
02:26:41 less than convenient point but i think we can come back to this and pick it up again tomorrow
02:26:46 yes is that right yes yes well um as you have this cotton this line of questioning hasn't
02:26:54 come to an end but i think it's better if we stop now and we'll resume at 10 o'clock tomorrow
02:27:00 please i think you'd already arranged to come to my venture yes i had something yes good thank
02:27:04 you well we'll resume at 10 o'clock tomorrow then please and as before please don't discuss your
02:27:08 evidence with anyone over the break all right thank you very much that's a good reason too
02:27:16 thank you for the drill
02:27:24 thank you for a minute well we'll continue at 10 o'clock tomorrow then please thank you very much