Peter Cowup, former Head of Operational Procedures at LFB, gives evidence on the development of operational guidance for high-rise firefighting, including the critical GRA 3.2 and Policy 633. His testimony reveals systematic failures in evacuation planning and a sector-wide 'blind spot' on evacuation procedures.
00:19:01 good morning everyone welcome to today's hearing
00:19:04 hearing today we're going to continue hearing evidence from mr peter carp so would you ask mr carp to come in please
00:19:24 good morning mr carve good morning sir all right all ready to carry on i hope indeed thank you very much yes mr kanye when you're ready thanks sir uh good morning mr carrup um we're about
00:19:35 uh good morning mr carrup um we're about to start um consideration of the head of service review of pn633 so that's the topic i'd like to turn to first thing this morning we don't need to go to it but you state
00:19:46 we don't need to go to it but you state in paragraph 235 of your third witness statement and the references lfb double zero double one nine eight four nine forward slash 102. that you forwarded the then draft um 633
00:19:59 that you forwarded the then draft um 633 to david eagling on the 28th of june 2013 for the head of service review now we can see the email that david eagling then sent to the heads of service on the
00:20:11 then sent to the heads of service on the 1st of july and if we could turn to that document please and it could be found at lfb 0029155
00:20:20 me
00:20:24 that says insofar as is relevant for today dear all
00:20:29 all please find attached operational procedure pn633 high high-rise firefighting for heads of service consultation excuse me please be advised that this revised policy has been aligned with a
00:20:41 revised policy has been aligned with a new national high-rise generic risk assessment which has been written by the lfb
00:20:46 lfb and which is due to be published by clg shortly
00:20:49 shortly the final draft of the gra is attached both the gra and this revised pn policy note incorporate lessons learned from both the shirley towers and lachnal incidents and this has led to additional
00:21:01 incidents and this has led to additional material being incorporated within the revised procedure to cover scenarios and issues that the uk fire service had not previously experienced or planned for
00:21:12 previously experienced or planned for now we know that shortly after this email was sent that you had discussions with clg about evacuation and stay put and those conversations started can we look at the
00:21:25 conversations started can we look at the version of 633 that was circulated with mr eagling's email that can be found at lfb travel0034166
00:21:37 and if we go to page 15 we find the relevant section on evacuation
00:21:48 we've looked at this previously and i suspect you're all too familiar with it now mr cowop but would you accept that there is no reference there to the need to evacuate a residential high-rise building in the event that stay put
00:22:00 building in the event that stay put becomes untenable i would agree and and this clearly predates this hadn't caught up with the changes that we'd either made to or were about to make to the gra and
00:22:12 or were about to make to the gra and it's that point if i can follow that up we know that the potential need to evacuate uh with a staple policy was eventually added into the final version of 633 yes and that was published in
00:22:23 of 633 yes and that was published in 2015. if we could leave this version on one part of the screen and put up the final edition of 633 which can be found at lfb quadruple zero one two five six
00:22:36 at lfb quadruple zero one two five six forward slash 14.
00:22:47 and we can see that in the final version on the right hand side there's a new paragraph 7.46 which states that it may be necessary to undertake a
00:22:58 it may be necessary to undertake a partial or full evacuation in a residential building where a state put policy is normally in place and look below in 7.47 there is a new little b
00:23:09 little b which provides the resources required to support the evacuation or state of policy
00:23:16 policy presumably those amendments were incorporated as a result of your discussions with clg surrounding gra 3.2 indeed
00:23:27 presumably the heads of service were consulted internally about the draft 633 in july 2013 they would not have been aware of that specific concern of clgs
00:23:40 specific concern of clgs regardless no no i i mean the discussions that i was having with clg were not
00:23:47 were not generally shared i may have mentioned the issues in passing to colleagues in
00:23:55 in informal discussion but they certainly weren't shared it you know globally in the way that the documents were and is it right that none of the heads of service who were consulted raised any concerns at all about the
00:24:07 concerns at all about the provision for evacuation in the draft that we see on the left-hand side of the screen
00:24:12 screen i certainly don't recall anyone raising concerns about that no um
00:24:18 um was the absence of feedback on that particular point because they didn't consider there was a need to prepare incident commanders to be able to evacuate a high-rise building in the event the state put became untenable
00:24:31 event the state put became untenable i don't think i'm in a position to speculate why people the absence of of comments i i don't know you'd have to ask them wouldn't you and so
00:24:41 and so was there however is this an example of the blind spot that existed both in the uk fire sector and the lfb which you referred to in your evidence on monday about evacuation generally
00:24:53 generally i would accept that and and and i would reiterate
00:24:57 reiterate and i think it's important for the inquiry
00:25:01 inquiry to know that it was a blind spot for lfb but it was a blind spot for the entire uk fire service because there was an absence of of national guidance on
00:25:12 absence of of national guidance on evacuation and fire services rightly or wrongly reacted to national guidance
00:25:23 and and without that national guidance you would have had to have foresight to
00:25:30 to to develop your own evacuation policy it's very clear to me now that that was a gap
00:25:36 a gap in our portfolio of guidance but at the time it was not understood nobody regrets that more than me and
00:25:47 and at the time was there much prompting within the sector or outside the sector for detailed guidance on evacuation when evacuation would become necessary what modes of
00:25:59 become necessary what modes of evacuation there were and how to conduct evacuation safely so looking at the minutiae of the process no there wasn't but i suppose to to to act as a bit of a
00:26:11 but i suppose to to to act as a bit of a counterbalance to what i just said and again i'm speaking from my own experience of attending many incidents some of which did involve what what we would now call mass evacuation so for example i was
00:26:23 mass evacuation so for example i was involved in in the 7-7 incident at king's cross that was a very large evacuation it was mainly self evacuation but up front where the incident was its
00:26:36 but up front where the incident was its most severe the evacuation was assisted by firefighters and other emergency responders so i think it's important for the
00:26:45 the inquiry to recognise that although guidance was missing it wasn't that we couldn't do evacuation because i think self-evidently we could
00:26:56 because i think self-evidently we could and that was in effect intuitive i fully accept that that's not good enough
00:27:04 enough and that we knew need to provide guidance particularly in a in a fire situation where by having that guidance you can anticipate a problem before it becomes a problem
00:27:15 a problem before it becomes a problem because i think that's the point of evacuation is to remove people from harm before the harm is done do you think that the gra 3.2 when it was published in february 2014
00:27:27 was published in february 2014 uh filled part of the gap uh for national guidance on the topic of evacuation i do and
00:27:36 i do and and despite all the criticism i remain proud of the document it was a big step forward from where we were there was precious little mention of evacuation in version two
00:27:50 mention of evacuation in version two there was absolutely no mention of fire survival guidance and i think we made a significant contribution to both of those areas particularly for
00:28:01 to both of those areas particularly for survival guidance because that was completely missing in in the development of that document can i because it's an interesting
00:28:12 can i because it's an interesting point to discuss looking at quite why that blind spot arose you were very helpful on monday when you said evacuation part of the blind spot's explained by the fact it's intuitive and that incident commanders get on with
00:28:24 and that incident commanders get on with it they know when to call it because they know what they're looking at is there an element also though that there was a degree of faith in compartmentation based on the rarity or the relative rarity of whole building
00:28:37 or the relative rarity of whole building evacuation residential high-rise buildings
00:28:40 buildings i would characterize it as faith
00:28:45 there was expectation which was based on people's understanding of the regulatory environment and the requirements that were placed on
00:28:57 requirements that were placed on buildings to to be safe and an absolutely key component of that is that there is compartmentation now i think we'd learn hard lessons from incidents like
00:29:08 hard lessons from incidents like lachenal that we couldn't always rely upon that
00:29:12 upon that compartmentation and i think to the extent we understood it at that time
00:29:18 time we'd reflected that in the changes that were made to certainly gra 3.2 but we're also reflected in pn 633 and indeed in
00:29:29 pn 633 and indeed in other lfb policies so so again we perhaps shouldn't be looking solely at 633 because there's a whole raft of policies that are relevant to the response at a high rise fire and would
00:29:41 response at a high rise fire and would have been relevant at grenfell looking at other possible reasons looking at the reason for a blind spot was there a concern or an apprehension of the risks associated
00:29:53 an apprehension of the risks associated with the resident evacuation an apprehension of panic or a fear of panic on the part of people being evacuated and therefore endangering themselves and potentially firefighters
00:30:05 themselves and potentially firefighters tasked with search and rescue duties that that's that's not been my experience of people evacuating so i've been preparing for for my appearance i
00:30:16 been preparing for for my appearance i i've heard people comment on that that's not been my experience in the incidents that i've seen i would accept the point that people are often calm i'd go further than that
00:30:27 go further than that in my experience people are often blase because if they haven't been directly involved in the incident they can't understand what all the fuss is about
00:30:38 what all the fuss is about and they just want to get on with their day so i'll go back to 7-7 because that's where it was perhaps at its most apparent
00:30:45 apparent there were people asking me and i was in charge of the incident at the time you know what bus they could get on because the tube had been shut and they wanted to get to an important meeting so i absolutely accept that people
00:30:59 i absolutely accept that people don't panic i i think there can be an element of panic for those that are most directly affected because of course they quite rightly fear what they can see and feel and
00:31:10 fear what they can see and feel and touch but for those who are a little bit further back and who are less touched by the incident i completely accept there's there's not likely to be panic and i've
00:31:21 there's not likely to be panic and i've not experienced it so that's kind of roundabout way of answering your question i don't think there was a fear i can only speak for myself ultimately but i've never feared evacuation
00:31:33 but i've never feared evacuation there is a risk of course that if people evacuate unnecessarily particularly if they start going down a single staircase in large numbers there is a risk that people would become
00:31:45 is a risk that people would become injured
00:31:46 injured you know that you know the hillsborough disaster is one example where you get large numbers of people moving at speed downstairs and you've got a higher level of risk so
00:31:57 and you've got a higher level of risk so i think we would always need to strike a balance
00:32:01 balance between the risk of people being in an area where they may be affected by fire and other products of combustion compared with the risk of them leaving
00:32:13 compared with the risk of them leaving the building and becoming injured in doing so and and that's a fine balance uh to
00:32:20 uh to to juggle that's that's very useful indeed we've got the final version of gra 3.2 on the screen on the right hand side could we keep it on the screen but
00:32:31 side could we keep it on the screen but go to page 36.
00:32:50 36.
00:33:09 and we'll come back on to that i think one of the references we've been given is wrong but one of the points that um seems to have arisen about the the consideration of gra 3.2 that you touched on yesterday
00:33:21 gra 3.2 that you touched on yesterday the it appears that the fbu had identified a number of research materials during their discussions with you do you have any recollection of that
00:33:34 no i i don't recall them mentioning the research materials at all during the discussion i don't deny they they added them in track changes but
00:33:46 they added them in track changes but they didn't refer to them when we were discussing the document so far as i can recall and so they weren't saying to you have you considered article x on the subject of evacuation
00:33:58 article x on the subject of evacuation or anything like that absolutely not the predominant discussion with the fbu was around should and must and and and where that
00:34:09 and and and where that would fall in the document did you consider the materials that the fbu recommended to you no
00:34:18 no do you know whether anyone on your team said mr morton or anyone else um considered uh
00:34:24 uh on the back of those materials whether and if so to what extent to provide advice in jra 3.2 on how best to carry out an evacuation safely i can't speak for mr morton or anyone else for sure
00:34:38 for mr morton or anyone else for sure but i think if he'd have looked at those materials and found anything of substance he would have shared it and discussed it with me and i don't recall him doing so so i would it almost be certain that he didn't look at
00:34:51 almost be certain that he didn't look at them
00:34:52 them and and that again on reflection uh
00:34:56 uh is clearly an omission but
00:35:00 but if i was going to add a reference to a document i think i would say to the person i was adding it to i've added this reference because and i would have explained
00:35:11 and i would have explained what i thought it was going to contribute to the document and and that to my
00:35:16 to my fairly certain recollection never happened
00:35:19 happened in your experience um over nearly four decades uh in the fire service um do you think that the commonly trained and instinctive response of firefighters is to focus
00:35:30 response of firefighters is to focus more on rescue rather than develop learning around the behaviour of residents in fire and the potential for firefighters to coordinate itself or
00:35:40 itself or ordered evacuation in my experience uh
00:35:46 uh and i can't you know i can't speak for every firefighter but the vast majority of firefighters have a really strong sense of vocation
00:35:58 really strong sense of vocation and
00:35:59 and an instinctive desire to make a difference and
00:36:04 and top uppermost in their mind at every incident is the desire to save lives and i think they'll always act sometimes to their own
00:36:16 to their own danger they'll always act in ways to save lives so i'm very very clear about that and i was always very proud to be part of service where that was the central
00:36:27 service where that was the central tenant
00:36:29 tenant i think the learning that come one of the key pieces of learning that comes from this tragedy and this inquiry is the need perhaps to be more scientific and more measured
00:36:43 scientific and more measured in our understanding of key issues like evacuation and the fire service already talks a lot about human factors i think we probably tend to talk it talk
00:36:56 i think we probably tend to talk it talk about it in the context of incident command
00:36:59 command but i think perhaps we need to understand better the public when we did exercise
00:37:04 exercise unified response we had a lot of academics involved in the evaluation and one of those who's working at the university of liverpool and i can't right at this moment
00:37:16 and i can't right at this moment remember his name he that was his focus was casually evacuation and the interplay between casualties and the emergency services
00:37:28 and the emergency services and
00:37:29 and if the inquiry is interesting i know he wrote quite an interesting report on the back of that exercise because that was one of the first times it
00:37:37 it he got very up close and personal to a very authentic rescue situation and i know it played a big part in his research so i think things like that
00:37:48 research so i think things like that that kind of research fire services perhaps engaging more with with those kind of institutions and working together to build understanding would be
00:37:58 would be would be a fitting legacy to come out of this would the uh your views in relation to the need for a scientific measured approach apply equally to instant
00:38:10 approach apply equally to instant command
00:38:11 command and evaluation of training for instance command to allow those people to respond appropriately to the situations which confront them particularly in the context where we're seeing a diminishing
00:38:22 context where we're seeing a diminishing number of fires year on year absolutely and and i think it's a massive challenge in that environment to to develop
00:38:34 environment to to develop and support incident commanders so that
00:38:38 so that they can be effective i think i think we've made certainly when i was in service i felt we'd made
00:38:44 we'd made some big leaps over time because when i started incident command was a very lonely task
00:38:54 task and and you were pretty much on your own i think over over time we developed a much more team-based approach and i think
00:39:05 and i think one of the key issues for me was always the the confidence as an incident commander to recognize that you
00:39:16 that you didn't necessarily have all the answers there's a great pressure upon you when you get on the back of a command unit to be the oracle but i think a better approach
00:39:27 but i think a better approach is to be
00:39:29 is to be clearly in command but to use your team to draw in information from others tactical advisors for example didn't
00:39:41 tactical advisors for example didn't exist 15 years ago at all now there's a whole raft of tactical advisors who can offer specialist advice and support around things like rescue
00:39:53 and support around things like rescue bulk movement of water fire safety and a good incident commander will always tap into those people and ask the right questions i think the
00:40:05 and ask the right questions i think the trick of being a good incident commander is not knowing all the answers it's knowing which questions to ask right rather like a good lawyer
00:40:16 a good lawyer thank you
00:40:17 thank you can i apologize i've diverted you uh mr cut but that was very interesting indeed would you mind if we return to the head of service consultation which i diverted you from
00:40:29 which i diverted you from um once
00:40:31 um once you had received the comments from clg in the final version of gra 3.2 had been signed off at that stage did you consider whether there needed to be a further round of
00:40:42 there needed to be a further round of consultation with heads of service to deal with the additions that concerns stay put which were previously on the screen i didn't
00:40:51 i didn't for the reasons that i think were made apparent yesterday that although the the comments from clg were well certainly the ones that i was aware of
00:41:02 certainly the ones that i was aware of and again recognizing i wasn't aware of the full range of their comments but the ones that i was aware of they they added value and they added detail but i didn't feel they
00:41:14 detail but i didn't feel they substantially changed the document so i didn't feel there was a need to formally consult thank you
00:41:22 thank you yesterday you very helpfully referred to the operational sounding board and their role in the consultation can i come back to that just to give some structure on that now
00:41:34 now you've dealt with this at paragraph 266 of your third witness statement which can be found at lfb double zero double one nine eight four nine forward slash
00:41:45 one nine eight four nine forward slash one one
00:41:46 one one two
00:41:48 two and you set out there that the draft policy was submitted to osb in january 2014
00:41:56 2014 and just to recap the board consisted a number of station-based personnel who are part of the consultation process for new operational policies to ensure that their development is takes into account
00:42:08 their development is takes into account the views and experiences of those who will be applying them on the ground is that a fair summary of what you said yesterday absolutely can you help us as to why there was an apparent delay between carrying out the
00:42:19 apparent delay between carrying out the heads of service consultation in july 2013 and consulting the operational sounding board in january 2014. were you waiting for gra to be finalized
00:42:31 were you waiting for gra to be finalized i would imagine that is part of the answer
00:42:34 answer but the full duration of the delay i can't really explain that or provide any particular reason for it but certainly part of it would have been waiting for the gra to
00:42:45 would have been waiting for the gra to be finally finished and published now yesterday you referred to mr goodall who i think gave evidence in phase one regarding events on the night but you also exhibited patrick utting's email of
00:42:57 also exhibited patrick utting's email of the 8th of january 2014 to mr goodall and donna harkin-perry for the purpose of consultation with the osb we can find that at lfb00102522
00:43:20 thank you
00:43:23 mr utting said this tom donner here is the very latest version of the policy for distribution to the osb it has been for heads of service review and we are awaiting feedback from fire
00:43:34 and we are awaiting feedback from fire safety
00:43:35 safety this means that appendices 2 to 6 are still a work in progress the rest of the policy has been reviewed to reflect the new high-rise generic risks assessment which is due to be published shortly and the latino house
00:43:47 published shortly and the latino house inquest
00:43:49 inquest now we can see that by this stage the new paragraph 7.46 which we looked at earlier referring to the evacuation of residential high-rises where statehood
00:44:00 residential high-rises where statehood is untenable is incorporated and that can be found in the attached draft of the policy and if we go back to that lfb trouble zero eight double three seven nine forward slash one five
00:44:18 and we can see seven four six there towards the bottom of the page and that appears to reflect the final version is that a fair observation indeed
00:44:29 indeed now you explained in paragraph 267 of your third witness statement we don't need to go to it but the reference is at lfb double zero double one nine eight four nine forward slash one one three
00:44:41 four nine forward slash one one three that the feedback from the osb was collated into a spreadsheet which you exhibited and it's what you referred to yesterday afternoon now that spreadsheet can be found at lfb double zero one zero
00:44:53 can be found at lfb double zero one zero two five three seven
00:45:05 again apologies it's one of those documents that needs to be downloaded mr carr
00:45:16 and could we look at line 46
00:45:25 and this is one piece of feedback mr cap that was received from a john button from the stoke newington greenwatch and the substance of his feedback is in column e
00:45:37 column e and he said this and i quote in general i believe a subject matter is important as high-rise firefighting deserves a separate policy for commercial and residential i find the current and draft policy
00:45:48 i find the current and draft policy leaves a lot of questions unanswered especially concerning reconnaissance and where to set into if fire spreads to another floor it is good for identifying hazards but
00:45:59 it is good for identifying hazards but does not give guidance on how to deal with them
00:46:02 with them is good for dealing with a fully developed fire contained to one compartment flat without savable life involved
00:46:09 involved however it is flawed for a small fire due to a delayed attack leading to fire growth is also flawed if fire spreads beyond compartment and floor without the aid of a controlled dividing breaching
00:46:21 aid of a controlled dividing breaching has this policy been tested practically i'm in the process of organizing a combined high-rise exercise if you would like to utilize this exercise to check the robustness of the policy i would be
00:46:32 the robustness of the policy i would be happy to accommodate now the response to that feedback is set out in column f and states reg r e j which presumably means rejected is that right
00:46:44 means rejected is that right uh
00:46:45 uh yes and if we look to column g i think that's the the rationale for rejection which says this the national gra does
00:46:56 which says this the national gra does not distinguish between commercial and residential having two policies would add confusion also which would you use at a multi-use building we're working on a policy called operational risk assessment it is
00:47:08 called operational risk assessment it is like the current dra policy except it allows for operational discretion whereby you may deal with a small incident as you describe breachings are being looked into
00:47:19 being looked into do you know who rejected mr button's view i don't for sure i
00:47:29 i don't actually recall being privy to this document certainly at the time but i think i've seen it in my preparation for this but i don't think i saw it at the time
00:47:42 don't think i saw it at the time if it helps the inquiry i'm happy to pick up on some of the issues that mr button raised not necessarily it's really what i want to do is
00:47:50 to do is to find out whether you were aware of this at the time and it appears that you were not no not not in not in any uh detail no i don't believe that was now one point i would like to have the
00:48:01 one point i would like to have the benefit of your assistance on is this the point he makes about the policy identifying hazards but not giving guidance on how to tackle those hazards
00:48:12 guidance on how to tackle those hazards would you accept that's the legitimate criticism of the policy
00:48:18 no why
00:48:20 why uh
00:48:21 uh because because i believe that the policy did provide guidance to deal with all of the identified hazards i think that's demonstrated clearly in the risk
00:48:32 demonstrated clearly in the risk assessment because for every hazard we set out the the applicable control measures i
00:48:41 i you know i don't wish to dispute what mr button says he's entitled to his view i think it's important inquiry realize that sometimes firefighters can be quite challenging people and they enjoy
00:48:55 quite challenging people and they enjoy tipping a wink at things like this and so some of these comments they look very serious and profound they may not be i'm not saying that mr button was was was doing that on this occasion but
00:49:07 was was doing that on this occasion but i i don't accept that the policy didn't provide guidance i think it did provide adequate guidance to pick up on his point about flexibility that was
00:49:18 that was one of the driving forces for discretion the problem with procedurally setting out that flexibility and i know exactly what he means and it's kind of i know you've
00:49:31 means and it's kind of i know you've received evidence from dr grimwood and and kent's approach to reconnaissance the the issues there for me are that you've always got to strike a balance we'll be coming on don't oh okay
00:49:42 balance we'll be coming on don't oh okay we're coming on to dr grimwig so don't worry but if we can just look at matters first of all that mr button was raising hasn't he hit upon something here that 633
00:49:53 that 633 it identified the need to carry out an evacuation in certain circumstances but it didn't give any or any detailed guidance to an incident commander as to how to go about conducting that
00:50:04 how to go about conducting that evacuation or conducting it safely i would accept that but as i've said previously
00:50:14 it was a blind spot but when such guidance is provided it shouldn't be provided in a high-rise policy it should be provided in an evacuation policy
00:50:26 evacuation policy and i know london fire brigade has now created such a document and indeed shared it with the british fire service nationally so so that to me is the right approach i completely accept your point
00:50:37 approach i completely accept your point but
00:50:38 but one of the one of the other criticisms that policy writers face is trying to be all things to all people and creating documents that become mr button might have accused us of being too too wordy
00:50:51 have accused us of being too too wordy there's too much information here you know people have only got a finite capacity so you've always got to strike that balance
00:51:01 did mr button's comments trigger any further discussion that was escalated to you at the time no can we now turn to the training commissioning process and the net that
00:51:12 commissioning process and the net that appears to be the next stage um that was started in relation to policy 633 if we go back to your third witness statement at
00:51:21 at double zero double one nine eight four nine forward slash nine nine
00:51:32 and if we look at paragraph 228 at the bottom of that page in the first sentence
00:51:37 sentence you say there which you repeated yesterday in evidence that you weren't directly involved in the the training commissioning process and therefore cannot speak to it in any detail however you've helpfully provided
00:51:48 detail however you've helpfully provided a number of documents and i'd like to ask you about the content of some of those the extent to which you're able reliably to assist the inquiry now you refer in this paragraph
00:51:59 now you refer in this paragraph to patrick arting's email to bjchsw that's the brigade joint council for health and safety at work and work now that email is dated the 19th of february
00:52:10 that email is dated the 19th of february 2015 and it can be found at lfb 0074798
00:52:26 there we go thank you
00:52:32 now in relation to that email sent on the 19th of february 2015 it's right that uh gre had been published for just over a year by that stage is that right
00:52:44 correct and also it'd been uh nearest uh
00:52:49 uh nearly a year or something more than a year since the views of the operational sounding board had been sought as well isn't it correct can you help us as to why it's taken the
00:53:00 can you help us as to why it's taken the lfb until february 2015 to reach this stage in their own internal process for developing policy 633
00:53:09 sorry
00:53:12 not in any detail i'm afraid uh i can't really explain that is that something for mr rutten i think mr attend would be better place to answer it
00:53:23 answer it were any concerns raised with you between february 14 and february 15 that insufficient progress was being made in terms of rollout of training to support
00:53:34 terms of rollout of training to support the new 633 or the anticipated 633 no but i think it's helpful to remember that many of the lessons that were
00:53:47 that many of the lessons that were incorporated in gra 3.2 were in fact incorporated in the 633 that had been published in 2011 so the gap
00:53:58 so the gap between
00:54:00 between the document that was available at that time and this document was less than the gap that the gra would identify would suggest if that makes sense i'm not denying there was a gap
00:54:12 denying there was a gap and and that you know in an ideal world we would have published
00:54:17 published uh sooner and i and to answer your particular question i can't explain right here and now why we didn't submit it for consultation until uh february there was sometimes an
00:54:31 until uh february there was sometimes an issue with the the amount of documentation that bjc hsw was dealing with so there may have been an element of smoothing out the workflow
00:54:44 smoothing out the workflow this was also a difficult period industrial industrial relations wise and there may have been a question of timing i think
00:54:55 timing i think one of the things as it alludes to in the email
00:54:58 the email is that we wanted to go to the trade union
00:55:02 union with the
00:55:03 with the enhanced predetermined attendance in place
00:55:07 place because i i certainly anticipated if i had been the trade union official i would have been asking about the resources
00:55:14 resources to cope with the additional hazards so that may be one of the explanations thank you now one of the documents which uh mr utting attached to this email was
00:55:25 uh mr utting attached to this email was the tcap form for policy 633 and can we go to that which is a lfb treble zero five one six four eight
00:55:38 now this form it's sent and to the training department by the commissioning department isn't it correct and as we discussed yesterday that marks the beginning of what's described as a dialogue between
00:55:50 what's described as a dialogue between the commissioning department and the training department and ultimately babcock as the training provider is that right
00:55:56 right correct
00:55:58 correct that just for the inquiries benefit the training department at this point it's not a training department in the conventional sense we've heard evidence mr greg don't worry
00:56:10 we've heard evidence mr greg don't worry about that they're just facilitating a process yes now we see that patrick garcia was forwarding the tcap form to the brigade joint council just for
00:56:21 just for apologies for dipping into unduly formalistic matters but that step did not start the tcap process did it no no because it's the submission to the training department's
00:56:32 submission to the training department's the key step isn't it to initiating matters
00:56:35 matters do you know whether the tcap form was ever submitted to the training department i believe it yes i believe it was and what are the reasons why you believe
00:56:48 what are the reasons why you believe that it was submitted to the training department
00:56:52 my recollection is that we have submitted email correspondence to confirm that well we'll come on to this because it's not quite as clear as that but it may well be these matters
00:57:04 that but it may well be these matters are outside your direct knowledge and i wouldn't want you to invite you to speculate yeah i i certainly as i've already explained i was not involved in the detail of the tcap so i think mr hutton
00:57:17 tcap so i think mr hutton would be okay the right person to answer any detailed questions let's just go through this and see what you can properly help the panel with i'll help i can if we can go to page six in the
00:57:28 can if we can go to page six in the third box and it's uh the one that identifies the client
00:57:35 and we see that's 1.3 you are identified as the client in your capacity as head of operational procedures is that right uh
00:57:43 uh yes
00:57:46 would you have seen this tcap form before it was submitted
00:57:52 uh not necessarily uh
00:57:56 uh it may well be that kevin hughes as the dic
00:58:00 dic would have seen it i i wouldn't necessarily have uh remember seeing this before says i don't know can we look at page 10
00:58:18 and we see question 4.1 which asks what do you want this training to achieve that is directed to be completed by the commissioning officer now that officer
00:58:30 commissioning officer now that officer is patrick gutting is that right correct now if we can look at the text under question 4.1 it reads as follows staff will be able to explain the hazards associated with
00:58:42 explain the hazards associated with building height layout and design explain the hazards associated with fire behavior and development explain the hazards associated with firefighting and rescue operations
00:58:54 firefighting and rescue operations describe the firefighting facilities and fixed installations available explain the need for planning describe the process of securing water supplies describe the process of
00:59:05 supplies describe the process of securing and using a firefighting lift explain the process of establishing a bridge head and fire sector list the items of equipment to be taken
00:59:16 list the items of equipment to be taken to a bridge head explain the safe systems of work that need to be in place in order to be able to send high-rise implemented message describe control measures when committing crews
00:59:27 committing crews undertaking search and rescue evacuation fire survival guidance and ventilation list the considerations when undertaking a 7-2 d visit
00:59:39 a 7-2 d visit demonstrate where possible applying high-rise procedure now having gone through that list uh
00:59:50 uh i'm assuming you will agree that there is nothing there to indicate that instant commanders should be able to know when and how to evacuate a building with a state policy would you agree with that proposition
01:00:03 that proposition i would agree that it's not stated explicitly but
01:00:07 but i would equally suggest that as part of the second bullet from the sorry third bullet from the bottom
01:00:18 bullet from the bottom the describing control measures there would be greater detail than this provided in this basic summary in terms of how do you initiate and
01:00:29 in terms of how do you initiate and manage an evacuation but in light of lachnal
01:00:33 lachnal in light of the evidence that come out at lachna on the coroner's recommendations would you agree that it was a fundamental omission not to expressly provide in this document which was intended to
01:00:45 in this document which was intended to learn and apply the lessons of lachnal the instant incident commander should be able to know when and how to evacuate a building with a state put policy i do indeed accept that
01:00:57 i do indeed accept that the point i think i was trying to make perhaps a little bit clumsily was that there may well have been and i would have expected there to be considerably more detailed discussion around these
01:01:08 around these quite basic points these are navigation points through through the policy that that's not to say uh that that when this was discussed in in detail i would have expected that to
01:01:19 in detail i would have expected that to have been at each point to have been fleshed out and because i wasn't privy to those discussions i can't really comment on the extent to which that happened but but that's my
01:01:30 which that happened but but that's my expectation now the inquiry the rest of the tcap form is largely blank a completed version has not been found by the inquiry in lfb's disclosure we've seen
01:01:43 inquiry in lfb's disclosure we've seen no record or minutes of meetings about the progress of this tcap and there is no indication in the documents that a tcap working group was in fact established do you think
01:01:54 do you think if those matters are right that it's likely to mean that the tcap form was never submitted to the training department it's certainly possible uh
01:02:04 uh again i wouldn't want to speculate on an issue that i've got no detailed knowledge of but does it follow therefore that no training process was ever instigated
01:02:15 no training process was ever instigated in relation to the 2015 version of policy 633
01:02:22 again i i certainly don't know whether that's the case or not and if i was to comment on that it would be speculation but ultimately didn't the burden lie with your department as the
01:02:33 with your department as the commissioning department with responsibility for 633 to ensure that the supporting training program was in fact implemented yes and ultimately your responsibility
01:02:44 responsibility yes and i wouldn't seek to walk away from that
01:02:47 from that at all
01:02:48 at all but
01:02:49 but if i look at the timing of this and knowing how long training commissioning processes tended to extend
01:02:59 to extend when when do we think this was submitted to
01:03:02 to training and development well it it's not entirely clear we've got the email from mr utting which attached it which was dated the 19th of february 2015
01:03:13 february 2015 right and that's when he submitted it to the brigade joint uh council or joint committee
01:03:19 committee no but that's not necessarily when it was submitted well we know that yeah that's all we know that's the problem so
01:03:27 so so again knowing the way the process works i i'm until the
01:03:36 until the document sorry until the policy was agreed which i believe was shortly before publication i.e in and around june 2015
01:03:49 in and around june 2015 the tcap would not have been certainly would not have been initiated because there was a resistance and a reluctance on babcock's partner and i understood the reasons for this
01:04:01 and i understood the reasons for this to not start work on on documentation that wasn't agreed so obviously when the document went into bjc hsw there was always the possibility
01:04:12 bjc hsw there was always the possibility that would result in amendments so
01:04:15 so the
01:04:16 the training commissioning process would would likely have started post june
01:04:22 june 2015.
01:04:24 2015. but these aren't matters you can directly speak to but i can't th this is me trying to be helpful and set out a timeline for you thank you but we have to be careful just to i accept that allow you to speak to
01:04:35 i accept that allow you to speak to facts you can speak directly to in that case i i can't help you any further can we now turn to the risk assessment for policy 633 that was also attached to mr hutting's email of 19th of february 2015.
01:04:47 email of 19th of february 2015. we can find the risk assessment at lfb trouble 0-30368
01:04:58 now the essential purpose of the risk assessment is to inform the content of the new or amended policy is that a fair summary
01:05:06 summary correct
01:05:07 correct does the risk assessment also inform the training consequences that are needed to support the new or amended policy
01:05:16 i think it's fair to say that the predominant influence on the training is the policy rather than the risk assessment what one of the things more globally not not specifically about high rise that i
01:05:28 not specifically about high rise that i was
01:05:29 was keen to see happen is that babcock and the people designing the training were fully cited on the risk assessment as well as the policy because in some senses the risk
01:05:41 because in some senses the risk assessment provides great greater clarity of the actions and considerations in terms of what we call control measures than the policy does so i i for me it
01:05:55 than the policy does so i i for me it made sense to involve both documents in in the training design and development thank you do you remember seeing the risk assessment at the time it was compiled and it's dated the 19th of february 2015.
01:06:09 dated the 19th of february 2015. i i quite possibly had sight of it but as as i've said previously the detail of this
01:06:16 this was was largely being managed at the level of jimmy call with possibly more oversight from kevin hughes so yes i may have seen it but i don't believe i
01:06:27 i may have seen it but i don't believe i paid any
01:06:28 paid any close attention to it now if we turn over to page two
01:06:35 you see at the top there as i've just put to you that the date of its issue is the 19th of february 2015 so
01:06:42 so the same date as mr utting's email now you can take the following from me there is no reference here in this document to the need for instant
01:06:53 document to the need for instant commanders to know when and how to implement an evacuation in a building with a state policy secondly there is no reference to the need to re-evaluate the advice being given to fsg callers and the potential
01:07:05 given to fsg callers and the potential need to change the advice being given depending upon circumstances and thirdly there is no reference the need for contingency plans in the event of fire spread beyond the compartment of
01:07:16 of fire spread beyond the compartment of origin
01:07:17 origin can you help us why those important aspects of 633 and they
01:07:24 and they were not referred to in this risk assessment so if i take that list in reverse order of course
01:07:32 of course the
01:07:33 the the third element the contingency planning i think you'll find there is a reference to planning and i think
01:07:44 and i think if it helps the inquiry the the way in which control measures are described in a risk assessment given the very limited space on the page is a very much a shorthand
01:07:55 shorthand approach so if it says planning and i think you'll find it does or it certainly should do planning would cover contingency planning so that i think is my answer to
01:08:08 planning so that i think is my answer to the third point even though it were it was an express point that had been raised at lachnal it wasn't given express reference in the risk assessment do you accept that i i
01:08:21 risk assessment do you accept that i i do accept that but i don't i don't necessarily accept that that's the deficiency that's inferred from the way you put that question but you say it's generically covered by planning yes
01:08:31 yes the second point take taking reverse order
01:08:34 order there's no express reference the need to reevaluate evidence being given to fsg callers and the potential need to change that advice similarly
01:08:44 similarly it and i think you'll find there is reference in there to fire survival guidance procedure and or evacuation the same shorthand approach
01:08:55 evacuation the same shorthand approach would be
01:08:57 would be a reasonable thing in a risk assessment because the risk assessment isn't trying to set out the detail it's merely rehearsing in a fairly brief way the control
01:09:08 in a fairly brief way the control measures that either should be applied or should be considered for the hazard that's being addressed and you'd give the same answer presumably in relation to the first absence of an express reference namely
01:09:21 absence of an express reference namely to the need for instant commanders to know when and how to implement an evacuation in a building with a state put policy yes and those two absences were notwithstanding their prominence and the
01:09:33 notwithstanding their prominence and the subject of recommendations at latino
01:09:37 no but at the risk of repeating myself the risk assessment wouldn't be the place i'd expect that prominence to be provided
01:09:47 provided can we now turn to the publication of pn 633 in june 2015 can you help us as to what was happening to the policy between february 2015 and june 2015 or is that a
01:10:01 february 2015 and june 2015 or is that a matter we should take up with mr artem it is
01:10:08 it was in bjc hsw so it was subject to consultation i i you wouldn't be able to publish it we wouldn't publish a policy
01:10:20 wouldn't publish a policy other than in exceptional circumstances without that formal consultation period closing
01:10:29 policies being in bjc hsw for a period of months sometimes many months was sadly
01:10:37 was sadly the common experience at that time and that reflected those poor industrial relations and that lack of
01:10:46 of trust and and what was quite a difficult environment in which to make good progress so i know looking at it now and all the work that had happened
01:10:57 and all the work that had happened previously it it seems strange that it would take that long but that's why but in some ways the i think it was only a period of three or four months that that actually was quite quick
01:11:08 actually was quite quick now you say in your third witness statement
01:11:11 statement paragraph 270 which can be found at lfb double zero double one nine eight four nine forward slash one one four
01:11:22 one four but the aim of the communication strategy was to explain the key changes in the revised version of 633 in the june 2015 edition of operational news
01:11:33 june 2015 edition of operational news what other measures apart from publication in operational news were implemented to publicize the new 633 and in particular to highlight the relevant
01:11:44 in particular to highlight the relevant changes
01:11:45 changes i i think it went on what was called hotwire which is the brigade's intranet site so
01:11:52 site so i believe there was a short piece on hotwire with a link to the policy but the main method of communicating a new policy to staff would be
01:12:03 a new policy to staff would be operational news could we look briefly at the addition of operational news that you exhibited to your third statement and this can be found at lfb-00102558
01:12:24 and if we can turn to page two
01:12:33 and if we can see the subheading at the bottom of the left column
01:12:38 column high rise firefighting is that the section to which you were referring in your statement uh i believe so yes
01:12:48 no to ri
01:12:52 to ri there is no reference there to the revised version of 633 having been published
01:12:58 published would you accept that
01:13:03 okay can we look at the date that this was actually on the front it's june 2015.
01:13:09 2015. okay
01:13:12 and that page you just showed me is there anything is there anything on the back
01:13:16 back sometimes
01:13:19 sometimes it might be on the reference section of the matrix table back page
01:13:24 back page i can't they're only about four or five pages long on there i think generally yeah
01:13:30 yeah there you are summer season
01:13:34 633 at the top and that's where firefighters would be directed to have a look at with it yes yeah as it says in the box at the top amber represents training themes that
01:13:46 amber represents training themes that are mandatory so although it's not mentioned in the substance of the article it's it's mentioned there the personnel would be directed towards that yes and i believe the
01:13:58 believe the stars
01:14:00 stars personnel application would the training element of that would would upload would reflect that
01:14:08 requirement to undertake that training and that would then trigger watch managers on others to to deliver it and so it wouldn't be operational news that would for example highlight
01:14:19 news that would for example highlight relevant changes in a new policy it would be the subsequent training with it
01:14:25 it certainly in detail ops news was you it was more of a magazine it was meant to be conversational informal it often gave a flavor
01:14:35 flavor of of those changes which i think the article probably did try to do how successfully i'm not so sure but it you know it was giving a flavor of the changes it
01:14:47 giving a flavor of the changes it wouldn't be a an exclusive and full list of those changes that clearly would be for the training package and indeed you know for people to read the policy
01:15:02 you question you adverted there to doubts as to how successfully the article achieved the aim
01:15:10 i didn't intend to to cast out on on the article i just recognized that it may not have been a full explanation of what the changes
01:15:21 of what the changes were provided by the policy it doesn't indicate though looking at that top box that it's a revised policy does it
01:15:31 it doesn't no
01:15:39 so again you're dependent upon the training package communicating the fact it's revised and the relevant changes contained in that revision
01:15:49 yeah i'm just trying to think whether any other communication
01:15:55 would make that explicit point that this is a new version of 633 it would be apparent for anyone reading it it would be apparent from the first page because the the date
01:16:06 from the first page because the the date would make that apparent but i i fully accept that's that's not as acceptable as as making a clear statement and i can't truly answer that but the panel will make of the article
01:16:18 but the panel will make of the article what they make of course um can i now turn to uh the meeting you had with dr grimwood in respect of his rice model yes
01:16:30 rice model yes now we've heard evidence from dr grimwood about the development of his rice model at kent in short
01:16:38 in short to remind
01:16:39 to remind those listening that the rice model is a command decision-making tool that prompts commanders to consider the possibility of evacuation as one of four key strategies
01:16:50 key strategies that may be implemented in any order when formulating an operational plan at a high rise fire first of all are you familiar with the the substance of dr grimwood's rice model
01:17:02 model i am as a result of preparing for this inquiry but not at the time i wasn't at all familiar with it at the time as a result of your more recent
01:17:15 as a result of your more recent knowledge of it would you agree that a core premise of the model is that it cannot be assumed that compartmentation will subsist hence the potential need to consider evacuation as a priority and potentially
01:17:27 evacuation as a priority and potentially as the first operational step to be taken in the case of a high rise fire that is indeed my understanding of it yes
01:17:34 yes now dr grimwood gave evidence of a collaborative task and finish group that was set up in 2011 and which included nine fire and rescue services from the southeast of england
01:17:47 services from the southeast of england that group jointly created a standard operating procedure that was largely based on dr grimwood's work in kent now the inquiry understands that the lfb
01:17:58 now the inquiry understands that the lfb was not part of that regional task and finnish group is that a correct understanding absolutely do you know why london wasn't part of that group because
01:18:09 that group because that group was based on the seafarer regions that existed at that time and london's a separate region and london wasn't part of the south east
01:18:20 london wasn't part of the south east dr grumwood said that a meeting was set up in september 2011 between yourself and a number of representatives from the task group to discuss how their work might align with the work
01:18:32 their work might align with the work that you were then carrying out on gra 3.2
01:18:36 3.2 first of all do you remember the fact of the meeting i do but i think dr grimwood was incorrect in the date i actually think it was in fact i'm very confident it was december
01:18:47 december 2011.
01:18:50 2011. does much turn on a discrepancy between september and december now i'm just trying to be accurate
01:18:58 now dr grimwood said that at the meeting he discussed stairwell protection strategies and the rise concept with you first of all does that accord with your recollection no my characterization of that meeting
01:19:11 my characterization of that meeting would be very different to dr grimwood's now first of all let's take it step by step do you remember what was discussed
01:19:19 the first thing i i think it would help the inquiry to to appreciate is i did not attend the whole meeting and it wasn't a meeting between myself and dr grimwood
01:19:31 a meeting between myself and dr grimwood it was a meeting of that group there were
01:19:35 were 20
01:19:36 20 people in that group it was chaired by somebody called david carson who i believe was east sussex fire service did you join at the beginning middle or end
01:19:47 beginning middle or end absolutely i joined at the beginning and the primary purpose of me attending that meeting was to update the group on what was happening with the gra
01:20:00 on what was happening with the gra to explain some of the changes that would already start to make in relation to lachenal and
01:20:07 and probably most importantly to encourage them to contribute to the gra through the consultation process so i think i was there
01:20:20 process so i think i was there for
01:20:21 for an hour
01:20:23 an hour uh possibly a little bit longer and and my recollection is that i left at the conclusion of my item on the agenda because i wasn't part of the
01:20:34 agenda because i wasn't part of the group i was a visitor and
01:20:37 and i had no
01:20:39 i had no role in the business of the group generally now do do you remember whether you discussed the evacuation element of the rice model i don't recall
01:20:51 i don't recall discussing the rice model at all
01:20:55 and let me qualify that slightly it's perfectly possible the term was used as indeed the term stairwell protection may have been used but there was
01:21:07 may have been used but there was i'm very sure there was no detailed discussion so i would not have come away from that meeting
01:21:15 meeting with any
01:21:17 with any clear understanding of those concepts would it follow from that therefore that you had insufficient knowledge of the detail to form a considered view of the
01:21:30 detail to form a considered view of the merits and disadvantages of the rice model
01:21:33 model i didn't form of you consider or otherwise because i didn't nobody put them to me again if it helps the inquiry my clear recollection
01:21:44 recollection is that dr grimwood himself made few if any contributions to the discussion uh that's my clear recollection
01:21:59 was there any discussion at this meeting first of all of the potential incorporation of dr grimwood strategies either into the gra
01:22:10 grimwood strategies either into the gra or into 633 no
01:22:16 was there any discussion of that potential after this meeting between you and mr grimwood or indeed anyone else no but i think it would help the inquiry if if i explain because this is i i
01:22:30 if if i explain because this is i i fully recognize this is this is quite significant i'm very clear that through the two rounds of formal consultation which is where i would have expected
01:22:41 where i would have expected those ideas to be brought forward we did not receive any substantive response
01:22:48 response from either kent fire rescue service or the southeast region what i do know we received was an email from the chair
01:23:00 was an email from the chair of that task and finished group david carson
01:23:04 carson and i it's a very short response that says we're basically happy with the gra as we've seen it it raises two issues
01:23:15 it raises two issues one relating to the use of five fighting lifts
01:23:19 lifts and one
01:23:20 and one relating
01:23:21 relating to
01:23:22 to the terminology the command terminology used for the bridgehead i think at the point
01:23:29 point of that meeting or shortly after we were using the term bridgehead commander
01:23:36 commander that was out of step with the national incident command system and we'd have subsequently adopted the term fire sector commander as as would be appropriate they were the two issues he
01:23:49 appropriate they were the two issues he raised i think that email has been provided to the inquiry and beyond that we had no
01:23:58 we had no response from either kent fire rescue service or the region did you receive anything from kent after gra 3.2 was published in february 2014
01:24:09 gra 3.2 was published in february 2014 no thank you can i now turn to a series of discrete topics
01:24:14 topics and hopefully deal with them briefly um when you were preparing gra 3.2 was the learning from previous cladding fires in high-rise residential buildings i think if garnet court
01:24:27 i think if garnet court etc ever collected for you to review for the purpose of identifying cladding as a hazard and what the appropriate control measures might be no
01:24:38 are you able to explain why that wasn't collated for you or indeed why you didn't ask for it i've got to say when you say collated for me that presumes i had this big team of
01:24:49 that presumes i had this big team of people
01:24:50 people mr morton going off mr morton was very good but he wasn't a big team uh i think it goes back to what i said previously which is that we
01:25:02 previously which is that we we simply did not understand that cladding as a material presented the hazard that it so clearly does and and beyond that
01:25:15 and and beyond that nobody raised it during the consultation
01:25:20 so we had no reason to go searching and researching a topic that we didn't we weren't aware of and didn't understand the significance of and and i repeat that nobody regrets
01:25:33 and and i repeat that nobody regrets that
01:25:34 that more than me but it's a simple fact of where we were at that time that myself and others had no understanding
01:25:46 myself and others had no understanding and i don't deny material was available you showed me material yesterday but the people i would have expected to draw my attention to that for whatever reason that that didn't
01:25:59 for whatever reason that that didn't happen
01:26:00 happen thank you can we turn on to a separate topic which is knowledge of gra 3.2 within the lfb itself now did you expect gra 3.2 to be studied by instant commanders bearing in mind
01:26:13 by instant commanders bearing in mind that watch manager michael dowden had not and both commissioner cotton and now commissioner rowe thought it wasn't necessary i wouldn't er i would entirely agree
01:26:25 i wouldn't er i would entirely agree that the gra it's very clear in it in its scope it's provided for fire rescue services to inform their local risk assessment
01:26:36 to inform their local risk assessment and policy writing functions that's not to say individual firefighters can't look at it i know it's included as a reference and
01:26:49 i know it's included as a reference and that's what i was going to pick in 633 and i would respectfully suggest to the inquiry that that was a mistake well can can i stop you then just if we
01:27:00 well can can i stop you then just if we can get the document up so everyone can see what it says if we go to lfb quadruple zero one two five six forward slash one seven and it's section eight i think you're
01:27:11 and it's section eight i think you're referring to there it is
01:27:15 look at the very bottom and if we
01:27:19 these are references following policies are relevant to should be read in conjunction with this policy we see four set out there and if we can turn over the page we see the very last bullet point is jra
01:27:31 we see the very last bullet point is jra at 3.2
01:27:33 at 3.2 first of all why was that reference included in the first place i don't want to speculate but i'm guessing pat hutting included it
01:27:44 but i'm guessing pat hutting included it to be helpful because because it had loomed so large in this process i think if he'd put that one line below with a header that said for further
01:27:56 with a header that said for further information can
01:27:59 can you know access this document that would have been
01:28:02 have been entirely appropriate because there are many firefighters that want to know more and want to understand background detail and we would always encourage them in that context to look at
01:28:15 in that context to look at gra's and other national guidance direct i think that's a very healthy positive thing
01:28:21 thing but to be clear to do your job to
01:28:25 to carry out the role of a firefighter or an incident commander the doc the information you need is is contained within local policy but
01:28:34 but would you accept as phrased up reader is specifically directed let me finish is specifically directed to gra 3.2 indeed i do accept that
01:28:49 sir
01:28:52 i have now come to the end of my questions which conveniently almost chimes almost with the morning break might i suggest subject to your approval we rise now until say 25 past 11. yes
01:29:07 we rise now until say 25 past 11. yes right well when council gets the end of his questions or thinks he has we always have a break to enable him to review the position and also to enable other people to suggest questions which perhaps we should put to
01:29:19 questions which perhaps we should put to you and and it's a convenient point anyway to have a break for the morning so we'll rise now we'll come back at 25 past 11
01:29:28 past 11 and we'll see then if there are any more questions for you okay all right thank you very much would you give the usher please
01:29:46 uh mr kenya if it turns out it sometimes does that a bit more times required you just let the usher tell us thank you
01:45:14 would you ask mr carp to come back in please
01:45:30 all right mr cobb well we'll see if there are any more questions for you mr canoe thanks sir mr kerp i'm pleased to tell you there are no further questions for you all it leaves me to say is say thank you very much for pretending to
01:45:41 thank you very much for pretending to give evidence over these past three days it's very much appreciated so thank you thank you and it's right mr carp that i should thank you very much on behalf of all three of us on the panel here you've
01:45:52 all three of us on the panel here you've given us a lot of your time you've answered a lot of questions quite penetrating questions and
01:45:58 and we're really very grateful to you for coming along to tell us what you're able to
01:46:04 to tell us about the matters we've been hearing about so thank you very much indeed did you want to say something i would like to so if that's possible yes chris firstly it's it's been a privilege to be
01:46:15 firstly it's it's been a privilege to be part of the inquiry i i very much hope that some of what i've said
01:46:21 i've said is of benefit and and that the lessons that
01:46:24 that should and must be learned from this tragedy
01:46:27 tragedy are allowed to come through i really sincerely believe that i'd also like to take this opportunity to thank you and your team
01:46:33 your team for the way that i've been the manner in which i've been supported and assisted in the last few days it's much appreciated well thank you very much well as i say it really has been very helpful to us to
01:46:45 very helpful to us to hear what you've been able to tell us and we're very grateful to you happy to help and thank you very much and that's it now you're free to go and lets you get the usher thank you
01:47:07 no mr canelo where do we go next uh so that concludes the evidence for today we've investigated to see whether it's possible to bring forward witnesses um for a range of reasons that's not proved to be practical
01:47:19 to be practical um so you will hear from mr patrick utting who's been referred to several times in evidence over the past few days uh tomorrow morning starting at 10. thank you very much well in that case um we've made slightly
01:47:30 in that case um we've made slightly faster progress with mr garf i think that we did thought we might we did um we'll now rise for the day and we will sit again tomorrow at 10 o'clock
01:47:41 sit again tomorrow at 10 o'clock when we shall hear from mr hutting i'm grateful thank you thank you very much indeed 10 o'clock tomorrow then please
01:47:57 you