London Fire Brigade Evidence - Wednesday 6th October 2021 (1/2)

Full transcript

00:19:12 good morning everyone welcome to today's hearing

00:19:15 hearing today we're going to hear further evidence from a member of the london fire brigade yes mr clear who's your witness so with your permission may call david brown thank you

00:19:33 good morning mr brown good morning i gather you're going to make the affirmation yeah so the words are there on the screen if you'd read them out please

00:19:40 please i do solemnly sincerely and truly declare and affirm that the evidence i shall give shall be the truth the whole truth and nothing but the truth thank you very much now please sit down make yourself comfortable

00:20:00 all right yes thank you thank you very much yes mr cleo thanks sir good morning would you please confirm your name for the record david brown thank you mr brown thank you very much for attending to give evidence today um before we

00:20:11 to give evidence today um before we start just three pieces of advice i should give you at the outset um first of all if any of my questions are unclear or too long please say so the fault's mine and i'll shorten them or

00:20:22 fault's mine and i'll shorten them or clarify them secondly if you could keep your voice up that's so that the transcriber can capture everything you say and accurately and thirdly if at any stage you require a break please say so that's

00:20:34 you require a break please say so that's not a problem we will be having a break at about quarter past 11 in any event and then breaking for lunch now you have provided two statements to this inquiry is that right that's correct and the first one is date of the

00:20:46 correct and the first one is date of the 29th of january 2019 and we can find that at lfb treble zero 32166

00:20:56 and is that your first statement it is and if we go to page 25 is that your signature it is thank you um the second statement is dated the 16th of december 2019 and that can be

00:21:09 16th of december 2019 and that can be found at lfb trouble zero eight four zero two zero is that it that's correct and again if we can turn to page 25 in this statement

00:21:20 to page 25 in this statement is that your signature it is thank you um have you had the opportunity to read both those statements recently i have and can you confirm that the contents of each are true they are and are you happy to have those statements taken as your

00:21:32 to have those statements taken as your evidence to this inquiry yes i am thank you

00:21:35 you and i can take it that you have uh read and familiarize yourself with the exhibits to both of those statements yes i have thank you now the first part of your evidence today i'd like to discuss the roles and

00:21:47 today i'd like to discuss the roles and responsibilities you held uh most recently in your time at the london fire brigade

00:21:51 brigade um first of all am i right in understanding that you joined the lfb as a firefighter in 1985. that's correct and that over the next 20 years or so you held a number of positions

00:22:02 you held a number of positions progressing up the ranks until in july 2006

00:22:06 2006 you started in the temporary role of assistant commissioner that's correct and initially for service delivery but later in operational response is that right that's correct uh in june 2008 you were promoted to the

00:22:19 uh in june 2008 you were promoted to the permanent post of assistant commissioner for service delivery north east and northwest areas and mobilizing is that right that's correct now if we can go to

00:22:30 now if we can go to your first witness statement lfb trouble zero three two one double six forward slash three

00:22:40 paragraph six you say here this my primary responsibilities in the role of ac service delivery northeast and northwest areas and mobilizing were to

00:22:51 northwest areas and mobilizing were to take a strategic overview of the planning direction and delivery of lfb's operational service to londoners in the north east and northwest areas and the mobilizing service to the whole of

00:23:02 mobilizing service to the whole of london

00:23:03 london in that role i reported to the deputy commissioner which was roy bishop until october 2009 and then rita dexter until the 31st of march 2015.

00:23:14 the 31st of march 2015. now in that particular role were you responsible for managing all of the lfb's fire stations in the north east and northwest areas yes so london was split into four

00:23:25 yes so london was split into four areas north east north west south east south west so basically the north of london

00:23:31 london broadly defined by the river thames thank you and did that role include responsibility for overseeing the planning direction and delivery of section 72d visits specifically it did

00:23:42 section 72d visits specifically it did yes

00:23:43 yes and the management of operational risk information in the northeast and northwest areas of london in terms of uh collection and application yes and for those who may not be familiar

00:23:55 and for those who may not be familiar with those terms first of all section 72d

00:23:58 72d relates the lfb's duty to obtain information for the purposes of extinguishing fires and protecting life and property in the event of a fire in the area and visits to premises were the means by which the lfb primarily

00:24:10 means by which the lfb primarily gathered that information that's correct and in relation to the phrase management of operational risk that describes the lfb's procedures and systems to collect manage and use the information at

00:24:21 manage and use the information at operational instance is that a fair summary end in training yes thank you did your role as ac service delivery and mobilizing have a counterpart namely ac service

00:24:32 have a counterpart namely ac service delivery for the southeast and southwest areas uh yes it did and in the four years i was doing that role there was there was four separate colleagues that undertook that role at various times it was andy

00:24:44 role at various times it was andy barrett one of those individuals he was yes

00:24:47 yes and was andy barrett responsible for managing the lfb stations south of the river yes

00:24:53 river yes although separately responsible for your individual areas would you and ac barrett collaborate on london wide service delivery yes we had offices next door to each other and we met daily

00:25:05 other and we met daily and would that collaboration extend to matters relating to section 72d visits and the management of operational risk information yes now in october 2010 is it right that you

00:25:18 now in october 2010 is it right that you were given the additional role of third officer that's correct now if we can go back to your first witness statement which is on the screen in paragraph eight which is on page four

00:25:32 now here you describe what being the third officer involved and you say this my primary responsibility in the role of third officer was to provide

00:25:43 third officer was to provide brigade-wide operational cover the commissioner the director of operational resilience and training and the third officer provided brigade-wide operational cover between them for major or serious incidents 24 hours a day

00:25:56 or serious incidents 24 hours a day seven days a week and if we can go back to paragraph five at page three of this statement

00:26:06 you say in the final five or six lines of that paragraph this in june 2012 the role of ac service delivery northeast and northwest areas and mobilizing was disbanded and a single role was formed

00:26:18 disbanded and a single role was formed to consolidate responsibility for all four areas of north and south london mobilizing and community safety following that restructure the department was renamed operations

00:26:29 department was renamed operations prevention and response and i was the ac allocated to that department now did that role change mean that you became responsible for managing all of the lfb's fire stations across london

00:26:41 the lfb's fire stations across london from june 2012 onwards yes effectively the two ac roles were combined into a single role and so did it follow therefore the role included responsibility for overseeing

00:26:52 included responsibility for overseeing planning direction and delivery of section 72d visits for the whole of london yes now in april 2015 you started in the new position of director of operations into

00:27:04 position of director of operations into which your existing role and responsibilities as ac was subsumed is that a fair summary sorry can you repeat that again yes of course in april 2015 uh you start in the

00:27:16 course in april 2015 uh you start in the new position of director of operations into which your existing responsibilities were subsumed does that affect yes yes it was because it was a role that involved the amalgamation of two

00:27:28 involved the amalgamation of two assistant commissioner roles it was accepted from the beginning that it was an extensive role and closer to the other director in when rita dexter left in 2015 that role

00:27:40 when rita dexter left in 2015 that role was

00:27:41 was elevated to that of director of operations and was miss dexter's departure the prompting for that particular restructuring yes um now if we can go back to your first

00:27:52 um now if we can go back to your first statement in paragraph nine on page four

00:27:57 uh you say this just flowing on from the answer you've given actually my primary responsibilities in the role of director of operations were to take a strategic overview of the planning direction and

00:28:08 overview of the planning direction and delivery of lfb's operational service the mobilizing service and the corporate regulatory and community safety service to the whole of london in that role i reported to the

00:28:19 in that role i reported to the commissioner which was ron dobson until the 31st of december 2016 and then danny cotton until my retirement on the 31st of march 2017. four heads of department reports to me

00:28:31 four heads of department reports to me head of fire stations dominic ellis head of fire safety neil orbell until march 2016 then dan daly head of central operations adrian fenton and head of control and mobilizing tom george

00:28:44 control and mobilizing tom george now in broad terms then the new director of operations role included your previous responsibilities as ac of operations preventions and response as well as the additional

00:28:57 response as well as the additional responsibility for corporate regulatory and community safety service is that a fair summary uh regulatory fire safety yes i i already had responsibility for community

00:29:08 already had responsibility for community safety

00:29:09 safety so community safety and regulatory fire safety were amalgamated into a single department and we just called it uh fire safety and presumably given the answers you've

00:29:20 and presumably given the answers you've given you remained responsible for managing all of the lfb's fire stations across london uh yes although the addition here was there was assistant commissioner put into that role specifically to manage

00:29:32 into that role specifically to manage fire stations and then i was in the director position overseeing that so ultimately response ultimately yes but in effect took one step back as a director thank you and were your

00:29:43 as a director thank you and were your responsibilities as third officer also subsumed into your role as director of operations yes if i can just explain briefly the third officer role was purely an operational role it wasn't a

00:29:54 purely an operational role it wasn't a managerial role of any way shape or form it was it was prompted by the fact that there needed to be three most senior officers at a strategic level and when roy bishop left

00:30:06 level and when roy bishop left and rita dexter to become deputy commissioner there were only two so it was the commissioner and the other director so needed a third person to manage the operational rotor and uh after an interview process i was

00:30:17 after an interview process i was successful in that so i took on the operational responsibility but it never made any change to the managerial role in any way shape or form but you continued in that position as third officer until your retirement in march

00:30:28 officer until your retirement in march 2017. yes because when i became director there was therefore naturally three positions at that level that were operational so there was no need for a third officer as such thank you now your

00:30:39 third officer as such thank you now your statement your first statement in particular identifies specific actions relating to 72d visits and operational pre-planning for which you are responsible now as we go through your evidence we'll discuss those in more

00:30:51 evidence we'll discuss those in more detail but i think probably be helpful to identify those responsibilities now so to provide context for later questions

00:30:58 questions now if we can stay in your first statement and go to paragraph 14 which is at the bottom of page five

00:31:07 now you say there and over the page that you were jointly responsible for lachnal house board action 21 is that right yes now the latino house board actions were

00:31:18 now the latino house board actions were actions identified by the brigade after the latino house fire but before the inquests is that right yeah they were 34 pre-inquest actions that we identified ourselves as a board and just for

00:31:31 ourselves as a board and just for context the latino house fire was in 2009 and the inquests were held in 2013 is that right that's correct now as we can see if we turn to page seven of your statement

00:31:43 and we see that in the last row of the table on page 7 a description of action 21

00:31:50 21 and it related as can be seen to the level of pre-planning at residential high-rise buildings and specifically the move to include line drawings showing individual flats the crews would prepare as part of 72d visits

00:32:03 prepare as part of 72d visits is that a fair summary yes now if we can go to page 9 of your first witness statement and paragraph 22. now there we see another table

00:32:15 now there we see another table which shows the action points that were overseen by elfipa's lachnal house working group which you are either the lead or joint lead is that right yes these were actions that we we

00:32:28 yes these were actions that we we formulated ourselves in order to meet the coroner's recommendations we'll come on to that in due course but just for anyone who doesn't um isn't familiar with the phrase elfipa was the london

00:32:39 with the phrase elfipa was the london fire and emergency planning authority yes

00:32:42 yes now as you intimated there sorry before i interrupted you these were post inquest actions is that right that's correct

00:32:48 correct and they're intended to discharge the recommendations made by the coroner following the inquests yes and they include if we see in the third row action two b b for bravo

00:33:00 row action two b b for bravo which is the creation of an inspection regime targeted at high priority buildings is that right yes and the third work stream of which you were responsible was post inquest actions

00:33:12 responsible was post inquest actions and if we see in the fifth row of this table

00:33:16 action 2 d d for delta which was to set corporate targets for 72d activities is that right yes now if we can go to

00:33:28 now if we can go to page 22 in this statement paragraph 72

00:33:37 you say there in relation to action 2b b for bravo

00:33:42 for bravo this i was the lead for the introduction of lfb policy 800 management of operational risk information the policy sets out the way in which risk was assessed and inspections prioritized now

00:33:54 assessed and inspections prioritized now if we can just go briefly to that policy which can be found at lfb treble zero eight three eight four nine

00:34:05 and if we amplify the top third we can see that the policy 800 deals with management of operational risk information it was first issued in july 2012

00:34:17 first issued in july 2012 and reviewed his current in august 2015 when did you start work as the lead in relation to policy 800

00:34:26 so uh policy 800 first of all just to add some clarity it continued you can see an old instruction number on there so it was a it was a continuation and updating

00:34:37 continuation and updating uh of of what was an existing policy and we did this as a result of lack of house i think it originally belonged to one of the operational policy departments

00:34:49 the operational policy departments but then after lack of a house it became apparent really that it was my staff

00:34:55 staff within fire stations that were ostensibly working towards this so i then took ownership of the policy around about uh late 2012 early 2013. so after it's the

00:35:11 late 2012 early 2013. so after it's the original issue yes now

00:35:15 now i hope i'm not over simplifying matters uh in this regard but were you effectively the brigade senior point man in relation to 72d visits and the management of operational risk information

00:35:27 information uh in terms of 72d visits yes

00:35:31 yes although there were a variety of other senior officers that were a key part of that

00:35:37 that in terms of operational risk information then collection and application but the

00:35:47 but the systems that were used to support that were very much within information management which was in strategy and performance because they owned the database and they they looked

00:35:58 owned the database and they they looked after administered and quality assured the database

00:36:05 but bearing in mind your responsibilities at this time bearing in mind that it was your firefighters who are having to implement this would you accept that you

00:36:17 implement this would you accept that you were perhaps the best place or most the senior place person within the lfb in terms of knowledge experience and position to influence and implement the brigade's operational risk management strategy

00:36:30 strategy certainly it's the case if if there were questions about the operational risk strategy

00:36:37 strategy then yes i will be the person that someone will primarily come to put differently with the buckland with you

00:36:44 you uh

00:36:47 uh again in terms of in terms of collection and application yes now can we turn on to the question of section 72d visits and if we can go back to your first

00:36:58 and if we can go back to your first statement uh lfb treble zero three two one double six forward slash 15 and paragraph 41 and 42. now there you say under the heading

00:37:10 now there you say under the heading pre-planning for residential high-rise fires you say this section 72-d of the fire and rescue services act 2004 places an obligation on lfb to obtain store and disseminate

00:37:21 on lfb to obtain store and disseminate information for the purpose of firefighting and protecting life and property the way in which the lfb discharged this duty was by conducting visits to property 72d visits and

00:37:32 visits to property 72d visits and storing the information collected on that operational risk database the ord there was an incentive for firefighters to complete some 2d visits and record accurate information as ultimately

00:37:44 accurate information as ultimately it would enhance their safe working practices

00:37:48 practices now apart from complying with the statutory obligation itself in your view or indeed the corporate view of the lfb was there any other purpose served by

00:37:59 was there any other purpose served by 72d visits

00:38:02 familiarization familiarization with buildings familiarization with station grounds and then there was the the ripple effect because the more familiar station-based staff i.e firefighters

00:38:14 station-based staff i.e firefighters would become with the station's ground the better they would get to know the community

00:38:18 community so

00:38:19 so the inquiry i'm sure is aware of the fact that we were massively moving into a prevention based role we'd always carried out prevention work

00:38:30 work but certainly we was massively up in our game in so much as trying to reach out to the community reach out to hard to reach people in the community and try to prevent them having fires

00:38:42 prevent them having fires but one just one quick anecdote we'd go to public meetings and we'd say to the public you know what do you want from the fire service and they would say to us we want a fire engine now as soon as we call it when there's a

00:38:55 now as soon as we call it when there's a fire and we just say well no it's not really what you want what you want is not to have a fire engineer at all so we want to work with you to prevent there being a fire so we was working really hard to try to prevent fires which was

00:39:06 hard to try to prevent fires which was one of the reasons when i became director of operations that we amalgamated community fire safety which is about prevention and regulatory fire safety which is about protection into one realm thank you now if we can

00:39:18 you now if we can turn

00:39:19 turn to policy 800 and particularly appendix 1 of policy 633 now first of all can we go to the revised version of policy 800 which can be found at lfb

00:39:30 be found at lfb 0083849

00:39:34 and as you see this is one we looked at earlier this was the version published in august 2015 has the title management of operational risk information

00:39:45 of operational risk information at the top now policy 800 governs the lfb's approach to the collection and dissemination of operational risk information information which is obtained via some 2d visits is that a fair summary

00:39:58 2d visits is that a fair summary uh yes september 17th d visits but it does also mention there are other ways of obtaining the information as well so although 72d visits was a key component to obtaining that information

00:40:10 to obtaining that information i think in section 72d visits you accepted earlier on they were the principle of primary means by which that information was collected is that a fair summary uh initially yes but then ongoing revisits then we would

00:40:23 but then ongoing revisits then we would try to use other strategies as well to make life

00:40:27 make life uh more efficient in terms of firefighters time we'll come on to other means of collating information in due course but for obvious reasons i want to concentrate on section 72d today

00:40:39 concentrate on section 72d today now i think i'm right in saying that this version of 800 is the version that was in force at the time you retired in march 2017

00:40:49 yes i believe it was it was a year cycle so if this was viewed as current in august 15 then one imagines the next review would have been in august 18 by which time i was retired and so would

00:41:00 which time i was retired and so would have been the policy enforced at the time of the grandfather i believe so now would you agree uh that policy 633 which concerned high-rise firefighting

00:41:11 which concerned high-rise firefighting and in particular appendix one were also relevant to information collected as part of section some 2d visits yes um now can we go to policy 633 which we

00:41:24 um now can we go to policy 633 which we considered in detail at phase one but it can be found at lfb quadruple zero one two five six

00:41:36 again this is the version as at june 2015 so presumably you accept it's the one that was in force at the time the grenfell fire and when you retired uh yes i believe so and this would be subject to the same three-year cycle as

00:41:48 subject to the same three-year cycle as policy 800 is yes that'd be right now

00:41:52 now having looked at uh 633 if we just briefly go back to 800 which is lfb travel zero eight three eight four nine let me go to page two

00:42:07 now you'll see at the very bottom of the page i suspect this is well familiar to you in section three it sets out five stages of

00:42:17 of really designed for the identification and assessment of risk and if we just briefly go through those as providing context for the sort of next questions first of all stage one is the

00:42:28 first of all stage one is the identification of premises that might potentially give rise to hazards and risks

00:42:33 risks stage two is the initial site analysis and the guidance asks does this site does the site require a visit stage three is information gathering a detailed examination the site where

00:42:44 detailed examination the site where risks identified on the premises risk assessment the pra sheet can be verified if we go over the page stage 4 risk assessments using the information to decide whether

00:42:56 using the information to decide whether the site requires a scheduled station visit the frequency of the visits the level of information recorded where the site-specific training is required information on the tactical plan

00:43:07 information on the tactical plan and finally stage five completing the operational risk database recording the information the ord is linked to the station diary and will be completed updated for each scheduled station diary

00:43:19 updated for each scheduled station diary visit

00:43:20 visit now having looked at that five stage process is it right that in carrying out the risk assessment at stage four policy 800 requires crews to complete a

00:43:32 policy 800 requires crews to complete a premises risk assessment or prpra using the tick sheet at appendix 1 of this policy yes so that that premises risk assessment probably would have been

00:43:44 assessment probably would have been completed at stage three but stage four is is consolidating and considering the information in terms of determining frequency of future visits thank you and if we could turn to appendix one which

00:43:55 if we could turn to appendix one which is on page 13

00:44:05 this is the tick sheet in every where relevant each box would have to be considered and marked as appropriate by the visiting crew that's correct

00:44:16 now is it also right having regards to the five stage process that crews would then calculate the risk score of the premises using the premises risk assessment template which is on the screen here and

00:44:27 template which is on the screen here and apply that score to the risk matrix yes now

00:44:32 now let's look at the risk matrix itself and go back to page 8 and paragraph 10.1 is that the matrix it is yes

00:44:42 it is yes and in broad terms the matrix determines whether and how frequently premises should be subject to further scheduled section 72d visits is that right it is yes and we used it to maintain

00:44:54 yes and we used it to maintain consistency across the brigade now

00:44:58 now just so that we understand the significance of a premises being identified as requiring section 72d visits

00:45:07 visits is it right to say that essentially its significance is twofold first of all the fact of the visit and secondly once premises are identified and if its risk score is high or sufficiently high the premises

00:45:20 high or sufficiently high the premises and relevant details are then recorded on the operational risk database that's correct there was also something called a premises information plate which i guess

00:45:31 premises information plate which i guess we may come on to later that sat alongside this but that was almost exclusively for high rise thank you

00:45:39 thank you now is it also right that frequency of visits were determined by the premises risk or

00:45:45 risk or yes and in professional judgment of the station manager so there are two stages two stages yes yeah and we can work this through but if we can

00:45:56 we can work this through but if we can look at the risk matrix itself and if we could look at the the yellow row which is medium to low risk we can see that if a premises scored between 250 and 499

00:46:10 between 250 and 499 that would require a visit at least every three years and then moving the column further to the right

00:46:18 the right it says if deemed appropriate by station manager

00:46:22 manager now would that mean that the station manager could make visits more or less frequently depending upon his assessment of the risk presented by a particular high-rise building

00:46:33 a particular high-rise building depending on his or her assessment uh yes they could but the expectation wouldn't be that they would make it less frequent it will be more frequent thank you can we just check that we haven't misunderstood this

00:46:45 check that we haven't misunderstood this um

00:46:46 um when i looked at this the first time on the screen i assumed that the box which says if deemed appropriate by station manager actually relates to the heading on the top on-site exercise

00:46:58 the heading on the top on-site exercise required yes so

00:47:01 so um

00:47:03 um whether visit frequency would always i suppose be at the discretion of the station manager um but it would be at least

00:47:11 at least once in every three years absolutely uh if if the station manager in his or her professional judgment felt that whilst the matrix

00:47:22 that whilst the matrix suggested this there should be a reason why that frequency should be more often then that's when we would expect them to intervene and change the operationalist database to reflect that yeah but

00:47:33 database to reflect that yeah but but

00:47:35 but whether an on-site exercise required at all

00:47:39 all would be as the box suggests up to the view of the station manager yes although if i can just add one thing of

00:47:49 i've seen different versions of this within that document so this matrix appears twice i think it appears once within the body of the document the policy but it's also in the appendices

00:48:01 policy but it's also in the appendices as well

00:48:02 as well and

00:48:03 and it'll be useful to see the one in the appendices because i'm not quite sure whether

00:48:07 whether the visit frequency is different because in all others i've seen it suggests uh one to one year one to two years not every five years or three years

00:48:18 every five years or three years if we go to page 17

00:48:27 it seems to be the same okay i've seen other versions where the low was uh one or two years and it was asterisked and it was for the station manager to determine whether it was one

00:48:39 manager to determine whether it was one or two years so uh i think subsequent uh iterations and earlier iterations it was uh it was it was demonstrating a more frequent uh

00:48:50 more frequent uh in this version of 800 which was current at the time of the fire both the matrices both the one at page 8 and 17 are identical okay you can take that from me

00:49:02 that from me now um

00:49:04 now um if we can go back to page eight

00:49:12 and if we can look at the green row

00:49:17 and it sort of sets up the the approach to premises attracting a score of 150 plus

00:49:24 plus again

00:49:25 again would those premises be added to the ord and subject to regular visits yes

00:49:31 yes and in relation to premises your score was under 150 um paragraph 8.2 which can be found at page seven of the policy

00:49:42 that could be amplified that provides thus any new premises that scores between 0 and 149 will not be included on the operational risk database

00:49:53 operational risk database any existing premises scoring between 0 and 149 should be deleted from the outside duties master schedule so is the practical effect of that provision this that if a premises risk

00:50:05 provision this that if a premises risk score falls below 150 the premises will first be deleted from the ord and secondly they will not be subject to future scheduled visits that is the intention and just to put

00:50:17 that is the intention and just to put some context behind this the

00:50:20 the operational risk database had taken over from a previous application called the central risk register

00:50:27 register and this was before we had more

00:50:30 more advanced

00:50:32 advanced systems that we have now and even at the time

00:50:35 time and so the central risk register in transferring over needed to be cleansed so i guess that's what's referring to when they should be deleted from the schedule because in case there was someone there that never really should

00:50:47 someone there that never really should have been on there but now we had a much more advanced and technologically supported way of determining what should go on the register

00:50:56 register in saying all of that if and and staff understood this station managers have understood if a premises did come out to between 0 and 149 but the professional

00:51:09 between 0 and 149 but the professional judgment was such that it that just isn't a front to common sense then that could be included necessarily on the operational risk database um was that overriding discretion vested in station managers

00:51:21 discretion vested in station managers something was well understood by those station managers i would say so yes and certainly by borough commanders and that

00:51:30 and that can you identify when and in what format station managers were told that they ought not to follow the risk matrix robotically that was always always going to be subject to their discretion

00:51:41 to be subject to their discretion yes so i used to host borough commander meetings

00:51:46 meetings religiously every quarter and it was something that that had been done even prior to my uh commencement in service delivery in 2006

00:51:56 2006 and that was uh that was a fantastic way of keeping touch with what was going on within boroughs how did you make sure that the borough commanders were telling their station managers

00:52:08 station managers not to follow a robotic approach to the risk matrix but to ensure it's subject to your to their professional judgment as to the risk presented by a particular building well firstly it wasn't just about not following a robotic approach

00:52:19 about not following a robotic approach to the risk matrix it was about uh having sound judgment and integrity to be able to stand up and say things are wrong or a right whenever they felt that to be the case

00:52:30 whenever they felt that to be the case so it was it was far broader than just a matrix but the way i would determine it is because in addition to meeting barrow commanders on a quarterly basis on mass then i had a a scheduled program of

00:52:43 then i had a a scheduled program of meeting the area depth assistant commissioners on a monthly basis on a one-to-one and that would include me visiting them out in their areas with the relevant

00:52:55 out in their areas with the relevant borough commander so for example in the north west there i'd meet the northwest uh area deputy assistant commissioner maybe one month at wembley and see the borough commander for wembley there at the same time

00:53:07 wembley there at the same time and

00:53:08 and another month i might meet them heston and uh and and talk to them there so i would i would be able to personally satisfy myself that people understood and and

00:53:19 and and and the

00:53:20 and the the dialogue that we used to have with borough commanders and station managers was very much in terms of staff would stand up and say things that they didn't agree with

00:53:31 they didn't agree with thank you now if we can go to page 14 in this policy in the very bottom of that page

00:53:39 we see that the very last box says this high-rise premises eg over six floors or 18 meters

00:53:46 18 meters would attract a score of 75 points now that that provision aside is the process for determining which pro which properties would be recorded on the ord

00:53:58 the ord applied equally to high-rise buildings as to any other building yes put differently there was no bespoke 72d process particular to high-rise buildings

00:54:10 buildings no

00:54:11 no thank you

00:54:12 thank you so is it right that whether a high-rise building received scheduled 72d visits depends upon the nature of the risks that a particular building presents which in turn determines that building's

00:54:24 which in turn determines that building's risk score

00:54:27 yes now during your time at the lfb would you have expected that all high-rise buildings would have met the threshold of 150 points

00:54:39 yes i think i think for a higher rise not to meet that threshold it would need a combination of two things one would be [Music]

00:54:49 [Music] absolutely zero risk whatsoever and you you could go through the various iterations of this matrix and see all

00:55:00 iterations of this matrix and see all the various things that factored into it such as no elements of holding no no one living in the high rise that was

00:55:09 that was non-ambient no

00:55:11 no no unoccupied premises so so first of all it would need a near perfect solution

00:55:18 solution and then also it would need quite possibly some advanced fire suppression systems because with some aspects of this actually reduce the

00:55:29 some aspects of this actually reduce the score rather than add to the score so your practical expectation would be that all high-rise residential buildings would be recorded on the operational risk database is that right invariably you know there may well be

00:55:41 invariably you know there may well be some that do fit in that category but i'd say looking at all of them i'd say the the absolute vast majority would be on there and if they weren't on there there would need to be very good reason why not put differently were you

00:55:53 reason why not put differently were you ever aware of a high-rise residential building uh that a decision had been taken not to include it on the operational risk database there was no such building never brought to my attention thank you

00:56:04 attention thank you now um can we go back we touched on um appendix 10633 if we can go back to that that can be found at lfb quadruple zero one two five six forward slash one nine

00:56:18 again this is a document that was subject to particular scrutiny at phase one

00:56:24 phase one and it provided guidance to crews carrying out some 2d visits at highrise premises

00:56:30 premises and we see at paragraph one at the top of the page the guidance says this during 72d visits personnel should ensure they are familiar with the following and their impact on

00:56:41 following and their impact on firefighting and search and rescue operations and then it sets out 22 particular items now in her evidence at phase one the then commissioner danny cotton was asked

00:56:53 then commissioner danny cotton was asked whether from a practical frontline firefighting perspective some of the matters in appendix one were impractical and she agreed that that was the case and stated the appendix one list needed

00:57:05 and stated the appendix one list needed and i quote rewording close quotes and that some of the items on the list were quotes not realistic close quotes and she also stated that frontline

00:57:16 she also stated that frontline firefighters don't have the technical knowledge or ability to be able to do some of those things now during your time as director of operations

00:57:27 operations and also as your times third officer did you expect crews carrying out section 2d visits to familiarize themselves with each of the 22 matters set out in paragraph 1 of appendix one

00:57:40 set out in paragraph 1 of appendix one my expectation was that they would use this as an aid memoir and they would look at these various component parts and where practicable and possible and realistic

00:57:53 and possible and realistic then they would take them into consideration just looking at paragraph one uh

00:58:00 uh the words where realistic or where practicable aren't there are they no uh

00:58:06 no uh but i think if i if i again if i can put some context behind this and and i understand this has been an issue in phase one but the word should carries

00:58:19 but the word should carries carries a lot of weight in in london fire brigade we had

00:58:25 we had we had lots of discussion on terminology in terms of should versus must and

00:58:32 and where we say should we use that word carefully and deliberately and the the reason is because we see should as being a word that describes where practicable

00:58:45 a word that describes where practicable whereas must is there's no flexibility you will do it and we had lots of so every every policy that gets promulgated to staff has to go

00:58:57 that gets promulgated to staff has to go through union consultation and sometimes negotiation we were going through a period for quite some time actually where relations with staffside

00:59:08 staffside were not as good as we would have liked and we had to carefully tread through various terminology and our legal advice at the time was must means you will and should means you

00:59:20 must means you will and should means you may and we used to have have that understanding with the fiber goes union and staff at stations as far as i'm concerned understood the difference between should and must

00:59:32 between should and must i suppose

00:59:33 i suppose your evidence is perhaps slightly more subtle than former commissioner cotton's what you're saying is depending upon the particular building it may not be realistic or reasonably practicable to do each of the 22 items set out in

00:59:45 do each of the 22 items set out in appendix 1. yes i think probably it does need rewording because from the outside looking in if it needs a level of explanation i've just given then clearly it could be

00:59:56 just given then clearly it could be clearer i accept that looking at it from a different perspective and based on the evidence that commissioner cotton gave would you agree that front crew got frontline crews lacked the

01:00:07 crew got frontline crews lacked the technical knowledge to look at each and every one of these matters not each and every one there are there are some issues within here that are that sit perfectly and exclusively in terms of uh frontline

01:00:20 exclusively in terms of uh frontline crews can we look at maybe look at it slightly more directly look at the 10th bullet point which is the likelihood and impact of any fire spread beyond the compartment

01:00:31 any fire spread beyond the compartment of origin and the potential for multiple rescues

01:00:35 rescues is that something that falls within the category you've just identified i.e that operational crews would be sufficiently able to identify

01:00:45 and assess the likelihood and impact of fire spread beyond the compartment of origin

01:00:51 origin fire fire crews at station so station based staff didn't have

01:00:57 have the technical fire safety knowledge to be able to look in depth in terms of breaches of compartmentation and fire safety regulations

01:01:08 regulations so i think unless there was something that was absolutely obvious so for example uh an open vent above a uh an exit door into a com common stairwell uh

01:01:20 exit door into a com common stairwell uh then no i think it's beyond that it is outside the the remit and wit of a firefighter no disrespect meant to firefighters they just weren't

01:01:31 meant to firefighters they just weren't employed or trained in that level of technical detail so the key word new evidence there is in depth and that if i can summarize it this way you'd expect the

01:01:42 expect the reasonably competent crew to identify obvious matters such as vents but nothing more than that that may have an effect on compartmentation yeah i've used vince just as an obvious example which i think any any person would

01:01:53 which i think any any person would realize but beyond that that required any specific training then no i wouldn't expect them to be able to do that and that probably is a good example of of where realism is its head in terms of this list and

01:02:07 is its head in terms of this list and i suppose looking at matters slightly differently how would you have expected them to have considered the issue of likelihood and impact of fire spread on a 72d visit uh well when they arrive the uh the

01:02:19 uh well when they arrive the uh the common uh

01:02:21 common uh way of conducting a 7-2 d visit on a high-rise would be to do what we call is walk the building so they would they would get in the lift they would go to the top and then they would walk down and they would check

01:02:33 would walk down and they would check each floor intermittently look in common areas dependent on the time of day and if applicable they they will be expected to maybe even knock on

01:02:44 will be expected to maybe even knock on a door and see if a resident would allow them access so they could just see what the construction was in terms of the way the the compartment was laid out they

01:02:55 the the compartment was laid out they will also

01:02:56 will also if possible do it with the responsible person so who whoever had oversight of that building and they then could give them some

01:03:04 them some advice and guidance in terms of some of the questions well come on to the involvement the responsible person in due course but if

01:03:12 if cruz you wouldn't ordinarily expect cruz to be able to assess likelihood and impact of fire spread beyond compartment of origin how would london fire brigade go about

01:03:24 how would london fire brigade go about assessing that likelihood in relation to high-rise residential buildings uh so high rise residential buildings uh in times in terms of fire safety regulation are uh

01:03:35 regulation are uh involve a mixture so there's the individual compartments which which don't come under legislation but then there's the common parts i stairwells and escape routes that do

01:03:48 escape routes that do so in terms of looking at that particular issue then fire safety would have been involved with the original planning and construction advice etc and

01:04:00 planning and construction advice etc and then in terms of regular audits or even if there had been an incident there fire so a bit of post-fire audit so fire safety regulation would have

01:04:11 regulation would have an involvement with a building in the same under regulatory reform order in the same way as uh firefighters at stations would have an involvement with it under 72d

01:04:23 an involvement with it under 72d so let's just look at that there are two means on the base of that evidence by which likelihood of spread is examined um first of all at the time of the original design now presumably you're indicating there's some the involvement

01:04:34 indicating there's some the involvement of fire safety in the in the building control process is that what you're thinking of yes and so if for example that building control process doesn't happen or fire safety is not involved

01:04:46 or fire safety is not involved that route does not allow the lfb to assess the likelihood of impact of spread does it if that hasn't happened originally then that is the case uh however in saying

01:04:57 that is the case uh however in saying that one would expect if station-based staff are out and about on stations ground doing a whole variety of jobs that they're doing a new construction clearly wouldn't bypass

01:05:08 construction clearly wouldn't bypass them

01:05:09 them they would involve themselves in terms of uh carrying out a 72d that would be placed on the operation of this database and fire safety had access to the operational risk database so eventually

01:05:21 operational risk database so eventually it would become within organizational knowledge although it would be a clear mission on behalf of the the uh construction uh engineers and the

01:05:32 the uh construction uh engineers and the responsible person while they never informed the fiberglade in the first place but it assumes uh a proactiveness on the part of a visiting crew doesn't it

01:05:42 it if that'll pick up that there may well be changes that require more detailed fire safety involvement oh sorry i was picking up on the basis that a building had been constructed

01:05:53 building had been constructed originally and never been alerted to the fire service not not so much about a building was all in existence and they were inspecting it and talking about some kind of constructional change now the second

01:06:05 constructional change now the second means you identified was a fire safety audit related to the rro now forgive me it's not entirely clear

01:06:14 clear when

01:06:15 when and by whom you saw that particular role being fulfilled fire safety audits will be carried out by

01:06:24 by fire safety inspecting officers and they would inspect buildings as part of a programmed proactive campaign or it might be a reactive visit because

01:06:37 or it might be a reactive visit because of something that's happened so that could have been a fire there so we carry a post-fire audit or it could be that they've been alerted by the local authority that there's been some kind of construction

01:06:49 construction going on in that building so they inspected to see but it still complies or it might be a complaint from a member of the public who might see things happening and say i'm not happy about this i live in this building i'm concerned or it could be a

01:07:01 building i'm concerned or it could be a borough commander in liaison the local authority has come to their attention and he or she would alert fire safety thank you now if we can

01:07:11 we can go back to the bullet point list if we look at the 12th bullet point which reads floor layouts and any building construction features which may promote rapid or abnormal fire spread

01:07:22 promote rapid or abnormal fire spread such as sandwich panels timber frame construction atria and voids again

01:07:28 again would that be the type of matter which you wouldn't expect a visiting crew ordinarily to pick up on yes this this will be something that's uh

01:07:39 uh that's at the extreme ends of the expectation of the knowledge of a firefighter and your assumption therefore would be that those issues would be picked up by one or both of the

01:07:50 would be picked up by one or both of the alternative means that we've just been discussing yes

01:07:55 now where the text refers to or uses words such as such as sandwich panels am i right understanding that that was not intended to be an exhaustive list of construction

01:08:06 to be an exhaustive list of construction features they should just be on the lookout for particular features that may well have an impact on fire spread evacuation the rest of it yeah that was an example to focus the mind

01:08:17 an example to focus the mind would you

01:08:18 would you would you expect a crew to be alive to the risks presented by cladding systems albeit in very high level terms

01:08:29 crews were aware and probably have experienced fires in higher eyes where cladding has become involved so it's within their

01:08:40 become involved so it's within their operational knowledge skills and experience in terms of whether they expect cladding to be a

01:08:48 to be a an issue

01:08:49 an issue that would be a predominant part of a fire and indeed uh

01:08:55 uh uh

01:08:56 uh flammable to the to the degree where it could envelop a building then no now just staying with that question of cladding could we go briefly to gra 3.2 which can be found at lfb quadruple zero

01:09:09 which can be found at lfb quadruple zero one two double five uh

01:09:13 uh and then once we've got that into page 18

01:09:18 there we go gra 3.2 and if we go to the second line of the fourth bullet point from the bottom of the first list and that bullet point starts with the words building construction features

01:09:32 words building construction features and it provides this building construction features such as the presence and location of maisonet style construction sandwich panels timber framing cladding systems surface mounted trunking ducting of

01:09:43 surface mounted trunking ducting of voids in addition to features which present a specific hazard such as asbestos

01:09:48 asbestos now can you help us at all as to why cladding systems which are expressly referred to in gra 3.2 were not specifically referred to in the

01:09:59 were not specifically referred to in the 12th bullet point of appendix one of six three three so can i just see the uh the the paragraph that sits above these bullet points

01:10:19 and can i read the bullet point again please of course yes

01:10:35 uh well so uh so gra genetic risk assessment 3.2 about high high-rise would have been national guidance

01:10:46 would have been national guidance and that would have been the responsibility of i think operational procedures to write the policy notes that took this

01:10:57 write the policy notes that took this into account in terms of why cladding systems aren't specifically mentioned in there i think that's probably a question that's better aimed at those who wrote

01:11:08 that's better aimed at those who wrote the policy notes however bearing in mind what we've just said in terms of the phrase such as i think

01:11:17 i think that

01:11:18 that we did also have this issue in a brigade about not overloading staff with information and just pointing them in the direction of things to consider but i think in terms of any deeper than that

01:11:29 i think in terms of any deeper than that i think those managing policy would probably

01:11:33 probably be better

01:11:34 be better uh able to to ask what answer what cladding isn't specifically in there thank you for that but bearing in mind your experience and your seniority did you have a view yourself as to whether cladding systems or external facades

01:11:47 cladding systems or external facades should

01:11:47 should be considered by crews as part of the 72d visit program it was never on my radar that uh that when the crews went to undertake a 72d

01:11:59 undertake a 72d either initially or as part of a an ongoing visit that when they stood outside a building they should look at the cladding on it and make a determination as to whether

01:12:10 and make a determination as to whether it formed part of a risk assessment though even after latino that was your view was it uh

01:12:17 uh lacking all obviously had its unique issues attached to it and certainly the uh the panel was below windows uh added to the uh the fire somewhat

01:12:31 uh added to the uh the fire somewhat organizationally i don't think we we saw la canal as a cladding fire in the way that you might determine grenfell as a cladding fire and there was other fires obviously uh

01:12:44 and there was other fires obviously uh shepard's

01:12:45 shepard's shepherd's cult where there was cladding and and fires were spandrel panels had caught the light so we were alive to the fact that they can add to the

01:12:56 fact that they can add to the fire

01:12:57 fire but not necessarily seeing them as issues

01:13:01 issues to put them in their own category as a cladding fire if you didn't see lachman as a cladding fire

01:13:08 fire you i mean corporately as the lfb what did you see lachnal as being i'm not sure i could could describe it in terms of a

01:13:19 in terms of a particular pigeon hole type explanation but certainly lacking all the fire at lac and all had some unusual

01:13:30 the fire at lac and all had some unusual aspects to it one of the main ones being that the fire traveled downwards but so i wouldn't i wouldn't really determine it in particular ways i'm not saying cladding is not involved in lack

01:13:42 saying cladding is not involved in lack and all clearly it was but i think to call it a cladding fire is a

01:13:47 is a would would be misrepresenting what what lacking was bear in mind that answer can we just go to a letter that former commissioner dobson wrote to sir ken knight when sir

01:13:58 dobson wrote to sir ken knight when sir ken was the chief fire advisor and that letter can be found at lfb double zero one zero four two nine one

01:14:10 now that letter is dated the 14th of december 2009

01:14:16 and in broad terms it raised concerns about the use of combustible cladding panels at lachnal and which commissioner dobson indicated the lfb were concerned might well be

01:14:27 the lfb were concerned might well be present on other high rise properties now

01:14:33 now first of all is that letter familiar to you have you seen it before i have seen it before yes i wasn't involved i don't believe in the construction of it but yes i'm aware of it

01:14:43 it but is the practical effect that notwithstanding that commissioner dobson was moved to right to sir ken to highlight the prop the problem of cladding particularly in the context of high-rise buildings nonetheless it

01:14:54 high-rise buildings nonetheless it wasn't something to use your phrase that crossed your radar as something that had to be uh emphasized to seven 2d crew visits

01:15:03 visits so could you could you rephrase that question please yeah commissioner dobson has seen fit to write sir ken knight in his capacity as chief fire advisor to highlight the

01:15:14 chief fire advisor to highlight the problems posed by cladding particularly on high-rise buildings now given that is it still your position that the risks posed by cladding on

01:15:25 that the risks posed by cladding on high-rise residential buildings was not on quote the radar close quotes in terms of giving advice to crews attending to visit high-rise buildings for the purposes of section 72d

01:15:39 for the purposes of section 72d okay there's a couple of answers to that so i think it's you know it's quite right

01:15:44 right for the commissioner to inform sir ken knight of the issues around cladding involved in lacking all because as i've said there clearly were issues it's the it's the definition of the fire

01:15:57 it's the it's the definition of the fire in terms of how we describe it i think is is more i would uh question

01:16:05 crews were aware of the issue of cladding as a result of lacking all the the lack of house presentation and the training that we did to crews and the specific training over and above that

01:16:16 specific training over and above that that we did with borough commanders clearly uh exposed that issue i think the issue for crews in terms of being honest their radar it's it's their ability to be able to

01:16:29 it's their ability to be able to to determine whether

01:16:31 whether looking at a building a 72d visit involves cladding that may be an issue because it goes outside of the remit of

01:16:40 remit of of their abilities and training to be able to do that can we look at the substance of this lesson we start with the first paragraph where mr dobson stated this

01:16:51 where mr dobson stated this i'm writing to inform you that as part of our investigation into the fire of latino house we have had tests carried out on the exterior wall panels of the building and that those tests have given rise to concerns which may well be relevant to

01:17:03 concerns which may well be relevant to other high-rise premises although our investigations are continuing and the matter is still to come before the coroner i feel that it is in the public interest to draw the issue to your attention so that the

01:17:15 issue to your attention so that the matter can be discussed within the department and any necessary advice can be given to owners and landlords of high-rise buildings and then if we go to the third and fourth paragraphs on that page

01:17:26 page mr dobson sets out the functional requirements of approved document b4 and before it goes on to say over the page

01:17:35 page and the third fourth and fifth paragraphs

01:17:40 this based on the tests conducted by the building research establishment it appears that there are external wall panels at lachnall house that do not have the necessary reaction to fire properties required for the location in

01:17:51 properties required for the location in which they have been used we have also become aware that this type of panel has been supplied by more than one company in the circumstances we believe it may be appropriate for a warning to be given

01:18:02 be appropriate for a warning to be given to housing providers that it would be advisable to check the specification for external wall panels in their high-rise housing stock and check that what has been installed meets the correct specification i.e that fire safety

01:18:15 specification i.e that fire safety requirements of the building regulations were taken into account and to include this and fire risk assessments for relevant properties now

01:18:24 now did you either at the time of this letter was sent or later consider whether operational crews should be directed expressly to look out for the presence of cladding or facade panels on high-rise residential

01:18:37 panels on high-rise residential buildings as part of their section 72d visit

01:18:40 visit no because there were various other issues in trying to deal with this so the borough commanders were well aware

01:18:51 the borough commanders were well aware of the issues having seen the presentations the detailed presentations by david crowder then there was toolkits being sent out by fire safety and the deputy commissioner

01:19:03 and the deputy commissioner in terms of local authorities to use so we were pitching it at a strategic level so that the appropriate people could be aware of this going back to for firefighters to check

01:19:16 going back to for firefighters to check it's uh they it wasn't and it wasn't an expectation that they should get involved in that level of detail on an external uh wall of a high rise

01:19:30 uh wall of a high rise it could have been no pitch at a practical level couldn't it simply by including the word cladding systems at the 12th bullet point on appendix one of 633 so they released a live to the need to look out for cladding systems which

01:19:42 to look out for cladding systems which may have an effect on fire spread in the event of a fire even if we had to have done that then there would have been questions in terms of well exactly what are we looking for

01:19:55 of well exactly what are we looking for how are we supposed to determine whether one piece of cladding is any different to another how do we know if there are voids what do we know about the construction of it etc but apart from that firefighters i

01:20:07 etc but apart from that firefighters i would suggest well i know uh were well aware of the issues of cladding

01:20:14 cladding in terms of uh firefighting and the uh within their knowledge and experience that if a fire escapes a compartment externally then you know there have been

01:20:27 externally then you know there have been some occasions where cladding has become involved so they were aware of it but there's a difference between aware of the potential and then knowing how to look

01:20:38 potential and then knowing how to look at something and determining whether it has the potential to become involved in a fire over and above any other type of cladding now did anyone else at the lfb uh seek to discuss with you

01:20:50 at the lfb uh seek to discuss with you the need to direct operational crews to have regard to cladding systems as part of the 72d visit program not that i can recall after the latino house inquests um

01:21:02 after the latino house inquests um which had established that the panels were not of the uh requisite standard and had contributed to the speed of the fire did anyone raise with you again the need to direct crews explicitly to the need to look at

01:21:13 crews explicitly to the need to look at cladding systems but not a correct call now did shepard's court fire in august 2016 prompt any consideration whether crews ought to be expressly directed to look

01:21:25 ought to be expressly directed to look at cladding as part of the 72d process not that i can remember no you touched on earlier on in evidence the involvement in of the responsible

01:21:36 the involvement in of the responsible person on fire safety visits

01:21:39 visits now the phase one report concluded that crews who carried out 72d visits at grenville should have obtained information about the building's cladding system from the tmo directly would lfb crews

01:21:51 from the tmo directly would lfb crews normally have made inquiries of the responsible person before or after conducting some 2d visits when when crews conduct a 72d visit when

01:22:02 when when crews conduct a 72d visit when they make the arrangement just out of sheer courtesy if nothing else they there's an expectation that they would contact a responsible person to let them know that they are coming

01:22:13 coming and that responsible person ideally would

01:22:16 would join them on the visit and answer any questions and show them any particular issues that they need to be able to complete the premises risk assessment

01:22:27 so the answer is yes yes was there any system for monitoring the quality of 72d in visits and the information they were collecting i.e were they collecting the information

01:22:39 were they collecting the information that they needed to in order to discharge the duty yes so

01:22:44 yes so a crew would having completed the premises risk assessment would then come back

01:22:49 back and they would get onto the operational risk database and they would put the information in there if there was any hazard information they'd fill that section in and if there was any tactical

01:23:00 section in and if there was any tactical plan to be considered then they would fill that in as well once they've done that then it sits in what's known as a work queue and the station manager needs to

01:23:12 station manager needs to quality assure that and make sure the station manager is content and satisfied that the visit has gained the necessary information if they if they're not then the station manager would send it back to the crew

01:23:24 manager would send it back to the crew to do what needed to be done once the station manager had quality assured that it then got sent up to information management the people who owned the operational risk database this is why i made the distinction between

01:23:37 is why i made the distinction between collection and application because there is another big part of it in terms of owning the database which was information management and they would quality assure the information as well make sure they were content with it if i

01:23:48 make sure they were content with it if i can stop you that how does the station manager go about discharging the quality assurance function say for example we found at grenfell that there were several errors yes in relation um to the information that was

01:24:01 relation um to the information that was recorded

01:24:02 recorded as basic as not correctly recording the right number of flaws for example how can the station manager assure himself that basic information is correct other than going out there and

01:24:15 correct other than going out there and inspecting the building himself how do you see him discharging that function

01:24:21 well i mean that's that's a good point and the station manager as i did when i was a station manager would be expected to uh

01:24:29 to uh to actually go and sample some of the visits that are being carried out the station manager managing the four watches would get a feel for the level of expertise and

01:24:41 the level of expertise and professionalism on the watches and it may well be that he or she needs to make visits accordingly could i um what policy direction let's confine ourselves to policy first of all

01:24:53 confine ourselves to policy first of all um were station managers directed to carry out this sampling exercise you've referred to well we

01:25:00 well we introduced or i introduced something called service standards so one of the one of the challenges that i have faced and the london fire go faced is that it's a a vast organization

01:25:12 faced is that it's a a vast organization the size of some of the four areas in london are bigger than most other fire brigades in the country so

01:25:18 so you know we could argue that we were managing four separate fire brigades some boroughs were bigger than some fire services in the country so we needed standardization and consistency

01:25:29 standardization and consistency the matrix is one of those ways of achieving that but service standards was another way was can i cut through this was there a specific provision in the service standards or any other policy that directed station managers to

01:25:41 that directed station managers to conduct a sampling exercise to verify the accuracy of information collected by crews as part of some 2d visit as far as i'm concerned service standard eight which is about contingency planning

01:25:52 which is about contingency planning advise station managers to sample

01:25:56 sample the accuracy of visits as well as quality assuring from a desktop

01:26:04 and it was also something that i would make sure again at these borough commander meetings and i can't and i'll probably over mention these during the next few days but they were absolutely

01:26:15 next few days but they were absolutely vital to the information flow between the strategy of the organization and the application at local level and i'll make it clear there as well was the sampling

01:26:26 it clear there as well was the sampling exercise

01:26:27 exercise defined by the risk presented by particular properties so the station manager's quality assurance program would be would concentrate on high risk buildings

01:26:38 high risk buildings uh the quality assurance in terms of uh desktop was for all buildings uh every single building that goes on the order would the sampling exercise be prioritized and focus on accuracy of

01:26:50 prioritized and focus on accuracy of information relation to high-risk buildings not necessarily

01:26:55 again would be subject to the individual discretion of a station manager

01:27:02 now can we look briefly at the lfb's lachnal assurance review which can be found at lfb quadruple zero four eight zero one

01:27:09 zero one and this document summarizes the required actions identified by the lfb following the the lachnal fire and it also includes the recommendations made by the coroner

01:27:20 made by the coroner now

01:27:21 now if we can go to page 28.

01:27:31 it deals with section 72d visits or high-rise premises and actions taken specifically in response to the coroner's recommendations and if we can see the second full paragraph on the left-hand side

01:27:44 which says this a review a review of the operational risk database shows that on average approximately forty four zero visits to residential high-rise premises that were

01:27:55 residential high-rise premises that were not yet recorded on the operational risk database were completed each month under the requirements of section 72d of the fire and rescue services act resulting in the production of an electronic premises

01:28:07 production of an electronic premises information plate for those premises note data between april 2014 and october 2017.

01:28:14 2017. using the same data set i.e as of october 2017 it was identified that approximately 1 700 residential high-rise premises had premises risk assessment recorded against a total of

01:28:27 assessment recorded against a total of approximately 6 900 residential high-rise premises in london mr canida i think it would help if we could scroll off a bit we'll rather scroll down

01:28:40 you scroll down a bit further i think please so i was assuming the scrolling was following me yep thank you very much thank you i'll let you read that mr brown before i

01:28:52 i'll let you read that mr brown before i ask a question

01:29:00 okay now i'm mindful that those numbers one thousand seven hundred and six thousand nine hundred late to october 2017 i.e after you retired but

01:29:10 but are we safe or reasonable in assuming that the figures would have been broadly the same during your time at the lfb i.e in terms of total number of high-rise properties in london and those

01:29:21 high-rise properties in london and those that have had pras conducted well the only thing i would say about that was i remember in september 2013 uh a presentation which uh mayweal

01:29:34 uh a presentation which uh mayweal we may be discussing and in there we highlighted it was 1 300 high rises on the operational risk database that was in september 13.

01:29:45 database that was in september 13. so

01:29:46 so so four years later more or less only an extra 400 i find surprising and and mathematically incorrect if 40 visits

01:29:56 visits uh

01:29:57 uh per per month were being undertaken then then one of those figures is wrong somewhere

01:30:04 somewhere well

01:30:05 well some of the data set post dates your retirement so yes i think we just have to bear that in mind but if we can take these figures at face value um they show or seem to show that 1700

01:30:17 um they show or seem to show that 1700 high-rise premises were on the ord yeah and subject to scheduled section 72d visits it would follow yeah i guess what i'm trying to say is i would have expected it to be more than 1700 but but

01:30:28 expected it to be more than 1700 but but taking that at face value let's it's unfair on you because you're not in a position to verify the data we have to state this at face value so we've got there 1700 which would be on the ord and

01:30:39 there 1700 which would be on the ord and therefore subject to scheduled 72d visits is that right yes and looking at the figures we've got here that would mean that 5200 high-rise premises were not on the ord and so

01:30:50 premises were not on the ord and so therefore not subject to scheduled some 2d visits but based on these figures yes

01:30:58 now

01:31:01 would it have been a source of concern to you let's assume these figures were whilst you were still in place would it be a source of concern to you that more than 5 000 high-rise properties were not on the ord and were

01:31:13 properties were not on the ord and were therefore not subject to scheduled some 2d visits absolutely and it was it was a concern of mine when i was in post and it was it was one of my

01:31:25 it was one of my many things that we were trying to improve

01:31:29 improve so there was clear instruction given to station-based staff and borough commanders and processes and procedures put in place that we could increase that number my utopia was the every single high-rise

01:31:42 utopia was the every single high-rise premises in london would have been visited and had and been risk assessed whether whether it stayed on the operation risk database after that visit was another issue but we needed to have carried out that

01:31:53 but we needed to have carried out that visit and a premises information plate been created and installed bearing in mind that answer was the position therefore there was a similar disparity

01:32:05 similar disparity during your time as director of operations between the number of high-rise buildings that were recorded on the ord and subject to 72d and those that which which were not uh it's true that there there wasn't

01:32:17 uh it's true that there there wasn't every single high rise uh on the old but it's also true that we were working really hard to rectify that i'm sorry to interrupt you mrs brown but it's not just that not everyone was

01:32:29 it's not just that not everyone was recorded the fact here we've got a disparity 1700 were more than 5 000 were not now my question is was that same

01:32:41 now my question is was that same proportion of disparity the case when you were director of operations a similar order there was there was a a

01:32:51 a a large number of high-rise that weren't on there

01:32:56 on there without wanting the split hairs i also want to

01:32:59 want to alert the inquiry to the fact that we we had a real challenge and it might seem strange but in finding out exactly how many high-rises there were in london we did an awful lot of work in trying to

01:33:10 did an awful lot of work in trying to actually determine that talking local authorities housing providers and we could never get a complete straight answer so we was never entirely sure how far we were away from achieving our

01:33:22 far we were away from achieving our objective but yes there was uh it was a significant amount that weren't on there but we were aware of that and trying to rectify that mr brown we will come on to that subject uh in

01:33:33 we will come on to that subject uh in due course so it's quarter past 11 um given where we're at in the examination that's convenient time yes all right well then that sounds like it's a good point at which to have a break well mr brown as you were told

01:33:45 break well mr brown as you were told earlier we have a break off partway through the morning we'll take that break now

01:33:49 break now we'll resume please at half past eleven and i have to ask you on this and every other occasion on which you leave the room please don't talk to anyone about your evidence or anything relating to it

01:34:00 your evidence or anything relating to it while you're at okay thank you thank you very much indeed would you go to the usher then please

01:34:14 thank you how fast

01:49:46 would you ask mr brown to come back in please

01:50:00 right mr brown ready to carry on thank you yes thank you very much yes mr community thanks sir um miss bryan can we turn now to your email um to lfb station sent on the 20th of april 2009

01:50:11 station sent on the 20th of april 2009 and it was sent on your behalf and you deal with this email and page 15 of your first witness statement and if we go to lfb

01:50:19 lfb trouble zero three two one double six forward slash one five and we said paragraph 43 you say and cite this email as being an example and following on from your

01:50:30 example and following on from your earlier evidence of the importance of the lfb placed on pre-planning for residential high-rise fires now if we go to the email itself which can be found at lfb 0032161

01:50:46 and we see at the bottom of page one the email says at its head and i quote this message is from ac brown service delivery and mobilizing

01:50:57 brown service delivery and mobilizing and it's for all station based station managers and borough commanders and it deals with section some 2d visits at the top of page 2.

01:51:10 and it says this a database of high-rise premises c attached has been compiled that falls within the criteria set out by ac web ops planning in april 2007

01:51:23 by ac web ops planning in april 2007 so roughly two years before which defined a high rise as a domestic residential premises which is fitted with a

01:51:30 with a firefighting lift and b dry or wet rising main as part of the ongoing familiarization training for station based staff station managers are to ensure that watch and

01:51:41 managers are to ensure that watch and crew managers diarize book and visit the high-rise premises on their station's ground during 2009-10 this process should begin should begin with immediate effect and then be

01:51:52 with immediate effect and then be undertaken annually thereafter borough commanders should liaise with their dac to discuss prioritization of these visits and first of all do you remember that email i do yes

01:52:04 that email i do yes now

01:52:06 now first blush your instruction appears to be a direction to visit all high-rise premises on a station's ground annually is that a fair reading of what you intended

01:52:20 can i just read it again of course

01:52:33 so there was a database that john webop's planning had prepared

01:52:40 and we wanted staff to look at that so so whether whether i mean by that or the high rise that was on that list prepared by john webb or whether i mean going above and beyond

01:52:51 or whether i mean going above and beyond that in terms of all high-rise i'm not quite sure but ultimately yes i would have expected all high-rise to be visited and yes at that point it would

01:53:02 visited and yes at that point it would have been annually and looking at really what you say in that paragraph at the top page do you say station managers are to ensure that watching crew managers die rise etc the high rise premises on their station's

01:53:14 high rise premises on their station's ground

01:53:16 ground now

01:53:18 now that suggests all high rises on a particular station's ground would you accept that

01:53:24 so where is that exactly can top paragraph yeah

01:53:30 third line oh yes yeah yeah absolutely but as i say whether it referred initially to horizon it was on john webb's email and on their station's ground or not i can't quite

01:53:42 station's ground or not i can't quite recall but i would accept that ultimately yes we expected that all high rises on their station to ground will be diarised and visited annually can you help us what was the reasoned

01:53:53 can you help us what was the reasoned basis for the annual requirement for cruz to visit all high-rise premises on the station ground

01:54:03 i think probably at that time

01:54:09 we wasn't quite sighted on the number of high rises that were available and we felt that that would be an appropriate and not an unreasonable

01:54:21 an appropriate and not an unreasonable expectation that was back in 2009 i think once the enormity of the task become more apparent

01:54:32 apparent then we took more of a risk-based approach as we saw with the premises risk assessment before you sent the email in april 2009 did you consider or take advice about

01:54:44 did you consider or take advice about whether it was reasonably practicable for all high-rise buildings on a station's ground to be visited annually

01:54:52 well done beluta so really the underlying intent was a scoping exercise to identify high rises and then take it from there is that a fair summary

01:55:03 summary there isn't a way i would have considered describing it but yes that's not an unreasonable way to describe it um when you sent this email was there a plan to monitor um

01:55:14 um how the aim of annual inspections was to be achieved

01:55:19 well yes but that plan would have been what i would describe as normal business so we were forever monitoring performance managing overseeing progress in terms of making

01:55:32 overseeing progress in terms of making sure that what we wanted to happen was happening

01:55:35 happening and then fitting in other objectives as well now can we look at the database that was referred to in your email and that can be found at lfb zero four five three five

01:55:57 or this document will need to be downloaded so there may well be a bit of a delay

01:56:09 there we go thank you do you remember providing uh or reviewing this document before it was attached to the email that was sent in your name

01:56:18 your name uh well i don't remember doing it and to be honest i don't think i did this was prepared by ops planning and i have taken this on face value that it was it was properly checked and

01:56:29 that it was it was properly checked and i've attached it there as guidance to station-based staff in terms of uh in case they weren't aware of some of the premises um can you help us as to where the

01:56:39 where the list of properties came from i'm afraid i can't i've i've thought about that in readiness for this inquiry and it was it was prepared in very early tenure of mine by a colleague uh in ops planning

01:56:52 mine by a colleague uh in ops planning and i don't know where they got that information from so you don't know what criteria they applied in determining uh well i can only imagine it was a criteria that i put in that email in terms of dry riser etc but

01:57:05 that email in terms of dry riser etc but but other than that i i don't know but that's an assumption it is an assumption yes um can you remember how is the database to be managed if this was the database

01:57:15 database well it was on the central risk register which was the the forerunner of the operational risk database so the idea for one of a better term was to cleanse the central risk register and

01:57:27 to cleanse the central risk register and the

01:57:28 the premises on here would find their way onto the central risk register audio process database whatever was in in process at the time so who would be ultimately responsible

01:57:39 so who would be ultimately responsible for managing this database this actual database i'm looking at now yes well once it got on to the operational risk database it would be information management thank you

01:57:52 information management thank you now can we look at the draft amendments for high-rise policy 633 that were circulated in 2010 and for that purpose can we go to an email sent by peter cowab which can be

01:58:04 email sent by peter cowab which can be found at lfb travel082695

01:58:14 now as you can see from the top of this mr cap emailed james knighton in relation to a draft version of 633 you are not included on the email chain

01:58:25 you are not included on the email chain mr brown i should make clear and his email is set out then i'd like to start but at the fourth paragraph where mr calp said this although i believe the current

01:58:37 this although i believe the current draft represents a significant step forward there remain a number of key issues and points that i believe require further work and consideration these include and if we go to the second bullet point the feasibility of station

01:58:49 bullet point the feasibility of station personnel visiting all high premises on their station's ground as this is a very significant task especially for central london stations i fully understand why we would state that in policy but it may

01:59:01 we would state that in policy but it may be worth giving the statement further consideration have left it in for now now that second bullet point appears to be a reference to paragraph 3.1 of the draft

01:59:12 draft policy 633 which is attached to this email and we can see that draft lfb trouble zero three nine four eight five

01:59:27 and if we go to page four of the draft and paragraph 3.1

01:59:34 and what that says in the second sentence is this station personnel should be familiar with all high-rise buildings on their ground mr kaup appears to have interpreted

01:59:46 mr kaup appears to have interpreted policy as requiring uh stations to visit all high-rise premises was that how paragraph 3.1 was being interpreted generally across the lfb at

01:59:57 interpreted generally across the lfb at the time or is it a policy aspiration

02:00:03 uh i think i think it's both really but but personally i was always of the viewer and i made it absolutely clear i cannot see from a moral or professional perspective

02:00:15 professional perspective that we could exclude any high-rise so if any building needs inspecting then we should inspect it whether it leads to further on-going inspections is another

02:00:27 further on-going inspections is another issue

02:00:28 issue but for me my position was that over a period of time every single high-rise should be visited and were you aware at the time that mr carrap had reservations about

02:00:39 that mr carrap had reservations about the practicability of visiting all high-rise buildings on a particular station's patch i wasn't no had anyone else raised that concern with you at the time or indeed afterwards

02:00:53 i don't recall anyone raising the issue with me

02:00:57 with me prior to

02:00:59 prior to in terms of afterwards there was extensive pressure that i applied to my own staff to achieve this objective

02:01:10 objective and yes

02:01:12 and yes i i then

02:01:14 i i then did get

02:01:15 did get feedback

02:01:18 feedback from a range of sources how challenging this was and i accepted and i accept now it is challenging but for me that's not a reason not to do it were you asked to contribute to this

02:01:29 were you asked to contribute to this particular review of 633

02:01:33 personally no but it would have been standard practice that heads of service would have been involved if i had received an email on it i invariably would have passed it on to

02:01:44 to people that work for me most probably central service delivery as they were called at the time and they would uh have commented on it on my behalf you don't remember expressing your own views personally about the

02:01:55 views personally about the practicability of annual visits not at this time though now in 2015 um policy sorry if i if i can just if i can just uh clarify there so the annual visits issue no uh the

02:02:08 so the annual visits issue no uh the concept of all high-rise being visited per se uh is is there two separate things you've made that clear yeah yeah thank you now in 2015 policy 633 was again updated

02:02:23 now in 2015 policy 633 was again updated and the new version published on the 1st of june 2015 and that can be found at lfb quadruple 0-1256

02:02:39 and if we can go to page seven

02:02:44 and section four you can take it from me that the paragraph 3.1 of the previous draft which required station personnel to be familiar with all high-rise buildings on

02:02:55 familiar with all high-rise buildings on their ground had gone

02:02:59 had gone now were you consulted about that particular change

02:03:05 not that i can recall

02:03:08 again can you remember whether you were involved or consulted as part of the revision process for this particular iteration of 633 and by you i mean you personally

02:03:19 personally other than the well laid out practice that i've just explained in terms of head-to-search consultation i don't specifically remember are you able to assist the panel as to whether

02:03:31 panel as to whether omitting

02:03:32 omitting what previously been power 3.1 was a deliberate change in policy to downgrade the regularity of visits

02:03:44 i i

02:03:47 i'd be speculating if i was to if i was to say yes or no today don't i not asking to speculate but mindful of your previous evidence you said that

02:03:56 said that members of your staff had forcibly emphasized to you the practical difficulties confronting annual visits to high-rise buildings is that a fair summary

02:04:05 summary it wasn't only members of our staff it would have been in discussions with staff side as well because i introduced certain practices that would enable

02:04:16 that would enable staff to be able to achieve the objective of visiting all high-rise which wasn't necessarily popular with staff side could we now turn onto operational news

02:04:27 could we now turn onto operational news and it's the edition number 20 which is an article published in november 2011. we can find this particular edition of operational news at lfb 0047224

02:04:45 and we can see there on the front page it contains an article entitled hirise firefighting the first few paragraphs of which are the text immediately below the photograph under the heading for

02:04:57 photograph under the heading for high-rise firefighting and it addresses the issue of of pre-planning now the operations directorate coordination board i think you were a member were you is that right that's correct now they were responsible for

02:05:09 correct now they were responsible for articles published in operational news is that right that's right yes who within odcb was responsible for the content of articles published uh it depended on who was the subject

02:05:21 uh it depended on who was the subject matter expert so dependent on that particular subject we would look at the section within a department that concentrated on that area and they would have been the author original author of

02:05:33 have been the author original author of each

02:05:34 each aspect so this particular article

02:05:38 article probably would have come from somewhere within pop's policy or ops assurance so can we take it from that you weren't involved at all in the drafting of this article would you have been consulted

02:05:49 article would you have been consulted about the contents of the article once the article was written it would then be

02:05:55 then be circulated to various people which may or may not have included me dependent on when it was certainly when i was a director of operations

02:06:06 i was a director of operations so after april 15 it would have done prior to that possibly not um is it right that the content of articles uh is a matter that

02:06:17 content of articles uh is a matter that would have been discussed at odcb and so they were the ones who agreed content and so you would have been aware at least from odcb meetings that this article was being published

02:06:28 article was being published well i was odcb meetings we would have determined the need for an article and an associated training package but then after that point and the article was written it wouldn't then

02:06:39 article was written it wouldn't then come back to odcb for approval and it would be the fact that it was being written they knew the parameters in which it needed to be written communications team had a big part to

02:06:51 communications team had a big part to play in terms of presentation and fitting in within a certain size of the document but it didn't come back in a loop for final approval to adcb before we published but you're aware in broad terms of the topic oh absolutely yes

02:07:03 terms of the topic oh absolutely yes yeah now if we can look at the article itself and if we can look stay on this page and look at the the middle column underneath the photo where

02:07:13 where it says this any visit to a high-rise building should be used as an opportunity to pre-plan this will include the location of the lfb premises information box if fitted as well as the accuracy and completeness

02:07:25 as well as the accuracy and completeness of information provided including evacuation plans any high-rise buildings which pose a particular risk should be subject to 72d visits now looking at that last line

02:07:37 that last line any high-rise buildings which pose a particular risk should be subject 72d visits

02:07:43 visits that appears to be a departure from the terms of your april 2009 email which required all buildings high-rise buildings to be inspected um was there a

02:07:54 buildings to be inspected um was there a conscious departure therefore in the operational news issue 20 away from the inspection of all high-rise buildings that you'd encouraged or directed in your april

02:08:06 encouraged or directed in your april 2009 email can you just remind me please of the of the date of this uh ops news article yes it's november 2011. okay i think there's i think there's a subtle difference here

02:08:17 i think there's a subtle difference here i don't think it is a departure i think the 2009 email was about making sure that every premises had been visited to

02:08:28 that every premises had been visited to determine whether it needed to be included on future 72d visits what this is saying is any any high-rise buildings uh which

02:08:40 any any high-rise buildings uh which which i and i would add having been initially inspected pose a particular risk should be subject to future 72d visits so so the concept was and remains as far as i'm concerned

02:08:53 was and remains as far as i'm concerned that no building can never be not inspected because that initial inspection determines future inspections and so this should not be read as a

02:09:05 and so this should not be read as a reflection of the concerns that peter cap had raised no absolutely the practicability of uh section 70d visits yeah so we need to know what what is out there and once we know what is out there

02:09:16 there and once we know what is out there we can then decide in terms of risk assessment whether it requires ongoing visits

02:09:24 visits are you able to help us what was meant by the phrase posed a particular risk

02:09:37 uh i would suggest that's just a broad terminology to reflect that there's a whole range of different risks that you might experience in in any building or in a

02:09:50 experience in in any building or in a high rise

02:09:51 high rise and

02:09:53 and again there would be an element of discretion exercise by the station manager based on his knowledge of the features of a particular high-rise building

02:10:03 building up until the point that we introduced a premises risk assessment which made it far more prescriptive and consistent thank you

02:10:12 thank you now can i turn to a separate distinct topic which is the introduction of policy 800 in 2012. now

02:10:19 now as we've seen previously it was first issued in july 2012 and its stated purpose was to assist station personnel with the risk assessment process for

02:10:30 with the risk assessment process for sites in their area now

02:10:33 now i think as we touched on earlier you were the lead senior officer in relation to the introduction of 800 though particularly in relation to action 2b

02:10:44 action 2b now

02:10:45 now one thing we i'd like to look at is that particular action for which you were responsible which was to create an inspection regime targeted at high priority buildings now

02:10:57 high priority buildings now were you the lead for the first introduction of policy 800 or only for the later version it seems to be i think the later version given what you said earlier on yes

02:11:08 can you um who was your predecessor as the lead on formulation of the policy uh

02:11:15 uh people i think it was operational assurance

02:11:19 assurance uh sorry opposition resilience that's right i think it was operational resilience and at that time

02:11:27 i know i know tim cut bill was the assistant commissioner for operational resilience at some point i'm not sure where he was at that time uh i i can't i can't recall exactly who

02:11:39 uh i i can't i can't recall exactly who that person would have been and in in summary what are what were the responsibilities of the lead in relation to 800

02:11:47 to 800 uh well the lead really would have been making sure that the policy was fit for purpose and that it was reviewed periodically as and when it was scheduled to be reviewed in terms of the

02:11:59 scheduled to be reviewed in terms of the specifics within it the lead would have delegated that to members of their staff so you weren't involved in the substantive drafting process

02:12:09 process now as we've seen policy 633 included a list of items which crews should consider

02:12:16 consider when carrying out section 72d visits or high-rise properties why was that list not included in policy 800 so as to give comprehensive advice as to what section 72d visit should be

02:12:27 as to what section 72d visit should be directed to

02:12:32 or i don't know for sure but in saying that there was a view within the organization that we wanted to

02:12:40 wanted to keep policies

02:12:44 say to a minimum we had too many policies at one point i think we wanted to rationalize our policies we wanted to make out sure our policies didn't overburden staff with

02:12:55 policies didn't overburden staff with too much information and that they just did what they needed to do so i can only imagine that there was

02:13:03 was to avoid duplicating lists just a mere reference from one policy to another was sufficient following on from that there's no reference in the 2012 iteration of

02:13:14 reference in the 2012 iteration of policy 800 to the guidance and appendix 1 of policy 633 how are crews therefore to know whether to cross refer to appendix 1 of 633 in

02:13:25 to cross refer to appendix 1 of 633 in the absence of any specific reference if if there if there wasn't a reference then then that's clearly an omission and that's something that hopefully has been

02:13:36 that's something that hopefully has been remedied now all i would say is that uh

02:13:40 uh policy notes 800 and policy note 633 to the information gathering and high-rise firefighting was such a a component part of a firefighter's role

02:13:51 of a firefighter's role that they would be aware of both but in saying that it is if it is the case that there isn't any reference at all then that's certainly something that was uh that that shouldn't have been the case

02:14:02 that shouldn't have been the case now

02:14:04 now would you accept i'm putting this too simplistically that because there was an absence of a cross-reference in the policy there was at least a risk of crews

02:14:14 of crews missing

02:14:15 missing or not being directed to securing relevant information as part of section 72d visits

02:14:23 i can see why you would say that but all i would say is high-rise firefighting was uh has always been high on the agenda of firefighters so i i cannot imagine that they wouldn't be

02:14:36 i i cannot imagine that they wouldn't be aware of what they needed to do under policy 963 would it be fair to say that the risk of information not being caught was not identified at the time that 800

02:14:48 was not identified at the time that 800 was issued in july 2012.

02:14:55 yes that's not an unreasonable way to describe it

02:15:00 can i now turn to a separate and distinct topic which concerned the incident at salamanca place in july 2011. now uh salamanca place was

02:15:11 in july 2011. now uh salamanca place was a high-rise building in lambeth wasn't it or is yes and if we can look at the

02:15:19 senior accident investigation report in relation to that instance which is lfb00102299

02:15:32 now we are proceeding on the basis that although this is watermark draft it is in fact the final version and that basis so people know what it is

02:15:43 and that basis so people know what it is is um paragraph 55 footnote 4 of mr carap's third statement which can be found lfb double zero double one nine eight four nine forward slash twenty eight

02:15:55 twenty eight first question uh mr brown is do you remember the salamanca house incident or salamanca place incident i don't remember it will but yes i do recall it

02:16:04 recall it um in summary a fire crew attended a fire incident on the 15th of july 2011. um during the incident four firefighters became trapped in a lift exposed to heat and smoke before being rescued

02:16:16 and smoke before being rescued by colleagues um are those the pertinent details yes now in summary the uh this report was the culmination of the s a i process which involved the

02:16:27 the s a i process which involved the investigation of safety events is that right yes and s a i stands for senior accident investigation yes and its purpose is to

02:16:39 and its purpose is to examine by senior and specially trained lfb personnel to identify any underlying systemic failures that might have led to a safety event occurring during an

02:16:50 a safety event occurring during an incident yes and to aid organisational learning to prevent it reoccurring thank you now is it correct that such an investigation concludes or should at least conclude with an action plan which sets out the

02:17:01 with an action plan which sets out the measures that the brigade intends to take to address any deficiencies identified it will be normal practice yes now during your time at the lfb sai action plans were monitored by

02:17:12 action plans were monitored by operational directorate's coordination board is that correct yes and we would we would had a rolling log of various actions under sais and we would add new ones to it to make sure

02:17:23 would add new ones to it to make sure nothing was lost now the sra report for salamanca place is on the screen if we could turn to page seven

02:17:34 there you see roughly the top third of the page the heading pre-planning

02:17:39 and what it says from the end of the second line is this the building was not on the brigade's central database for high-rise buildings and the fire and rescue service services

02:17:50 and the fire and rescue service services act 2004 section 72d visit had not been carried out by the watch involved now the report then goes on to set out relevant pre-planning policy provisions including 633

02:18:02 including 633 and 521 and if we turn over the page to page eight

02:18:08 now we can see the text in italics

02:18:13 italics is your email of april 2009 to station staff about the database of high-rise premises and the need to carry out annual visits to high-rise buildings on a particular station's ground

02:18:26 a particular station's ground now if we can go to the middle of page nine so over the page

02:18:33 we can see there the heading pre-planning analysis

02:18:38 and that states this and if we could expand it in such a way so that notes gr3 and gr4 can be seen by mr brown and the panel

02:18:50 can be seen by mr brown and the panel thank you the pre-planning analysis says this there was evidence that the crew at lambeth were aware of the premises and that there may be access difficulties the opportunity was not taken for a 72d

02:19:01 the opportunity was not taken for a 72d visit to be arranged there was a failure to carry out a 72d visit high-rise database it is unclear how the high-rise database is maintained or updated for new high-rise buildings there is no

02:19:13 new high-rise buildings there is no clear mechanism for fire stations to be informed of new high-rise buildings which require section 72d visits

02:19:23 now i have assumed that the reference there to highrise database is to the

02:19:30 is to the database that was set out in the excel spreadsheet that was attached to your april 2009 email is that a safe assumption to make either that or they refer into the electronic database either central risk

02:19:42 electronic database either central risk register or the operational risk database thank you now we can see um

02:19:50 um the comments on the side gr is gr gary reason i would imagine so and what he says in gr4

02:20:01 and what he says in gr4 is this it would be helpful to have a footnote explaining how stations access this database if they can now that comment requesting clarifications to whether stations are able to use the database

02:20:14 able to use the database is unlikely to refer to the ord isn't it given that the ord was capable of regular and easy access yes i think by by this time uh i think

02:20:27 yes i think by by this time uh i think the ord probably had formally taken over from the central risk register so yes

02:20:34 yes it would it would seem reasonable that it's referring to that at that moment yes yeah

02:20:46 sorry just to clarify your answer what i was suggesting to you was that it is unlike the database that is the subject of the text here is unlikely to be the ord is what i put to you

02:20:58 ord is what i put to you i just want to make sure you agree with that proposition i will say

02:21:03 i'm not sure i'm not sure we can say that to be honest i mean first of all there is

02:21:08 there is there is

02:21:09 there is to my knowledge there was no such thing as a high-rise database as such they were referring to a database that contains high-rise what and the and the ord and gary

02:21:21 what and the and the ord and gary was

02:21:22 was well aware of the existence of the ord at that time and it's for that reason mr brown i suggest you it's not the ood he's referring to

02:21:33 and the other factor that he appears to have in mind or the author of this report appears to have in mind is the excel spreadsheet that was attached to your april 2009 email because that's what has been quoted extensively on the

02:21:44 what has been quoted extensively on the preceding page i'm not sure we can draw the conclusion so if we look if we're looking at comic gr4

02:21:53 gr4 ie it would be helpful to have a footnote explain how stations access this database i don't think we can

02:22:01 we can necessarily draw the conclusion that gary's not referring to the ord it may well be he's just trying to have an explanation it just makes it helpful for the reader okay now if we can just look

02:22:12 the reader okay now if we can just look at these comments in more detail the first one gr3 said this as the building is adjacent to the fire station did it not occur to any of the watches that should be subject to

02:22:24 of the watches that should be subject to a 72d visit irrespective of whether it appeared on the database now that comment suggests that crews were not expected to use

02:22:35 use the database as a comprehensive list of premises they were required to visit and would you agree with that that assumes of course that the database is the excel spreadsheet which was attached to your 2009 email

02:22:48 i think the cruise crews or or certainly managers station managers borough commanders i'm sorry to to repeat the comment again but i think it's worthy of of just

02:23:00 but i think it's worthy of of just of clarifying how much of uh how important issue it was for us were aware that all buildings need to be have an initial inspection to determine their future inspection regime

02:23:13 their future inspection regime so

02:23:14 so whether it's on the database or not i wouldn't expect crews or managers to be led exclusively by the database because people should have known that not everything

02:23:26 should have known that not everything was on that database

02:23:30 and there may be cause for concern about the quality assurance process taking place if the crews had not identified a high-rise building immediately adjacent to the fire station well the quality assurance

02:23:42 fire station well the quality assurance process that we've spoken about was was assuring the quality of the information that's gone on the operations database once it's been inspected the proposition here is about buildings

02:23:54 the proposition here is about buildings that have never even received that initial inspection in terms of even carrying out their quality assurance so that boils down basically to uh station managers and borough

02:24:06 uh station managers and borough commanders uh making sure that all buildings have had that initial inspection which is which is a slightly different nuance to career assurance now the report on

02:24:17 career assurance now the report on salamanca plays led to the creation of an action plan entitled sai 282 salamanca place that can be found lfb0095

02:24:30 and that plan was dated the 22nd of august 2012 so more than a year after the incident i'd like to focus on two particular actions

02:24:40 actions and the first one is action two which can be seen in the second row in the table

02:24:47 the table and it provided thus carry out a review of the existing high-rise database to determine whether it is viable and beneficial to develop and maintain this data set

02:24:58 and maintain this data set the term beneficial relates to station staff being able to access this type of information to highlight new high-rise premises and informed 72d visits now that action

02:25:10 and informed 72d visits now that action was allocated to the head of information management is that right yes and the third officer which was at that time you yes and the head of information management

02:25:21 and the head of information management this time was david wyatt is that right yes and still is i believe

02:25:30 now does that help you identify what the database was that these people were referring to do you think it was the excel spreadsheet attached to your email or was it the ord i think it must be the ord because

02:25:42 ord because head of information management was managing the the contents of the ord was the review carried out to my knowledge yes by whom

02:25:58 i don't know for sure but certainly i would have made sure it would have been it would have almost certainly been david wyatt

02:26:08 wyatt and then maybe some people that worked for me

02:26:11 for me i can't recall any further details i'm afraid when it was carried out

02:26:19 i don't remember particularly when all i can say is on all of these whenever dates were given to carrier actions i was

02:26:30 i was very uh

02:26:33 very uh i gave a lot of scrutiny shall we say to uh making sure actions were carried out when they were supposed to be carried out so

02:26:40 out so if there was a completion date on it i'd be confident that it would have been done within that time i can't remember any further now there's no completion date identified there so in the circumstances what steps would

02:26:51 so in the circumstances what steps would you have taken to ensure the review was actually carried out well it was a it was an ongoing transfer so

02:26:58 so the wider picture is the crr the central risk register was being carried over onto the operation risk database the

02:27:06 the list of high-rise premises that john webb had collated was another area that was feeding into the operational risk database

02:27:17 database so it was it was a process an ongoing process

02:27:21 process that was

02:27:22 that was going on to make sure a everything was finding its way onto the new

02:27:29 the new portal if you like you know the complete database

02:27:32 database ie ord and that we continued in making sure new premises regardless of whether we'd been on a list or not before found its way on there can you remember

02:27:44 can you remember the substance of the conclusion of the review

02:27:49 don't speculate if you can't

02:27:57 no no i i can't remember specifically now can we go on to an email chain that was pertinent to this action and it can be found at lfb0095342

02:28:12 and it's an email chain initiated by david wyatt on the 22nd of august 2012. and if we can turn to the bottom of page two

02:28:23 we see an email that mr wyatt sent at 9 11 on the 22nd of august in respect of si 282 salamanca place draft action plan

02:28:35 draft action plan and he said this so the action in this plan for me with dave brown is the database is of course ord i'm assuming but we'll clarify

02:28:47 i'm assuming but we'll clarify now if we go back to page two we get an email from anna lockwood and if we go up the page so we can see that email

02:28:59 and that was sent at 9 50. and she said this i've had a conversation with andy lachlan about this a few months ago he was under the impression the pda section

02:29:10 was under the impression the pda section maintained a database of all high-rise residential flats i informed him that this was not the case

02:29:17 case some entries have been made in ord but not all

02:29:20 not all we can extract all the properties from the mobilizing system but this this does take time

02:29:26 take time and if we go to page one and clive eustace's email which is at the top of the page he says this i don't think it is ord

02:29:37 i don't think it is ord but do think it is a very confused message in the first place the high-rise database they refer to is i'm sure the list sent round to stations some months years ago and i have no idea

02:29:49 some months years ago and i have no idea who owned this but can pretty much guarantee it was never updated as therefore of no very limited value this was the knee jerk list where the message said visit every high rise and

02:30:01 message said visit every high rise and consider 72d but what dave meant was add one of the blocks in the state if there are unusual or very difficult circumstances to be found there he couldn't say this in an email of course

02:30:13 couldn't say this in an email of course and we

02:30:14 and we information management therefore had to make sure people understood it at information management days now

02:30:24 now that email chain appears to say that the sia action plan was referring to the high-rise database attached to your april 2009 email

02:30:35 your april 2009 email now having had your memory refreshed by contemporary correspondence would you accept that

02:30:45 well based on on uh so andy lotlin from what i can recall uh had a lot to do with uh senior accident investigations so if that was and his understanding

02:30:56 and his understanding then yes he may well have been referring to that list but i would i would clarify that and say the fact that that list was finding its way onto the operational

02:31:07 finding its way onto the operational risk database so so what it might seem i don't appear to be dancing on a pin head with this one but the information that was in that list was going into the opera operation with database the operations database

02:31:18 with database the operations database was going to be the all-consuming one-stop place where all information should be i think what this does highlight is yes there clearly was confusion and uh

02:31:29 was confusion and uh and part of our remit was to eradicate that confusion so everyone understood where they need to go to for information and so the basic position is that three

02:31:41 and so the basic position is that three three plus years after you sent your email of april 2009 there was still confusion about the basics of what high-rise properties were on the books as it were and what the risks were

02:31:52 books as it were and what the risks were arising from those properties

02:31:55 uh no not one no i wouldn't agree that there was confusion about what high rises were on the books there may have been some residual misunderstanding

02:32:06 been some residual misunderstanding that predetermines the section carried some kind of exclusive list of high-rise rather than just the all-consuming list on the operation risk database

02:32:18 on the operation risk database but i don't think it demonstrates there was confusion about what was on the list and what wasn't it was all about organizational knowledge so there's confusion looking back at your earlier answers to where to find that information there

02:32:33 well according to this email chain yes but i wouldn't i i don't believe there was such confusion to be honest because the century sorry to stop you there mr brown

02:32:45 century sorry to stop you there mr brown because

02:32:46 because i think if there's any confusion now it's about the evidence you're just giving if we could scroll back i'd understood you to indicate that you're accepting

02:32:56 accepting that there was confusion as to where the information regarding high-rise buildings was located is that your evidence or isn't it so can you repeat that yes

02:33:07 so can you repeat that yes i'd understood you to indicate that you're accepting that there was confusion

02:33:11 confusion as evidenced by this email chain as to where information regarding high-rise buildings was located do you accept that

02:33:25 in terms of whether it was located on an excel spreadsheet or on the operational risk database yes

02:33:34 yes and that's the clear thrust of what mr eustis is saying in this email isn't it

02:33:42 well he certainly says in the opening sentence i don't have the easy rd but it's a confused message yes he does say that

02:33:48 that now

02:33:50 now when he

02:33:52 when he says in this in his email he refers to a message that's

02:33:56 that's said visit every high-rise and consider every 72d

02:34:01 every 72d that appears to be a reference back to your email of april 2009 would you accept that yes

02:34:09 now mr uses described that list as a knee jerk

02:34:14 knee jerk list first of all do you accept that proposition

02:34:20 no can you remember what event might have triggered the knee jerk to which mr eustis is referring well that's why i wouldn't agree with it because i don't think there was such an

02:34:32 because i don't think there was such an event

02:34:33 event i i think the the the rationale behind the 2009 email was the fact that we become more organizationally aware there was an

02:34:44 more organizationally aware there was an ops news that had gone out not long before talking about highrise there was another option used coming out about a month later after that particular email there was the operational risk database being

02:34:56 operational risk database being formulated there was mobile data terminals about to come online which displayed the information to crews at an incident from the operationalist database so there was a number of things

02:35:07 database so there was a number of things going on

02:35:09 going on and then there was the ongoing and i can't underline this enough there was the ongoing uh

02:35:17 at the forefront of their minds about the importance of high rise for various reasons was though sorry to interrupt was that a knee jerk to the

02:35:27 the impulse behind your email of april 2009 no i don't i i wouldn't i wouldn't accept there was it was impulsive or it was a knee-jerk i'm not suggesting it was impulsive what i'm suggesting is

02:35:39 was impulsive what i'm suggesting is that the

02:35:40 that the the trigger for the knee jerk list was your underlying motivation for sending the april 2009 email the fact that a list existed certainly

02:35:52 the fact that a list existed certainly underpinned the email but it wasn't the motive for for doing it there was a range of other organizational things going on okay mr youssef says in that email and we can see that the message said visit every high-rise but what dave

02:36:03 said visit every high-rise but what dave meant was and he sets out there what he understood you to be saying now is mr eustace

02:36:10 eustace is mr eustis uh correctly summarizing your

02:36:14 your your true concern in that email no from where could you have got that impression do you think

02:36:22 i i don't know i think that's something that only clive would know himself but it was common knowledge that there were certain housing estates where they might but i can think of one in particular in east london where

02:36:33 in particular in east london where there's 12 high rise blocks and l absolutely are absolutely identical to each other um what were i m days oh i am days were something that clive used this

02:36:44 days were something that clive used this and his team would run and we would invite borough commanders and station managers up to headquarters and then clive and his team would go through with them all the various

02:36:57 through with them all the various technological support systems ord for one for example station diary outside master duties list that station managers and baroque commanders can use

02:37:08 managers and baroque commanders can use to make their role a lot easier and more efficient

02:37:11 efficient what guidance was given to the information management department to allow

02:37:17 to allow audience members at these im days to know what constituted unusual or very difficult circumstances

02:37:29 i i don't believe these days would have covered that kind of area because that wouldn't been the remit of of what an im day was and iron day was to was to know how to use the information

02:37:41 was to know how to use the information management systems that were in place now can we look at the fourth and fifth paragraphs of mr eustis's email and he starts with this it has been a constant battle

02:37:53 constant battle with some sms presumably station managers

02:37:57 managers insisting they've been told to add all 200 odd high-rises they have as visits in the station diary osd so it's i think outside

02:38:08 osd so it's i think outside outside scheduled diary is that osd i think it's outside

02:38:14 outside duty

02:38:15 duty masterless i'm not sure what the s is for which adds them to ord of course it is now back again that is exactly the same issue people cannot add all high-rise blocks on their ground to mdt

02:38:27 high-rise blocks on their ground to mdt via ord as they would have no time to visit them all and it would be of very little value anyway the ones that are dodgy upside down maisonets dr so dry razer at

02:38:39 upside down maisonets dr so dry razer at dry riser outlets only on alternate floors etc should already be on if we had a complete list we could add as an overlay of course but this is valueless apart from ticking a box

02:38:51 valueless apart from ticking a box unless the data held specific things saying there is a large high building here on mdt is pretty pointless when they're outside it and can see that etc

02:39:03 they're outside it and can see that etc now where mr eustis says there's been a constant battle were you aware of a constant battle or at very least concerns raised by station managers as the practicability of adding all high-rise buildings

02:39:17 i wasn't aware of of issues from station managers at that time i think as i said earlier once we put our systems in place to make sure every every horizon every building

02:39:28 sure every every horizon every building was visited then we did get some uh pushback feedback in terms of at least you know how we're going to achieve that i have a vague recollection of clive

02:39:39 i have a vague recollection of clive being

02:39:40 being concerned in the issues that he's raising but then he was coming it understandably from the point of view of managing the database and then the quality assurance issues

02:39:51 and then the quality assurance issues that go on there and understand his position

02:39:53 position but my position was and for for what his worth still is that every single building should be visited because just because and i use that example of this housing

02:40:04 and i use that example of this housing estate in east london there are 12 high rises that are identical the people that live in them aren't identical and the risks therefore are not identical and you could have you could have a holder in one of those 12

02:40:17 could have a holder in one of those 12 and you could have a different risk in another so you need to visit every single one and once you've done that if if having done that you can then determine that they remain identical then maybe we can

02:40:29 they remain identical then maybe we can move to the position that clive is talking about but up until that time my position was firefighter safety it was it was extinguishing fires gathering information and you can't make assumptions on that regard

02:40:41 assumptions on that regard did you said you were vaguely aware of the concerns that prompted mrs email were you concerned as a result of those matters which were exercising him that

02:40:52 matters which were exercising him that crews might be taking inconsistent approaches to which high-rise buildings to visit etc

02:41:01 yes clive understandably a professional officer uh likes things done properly and was very protective and uh of this new database opera

02:41:12 uh of this new database opera operational risk database and he wanted it to to be a clean and uh efficient and effective database which is what i wanted to yeah uh

02:41:22 uh but and and i had a lot to do with clive and so therefore in the margins of normal meetings yes i will be aware of of clive's views on this

02:41:31 on this with so as we discussed earlier on three plus years on from your april 2009 email and the position may not have materially improved um

02:41:42 may not have materially improved um did mr eustis communicate his concerns to you more directly at this time and so what action did you take to try and expedite uh the improvement of how you held knowledge in relation to

02:41:53 of how you held knowledge in relation to high-rise buildings

02:41:57 from what i can recall clive's concern was

02:42:01 was that we were putting too much information on the ord

02:42:07 ord whereas my concern is that i wanted to make sure everything was inspected and the appropriate information went on the ord but i think where we both agreed is that the premises risk assessment will be that

02:42:19 premises risk assessment will be that appropriate system to satisfy both of our concerns now

02:42:25 now let's focus on that and looking at the practicability of it mr eustis said people cannot add all high-rise blocks in their ground to an mdt as they would have no time to visit them all and it would be very little value

02:42:36 all and it would be very little value anyway

02:42:37 anyway um

02:42:39 um would you agree with the first element of that proposition that crews did not have time to visit all high-rise blocks on their station's ground well firstly it depends on the station's ground some stations grounded significantly more high-rise than others

02:42:53 significantly more high-rise than others and if he was to look exclusively at the cruise on some station's ground let's take for example in town hamlets there's a predominance of high rise if you was to say to the crews in tower hamlets

02:43:05 to say to the crews in tower hamlets it's your job to visit all those high rises in your job alone then yes it will be a very challenging task but that wasn't the approach that we took

02:43:13 we took and i suppose the more pertinent criticism is the is the second one here that he said it would be of little value anyway

02:43:20 anyway what would i think it would benefit the panel to have your views on that particular criticism he made do you accept that that exercise would have been of very little value no i don't because

02:43:31 little value no i don't because i think what clive is referring to is on the assumption that nothing changes and not all high rises within that particular area or state are the same but we can't make that assumption it

02:43:43 but we can't make that assumption it will be dangerous to make that assumption is there a problem that i've been thinking about matters practically that if you do require crews to visit all high-rise buildings and i'm mindful of your sensible caveat that depends how

02:43:55 your sensible caveat that depends how many there are etc there's an element whereby

02:43:58 whereby they go around them in order to tick that particular box but actually the purpose of the section 72d would be undermined because they're not doing the job properly examining all the matters they need to examine in

02:44:09 the matters they need to examine in order to collect all the information the law requires them to gather i i can see why someone might say that i would counter that with saying that

02:44:20 counter that with saying that this this contradicts their professionalism and what i always used to say to crews at stations every opportunity is you're carrying out this inspection this 72d inspection

02:44:32 inspection this 72d inspection uh because one day you might be called to go in there and risk your life and fight a fire and so it's it's within your it's for your own benefit and your family's benefit to make sure you've got

02:44:44 family's benefit to make sure you've got all the appropriate information so i don't think any any sensible professional firefighter would overlook that because they know that tomorrow they could be in there fighting a fire

02:44:55 they could be in there fighting a fire and they might miss something that could save their life put slightly differently were you

02:45:01 were you given any substantive evidence that suggested or indicated that the value of section 72d visits of high-rise residential premises was being debased

02:45:12 debased or was it materially insufficient as a result of them having to inspect all high-rise buildings on their ground

02:45:20 i wasn't i wasn't made aware of any any specific

02:45:25 specific issue

02:45:25 issue that would would underpin that that statement i guess i i could look at the number of high-rise buildings that were

02:45:36 number of high-rise buildings that were becoming

02:45:39 becoming involved in the operation of this database and recorded and then they weren't being loaded on as quickly as i would like so that caused me some concern

02:45:49 concern but i was i was satisfied with the various quality assurance process ahead in place to make sure that the quality of the information was correct notwithstanding the comments you've made

02:46:00 notwithstanding the comments you've made earlier about that on grenfell so the risk of oversimplification there are no red or amber signals flashing to you that the quality of information obtained through section 72d visits was

02:46:12 through section 72d visits was materially deficient no and if i if i can just add as well as the quality assurance process we had in place once we had the service standards in place

02:46:22 in place we created a group of offices called service standard support officers that didn't have managerial

02:46:30 involvement and they were sent around to do programmed audits of stations to look at the various service standards and the one that involved contingency planning which seven two days would sit under

02:46:41 which seven two days would sit under would involve an annual audit at each and every station looking at each and every watch in terms of their quality assurance so we were putting these systems in place to make sure

02:46:52 systems in place to make sure as far as we reasonably could that the processes were being adhered to now turning back to mr eustace's email he has a pungent turn of phrase and he

02:47:04 he has a pungent turn of phrase and he refers there to high-rise buildings that are dodgy

02:47:07 are dodgy uh upside-down maisonets dry riser outlets only on alternate floors etc should already be on um was it your understanding that those types of properties or those properties giving rise to particular

02:47:19 properties giving rise to particular issues had already been recorded on the ord

02:47:24 well i'd like to think so but i don't think we could say which is why i was so adamant that every high-rise should be inspected so we could be sure

02:47:35 so we could be sure nothing could have given me the assurance that what what clive is saying here that they should already be on he says exclamation mark so i guess yeah should already be on

02:47:46 should already be on but i wouldn't be satisfied they were hence why i wanted everything inspected yeah the sentence seemed pregnant with doubt

02:47:53 doubt um

02:47:54 um looking at it well well it could be read that way or or it could be i guess read as an area of frustration from clive that they should all be on so why are you doing this but but regardless of of clive's or anyone's view

02:48:06 clive's or anyone's view i felt morally and professionally responsible to make sure that everything should be inspected to make sure a decision made about whether it should or shouldn't be subject to future inspections looking from the lay

02:48:17 inspections looking from the lay perspective concentrating on quote dodgy close quotes buildings does that give rise to the danger that undue focus on those would ignore

02:48:28 undue focus on those would ignore other high-risk presentations on other high-rise buildings such as cladding for example oh

02:48:36 oh i mean clive has got a unique turn of phrase that's for sure but but his bluntness was appreciated i think what he's referring to in terms

02:48:47 i think what he's referring to in terms of upside down masonettes is is the challenges that you experience if you're not expecting them in terms of the dangers that you a firefighter going down stairs into a fire and the heat

02:49:00 down stairs into a fire and the heat rising up the stairs can be immense thank you now can we see some time ago now that we started it can we go back to the salamanca place yesterday report and that can be found

02:49:11 yesterday report and that can be found at lfb double zero one zero double six one five

02:49:15 one five forward slash two

02:49:22 and this is the action plan monitoring report and we see page two bottom row of the document is the latest position in relation to

02:49:33 is the latest position in relation to action two which is the the action we've been discussing what it says in the far right hand column as this at 28th of september 2012 no database to be

02:49:44 28th of september 2012 no database to be maintained ops news article to raise awareness for crews regarding the importance of carrying out and recording 72d visits in the correct format and below that at 20th of january 2012

02:49:56 and below that at 20th of january 2012 and 4th of december 2012 as above detailed in action 1 and then 14th of january 2013 it has agreed that there will not be a database maintained now looking at that

02:50:10 maintained now looking at that final entry um

02:50:13 um did you agree not to maintain a database i think this this must be referring to the issue about a

02:50:24 the issue about a specific high-rise database not that there won't be a database with high-rise on and

02:50:31 and and it's really important that we that we don't think that there wasn't a database with high rise on because there absolutely was and that was the operational risk database thank you my question was did

02:50:43 database thank you my question was did you agree

02:50:45 you agree not to maintain a database i can't remember specifically whether i did or didn't agree but looking back on it now providing it was recorded on the ord i wouldn't have had

02:50:58 recorded on the ord i wouldn't have had an objection to there not being a specific high-rise database can you remember who else was involved in making the agreement referred to here it would have been david wyatt

02:51:10 would he have acted unilaterally or in consultation with you

02:51:15 no you wouldn't have acted unilaterally can you remember now what reasons informed the agreement

02:51:24 i can't remember for sure but i am aware of the drive towards simplifying everything so one database

02:51:35 simplifying everything so one database one-stop shop and that that i think would have been the motivation behind it now

02:51:43 now in that regard can we turn to a witness statement former colleague of yours rita dexter and particularly her first witness statement and in that document she touched upon the difficulties of defining and identifying high-rise

02:51:55 defining and identifying high-rise premises in london which we've been discussing this morning if we could go to lfb trouble zero three two three six three forward slash eight

02:52:10 and if we see the very bottom of the pages paragraph 27 and she says this and apologies um for reading it out is probably helpful for people listening i was present at the second meeting of

02:52:21 i was present at the second meeting of the lachnal house working group on the 28th of august 2013 assistant commissioner steve churek who reported to me gave a presentation on the rro so the ready to reform order his

02:52:33 the rro so the ready to reform order his presentation included a recollection from information management colleagues who also reported to me go over the page about the problems of defining and identifying high-rise premises given the

02:52:44 identifying high-rise premises given the absence of adequate and appropriate data at the time this was seen by officers as an important issue because uncertainty about the number height location and purpose of high-rise buildings was an

02:52:56 purpose of high-rise buildings was an impediment to fire safety inspection familiarization 72d visits and community fire safety work it was an issue that we continue to work on over the following years

02:53:07 on over the following years now from what you've been saying this morning it appears that at least you brought share in broad terms rita dexter's concerns there about defining and identifying high-rise

02:53:18 defining and identifying high-rise buildings

02:53:20 buildings yes

02:53:23 would you agree that at the time as they were talking here about 2012 there was no clear defensive list of high-rise building locations for the reasons you've given

02:53:36 we wasn't we wasn't satisfied that we knew about every single high-rise that's for sure

02:53:42 for sure would you agree that the absence of clear data at its most basic as to how many high-rise buildings there were in london was an impediment to effective discharge of section 72d

02:53:56 it was a challenge that we were dealing with yes

02:53:58 with yes well

02:53:59 well challenges one of those words that's become tarnished with overuse impediment i suggest you as the more accurate

02:54:07 accurate word to use would you accept that

02:54:12 so without using the word impediment or challenge i would i would describe it as the fact that we understood our duty and we were we did not know

02:54:22 not know for sure

02:54:23 for sure that the amount of premises that existed within that definition and where they were and we were making every effort to find them and therefore discharge our duty

02:54:35 discharge our duty now

02:54:36 now she concludes in the final sentence of paragraph 27 that this was an issue that we continue to work on over the following years now from 2012 onwards

02:54:49 now from 2012 onwards what particular work streams that you're aware of were concerned with identifying and defining high-rise buildings

02:55:00 buildings so in terms of identifying high-rise buildings uh there was work going on with the borough commanders so just to put some context behind that for the for the panel the borough commanders worked

02:55:13 the panel the borough commanders worked uh very closely within their boroughs with local authority chief executives borough commanders of police etc tripartite arrangements so it was close working relationship and

02:55:24 so it was close working relationship and it would be that the chief executive local authority would see the borough commander as the the bl-1 indoor when it comes to the fire brigade and that was deliberately while that structure was set up so that was that was a crucial

02:55:36 set up so that was that was a crucial link into housing providers etc so a lot through borough commanders then there was obviously writing to chief executive level uh that rita

02:55:47 chief executive level uh that rita dexter was doing a lot of in terms of reaching out through london councils and trying to find out from housing providers working with housing providers independent housing providers

02:55:59 providers independent housing providers as well trying to find out the various lists that existed of high-rise premises but then there was also what is a high-rise and that was and that might seem

02:56:10 that might seem that might seem a crazy thing to say but it it really was difficult in trying to determine what is a high rise because people had different ideas and we ended up as you saw in the

02:56:22 and we ended up as you saw in the premises risk assessment work on an 18 meter rule with six floors but that was because when a dry riser no longer worked and we used a wet riser so that's where water is is already in the

02:56:34 where water is is already in the building on the roof and it comes down rather than being pumped up and so we use that for our own definition but you would you would find different definitions from different parts of london as to what was a high

02:56:46 parts of london as to what was a high rise

02:56:47 rise so so we were wrestling with both of those issues uh in terms of trying to define a definitive list did you before you retired looking at the last element of your answer there were you able to agree

02:57:00 were you able to agree and promulgate a unified definition of a high-rise building that applied across london

02:57:06 london we was we was for the purposes of our own staff and inspections uh where

02:57:13 where whether would every single housing provider agree with our definition uh i can't say it just in relation to an earlier answer you said

02:57:22 you said we'd find different different different definitions from different parts of london as to what was a high rise are you referring there to different definitions being applied by the area commands within lfb are you talking

02:57:35 commands within lfb are you talking there about different definitions applied by people such as um housing providers housing providers so not a confusion within the rfd no we with the lfb we adopted the the wet riser stroke dry riser definition and that was

02:57:47 dry riser definition and that was understood within lfb thank you

02:57:52 thank you can we now turn to action one arriving out of the salamanca place and if we go to the sia report lfb trouble zero nine five zero four two

02:58:08 and if we look at action number one

02:58:12 and the required action is this

02:58:15 is this raising awareness through operational news of the importance of station-based staff identifying complex and high-rise premises that should be inspected under the fire and rescue services act section 72d visits

02:58:28 services act section 72d visits the word complex had an asterisk next to it and the asterisk says this for the purpose of this s-a-i action the term complex relates to premises that have an unusual design layout that would

02:58:40 have an unusual design layout that would cause difficulties to cruise when responding to incidents now that action was allocated to the assistant commissioner oase which is operational assurance i think yes and at

02:58:52 operational assurance i think yes and at that time it was danny cotton is that right

02:58:55 right i believe so yes and third officer that would be you yes thank you now if we can go back to the sai action plan monitoring report from february

02:59:06 plan monitoring report from february 2013 which we looked at a few moments ago lfb double zero one zero double six one five four slash one

02:59:17 and if you look at the fifth column on the first page i had the most the extreme right now i'll let you just refresh your memory of that and let you read it briefly

02:59:58 yes now the thrust of uh the substance of that uh column is that awareness was raised through the publication of articles in operational news issue 24 in march 13. and in the november 2012 shout

03:00:12 march 13. and in the november 2012 shout exclamation mark newsletter is that a first summary of the actions taken yes thank you and the social training packages yes now in relation to operational news 24 can we go to that and that can be

03:00:25 24 can we go to that and that can be found lfb trouble zero five zero two on five

03:00:39 sorry it's an email says lfb

03:00:43 says lfb trouble zero five zero two one five

03:00:53 now this is a rod in the article itself as an email chain in relation to a draft of that particular edition and if we can go to page three in this email chain

03:01:05 and it's really at the top we see an email from graham ellis timed at 9 19 on the 12th of january 2013 and he forwarded the latest draft to danny cotton and gary reason

03:01:18 to danny cotton and gary reason helpfully mr ellis is set up further in the chain the draft check the draft text of operational news which is referring and we see that at the bottom of page one

03:01:34 so we see there starts description 72d visit so we can go over the page and it's really the third paragraph on page two i'd like to look at it said this fire station personnel will often be

03:01:46 fire station personnel will often be best placed to identify significant developments or changes to property which may have an impact on safe operations policy 800 information gathering contingency plans explains the risk

03:01:58 contingency plans explains the risk assessment process which should be used to establish whether a premises requires visiting and describes a method of recording on the operational risk database it is important that crews always refer to the risk assessment

03:02:09 always refer to the risk assessment process when carrying out initial and revisits as changes to the building or the risk matrix within policy 800 can affect whether the premises is added to or removed from the ord

03:02:21 or removed from the ord whenever a high-rise residential building is assessed to be entered on the ord a suitable line drawing of the layout should be included it it's also important that personnel plan for the possibility that any fixed installations

03:02:33 possibility that any fixed installations are unavailable now as we've referred to earlier the reference to the risk matrix in policy 800 is the formalized process by which a property is scored and on the basis of that visits

03:02:45 and on the basis of that visits determined in their regularity yes and the property score then determines frequency of visits is that fair yes

03:02:53 yes and in the case of properties that are scored as being very low on the matrix they don't need to be included on the ord at all below

03:03:02 below 149 and below yes yes now if we can go mindful of that context if we go to danny cotton's email which is in the bottom half of page two so the one we're looking at at the moment

03:03:16 and she says hi folks i still have some concern with the matrix in policy 800 and what happens if the watch manager deems the premises does not present a complex or unusual risk

03:03:29 not present a complex or unusual risk i've discussed this a number of times with dave brown as he and dave lindrich tried it out on lachen house and came up with different answers i'm just concerned that we may end up

03:03:40 i'm just concerned that we may end up with conflicting messages maybe you could have a quick chat at dmb what does dnb stand for a directorate management board i know that the commissioner wants the message to be reinforced in ops news but

03:03:53 message to be reinforced in ops news but i would hate for us to confuse the opportunity to make sure that crews are increasing their operational knowledge now danny cotton then says in a later email in the same thread and if we go up to the middle of page one

03:04:07 see email at 8 42 she says this my main concern is that db presumably dave brown dl presumably dave lindridge applied the

03:04:18 dl presumably dave lindridge applied the same matrix to lachnal house and came out with a or should i say lh which i'm assuming to be lacking house and came out with a different response and db you

03:04:29 and db you said that he was confident that all watch managers would opt to do the work and make the buildings fit the more complex challenging criteria and include drawings rather than take

03:04:40 and include drawings rather than take the easy option and just to conclude the email chain can we go to the top of page one and the email from graham ellis

03:04:52 row of dots he says this and it would be fair to assume that the situation will not improve when there are far fewer crews to go out and do the work in the first place i still think there needs to be a more

03:05:03 i still think there needs to be a more systems-based approach where crews are provided with a list of premises that they should visit the building information plates will also play a key role as crews will be traveling further to attend incidents off their local

03:05:15 to attend incidents off their local patch

03:05:16 patch we are looking at camden and lambeth to trial the plates i am keen that i we don't get dumped with making all work though we have provided the idea and wise council but i think rfs

03:05:28 wise council but i think rfs regulatory fire safety and orm

03:05:34 i've never heard that that one before

03:05:41 presumably operations response and mobilizing yeah maybe or operational risk management i'm not sure but need to take ownership to move it forward the matrix and policy owners

03:05:52 forward the matrix and policy owners really do need to get this sorted out though

03:05:55 though there's a lot in that email chain mr brown can we take it step by step sure um first of all did you and dave lindrich apply the risk matrix to lachnal has

03:06:06 matrix to lachnal has i don't remember doing that but it would have it wouldn't have been a an unreasonable thing to do are we safe to assume that the matrix referred to as the risk matrix we've

03:06:18 referred to as the risk matrix we've considered in policy 800 yes

03:06:22 why did you and mr lindridge apply the risk matrix to lachlan has if if we did do it it would have it would have been uh as a

03:06:33 uh as a scoping exercise as a test to see whether the likes of lacrimal house

03:06:38 house had the premises risk assessment been in place at the time would it or would it not have passed the test and been put onto the operational risk database and the reason dave lindrich is because

03:06:50 and the reason dave lindrich is because dave lindridge carried out the review of the lacrimal house action plan

03:06:58 when was that work done can you remember what the the the tester if you like for lacking or house or well again i want to caviat a bit i don't don't specifically remember doing

03:07:09 don't don't specifically remember doing it but if if it did happen and i've no reason to assume that this is wrong that's about to say there's no reason here to assume that that's wrong no no no no so you can proceed on the assumption you and lindridge did it yeah

03:07:21 assumption you and lindridge did it yeah if it did happen it would have been uh probably

03:07:26 probably around the time that dave lindridge was doing his reviews that have been late 2012 early 13. can you remember did you and dave lindrich come up with different answers

03:07:38 lindrich come up with different answers well i i don't recall that i would i would say though that uh if you look at the premises risk assessment it

03:07:48 it it is a guide so it isn't isn't beyond reasonableness to to think that you could come up with different answers and i'll give you an example to demonstrate

03:07:59 i'll give you an example to demonstrate that so one of the criteria is a building

03:08:04 building with

03:08:05 with 500 or more people residing there now if if one person looks it and think well actually there's less than 500 another person thinks there's more and there isn't a responsible person there

03:08:16 there isn't a responsible person there to be able to clarify for sure then then straight away whatever points are allocated to that decision might be on one person's risk estimate or another so

03:08:27 so it would be it'll be foolish of me to try to say that actually every single premises risk assessment would come out identical well what i would be very very confident of

03:08:38 what i would be very very confident of saying however though is even if there were these nuances as i have explained i am still absolutely satisfied that each risk assessment would land within

03:08:49 each risk assessment would land within the zone so for example 500 to 750 points

03:08:54 points one might get 550 and one might get 600 but they would both be in the right place

03:08:59 place so on the base of that answer you didn't necessarily share the full extent of danny cotton's concerns about different answers being produced by different people applying the matrix no i think what what what was

03:09:11 the matrix no i think what what what was behind danny's concern and and a genuine concern what was behind danny's concern is that if there was different answers that would be leading it to such a low

03:09:22 that would be leading it to such a low score that it's above or below 150 that's what danny's concern was and i didn't share that concern because whilst i accept there is the potential for two

03:09:33 i accept there is the potential for two different

03:09:34 different scores that they would come the right side of 150.

03:09:40 did you consider that any training measures were required to ensure

03:09:46 to ensure sufficient consistency in application of the matrix so that the score did end up on the right side of 150 if i could put it that way well there were there were options

03:09:57 way well there were there were options articles on uh mdts and operation risk database and there were associated training packages and then and then we we of course verified this because apart from the

03:10:09 verified this because apart from the systems we've spoken about already every training exercise that was carried out on high rise or any building for example part of that training exercise would be to look at what was on the

03:10:21 would be to look at what was on the operational risk database every performance and every performance review of operations would consider the initial information gathering which was therefore in the operation operation

03:10:32 therefore in the operation operation risk database every fatal fire review we did would look at information gathering so there was a whole range of what i would call reactive measures in place that we looked at as and when incidents

03:10:44 that we looked at as and when incidents arise and we ask ourselves that question was there sufficient information on the operational risk database looking at danny cotton's email her concern appears to be prompted by

03:10:55 concern appears to be prompted by the brown lindridge exercise were you aware at the time of any broader concerns that there was an inconsistency in application the risk matrix

03:11:06 application the risk matrix so that properties weren't being accurately or appropriately scored no i wasn't aware of any concern in that regard and uh and whilst i can

03:11:17 regard and uh and whilst i can understand people uh you know their professionalism asking that question i don't think it was a real concern because i i truly didn't believe that this would become an

03:11:29 didn't believe that this would become an issue particularly at such a low level of scoring thank you now if we just go back to it so you've got it on the screen so

03:11:36 screen so remember what i'm i'm talking about is graham ellis's email

03:11:42 top of page one there we go now he says there expressed a preference for a more systems based approach where crews are provided with the list of premises that they should visit

03:11:53 they should visit now

03:11:55 now had mr ellis been raising and explaining with you what he meant by quotes a more systems-based approach close quotes and i can't recall uh graham uh raising

03:12:07 and i can't recall uh graham uh raising this i can i can imagine what he means i think he goes on to explain this in this email in terms of or later email that you've shown me just now in terms of

03:12:18 you've shown me just now in terms of just being given a list oh yeah it does say exactly it's just it's the extract i've just quoted yeah it's a provision of a list so i think that's what he's referring to so it's not not much more of a substantive system

03:12:30 not much more of a substantive system beyond provision of the list no and and and for the record i would i would uh completely disagree with the list because firstly where is that list going to come from i was about to ask you it's going to be the station manager isn't it presumably

03:12:42 the station manager isn't it presumably or the watch manager well yeah and then and then where are they going to get their information from and and this is all about ownership this is about making crews own their station grounds and become part of the community

03:12:54 grounds and become part of the community and familiarize themselves with it and there's there's a whole range of other reasons why we would want them to get out and about on their station's ground and do this it's not just about information gathering it's about being

03:13:05 information gathering it's about being seen in the community being part of the community for people to come and ask advice it's about being able to recognize people that are in trouble and need our help and refer them serious

03:13:16 need our help and refer them serious outstanding risk home fire safety risk assessments all designed to work in partnership with local authority and the police to drive down fire and crime and to make you know achieve our overall

03:13:27 to make you know achieve our overall objective of making london a safer city so it's far far broader than just being out there and if staff were just given a list to do that then we miss a fantastic opportunity to do so much more good work

03:13:40 opportunity to do so much more good work was that discussion a discussion that you had with mr ellis at this time so start of 2013 you've given a a pungent analysis of the disadvantages of what he was suggesting was that a discussion

03:13:52 was suggesting was that a discussion that was had at the time uh i i don't recall uh graham ellis ever actually raising this issue with me in those terms but had he have done so then

03:14:03 those terms but had he have done so then i would have given the same answer i've just given then remember danny cotton or anyone else raising it with you because at this stage she was of ac operations assurance so it fell directly

03:14:14 operations assurance so it fell directly within her remit i i do recall that danny was concerned about the the issue that we've just discussed either things might might not make themselves onto the

03:14:25 might not make themselves onto the operational risk database and that was a genuine and professional concern but in terms of just giving a list as graham suggests i don't recall danny ever mentioning that to me thank you

03:14:38 ever mentioning that to me thank you so we're slightly early but we've come to the end of the questions in relation to this topic and

03:14:44 and the next topic will take longer than five minutes so it would be essential to stop a little early at this point it would sir yes very well well we would normally stop about one o'clock mr brown but the reasons that mr clear has just

03:14:55 the reasons that mr clear has just explained it's probably better to stop nerd

03:14:58 nerd so we'll break now we'll resume please at two o'clock and again please don't talk to anyone about your evidence while you're out of the room okay thank you very much thank you very much would you give the usher then please

03:15:18 thank you two o'clock thank you