Grenfell Tower Inquiry - London Fire Brigade Evidence - Wednesday 6th October 2021 (2/2)
00:19:40 would you ask mr brown to come back in please
00:19:54 all right mr brown ready yes good thank you very much yes mr kinnear thank you before the lunchtime break we were talking about operational news 24 and you referred to the training
00:20:05 news 24 and you referred to the training packages that were initiated by that can we now turn to those particular training packages yes
00:20:11 yes now
00:20:12 now if we can go back to the final publicized published version of operational news 24 it included the reference to training package on 72d visits and if we go to lfb double zero
00:20:23 visits and if we go to lfb double zero double one eight nine five nine forward slash four
00:20:37 and if we can look at the second to last red box on the page which states in relation to 72d this
00:20:46 this training pack available to watch officers through training support icon knowledge center ops news 24 watch training package was their mandatory training that all
00:20:57 was their mandatory training that all watches would have been expected to carry out yes now the inquiry is identified tcap zero double five uh entitled 72d ops news 24
00:21:08 double five uh entitled 72d ops news 24 and that can be found at bab quadruple zero double zero three five
00:21:18 and if we look at the first page of this tcap we can see that its title refers to section 72d and options 24. um for the avoidance of doubt was this the tcap that was specifically created
00:21:30 that was specifically created for the creation of the training package following on from operation operational news 24. i believe so although i just would add that i would never normally see the tcat but yes this this i'm
00:21:41 see the tcat but yes this this i'm satisfied this is a correct one now if we can turn to page eight within this document
00:21:48 we can see in the second box that could be amplified that ac cotton as she then was is listed as the commissioning officer and dac mick ellis is the client
00:21:59 mick ellis is the client is it right that dac mick ellis reported to you he did he managed central service delivery and reported directly to me
00:22:09 is he another ellis at the lfb he's neither dominic nor graham no that's correct there was an over abundance of ellises and he was he was one of them yeah now if we look in the following section
00:22:20 now if we look in the following section on on page eight which is entitled background and context it's at 2.4 it states in the second paragraph in that box this the odcb operational
00:22:31 that box this the odcb operational directorates coordination board stated that it requires a cbt package regarding 72d visits following their meeting of 3rd september
00:22:42 following their meeting of 3rd september 2012. this requirement is driven by concerns raised by the salamanca police investigation over when and how 72d visits are undertaken the concerns
00:22:53 visits are undertaken the concerns center around what risk-based approach is taken to identifying buildings including high-rise and how it is recorded on the ord first of all cbt stands for
00:23:04 first of all cbt stands for computer-based training i think yes thank you
00:23:07 thank you does that summary there accord with your recollection of the concerns which uh motivated odcb at the time i'm just going to reread it please do
00:23:25 yes thank you um now babcock who is x day the brigade's external training provider has provided
00:23:32 provided a slide show for this training program if we can turn to bab quadruple zero double zero five six
00:23:44 there we see it's entitled seven two d visits um do you remember having calls to read these slides before they were
00:23:51 they were trained out to personnel uh i didn't know and it wouldn't be normal practice for me to do that no put colloquially would it be below your pay grade to review these matters
00:24:02 pay grade to review these matters i would never use that terminology but but yes
00:24:06 but yes could we turn to page two on the bottom slide in particular
00:24:15 now these set out the learning objectives and if we turn to page six [Music]
00:24:25 and the bottom slide there is entitled what to look for on a 72d visit
00:24:37 now would you agree with me there there's no reference there to the 22 items identified in the appendix 1 to six three three
00:24:50 express reference sessions yeah yeah there's no express reference i mean i'd have to go through each of those icons and think carefully about how they cross reference with those 22 but but notwithstanding that
00:25:01 notwithstanding that those items aren't expressly listed no thank you and if we could turn over the page and just go through from pages seven onwards
00:25:11 now what we see here are a number of examples on how to calculate risk scores and what actions take based on identified risks now we've gone through these and you can
00:25:23 now we've gone through these and you can go through them yourself if you'd like to but the essential point is that the training nowhere provides any guidance on how crews should actually go about identifying risks when carrying out the visit now
00:25:36 risks when carrying out the visit now looking at this page would you accept that as a criticism for example of this slide
00:25:55 okay can i just qualify uh my answer on on this unless you give your answer first and then the qualification might be easiest okay no there isn't any specific
00:26:06 no there isn't any specific reference on here in terms of how you go about interpreting that risk the qualification i'd like to give to that is
00:26:16 that is i think the the premises risk assessment is very much a linear based approach so for example you either think there are 500 or more picture premises or you
00:26:28 500 or more picture premises or you don't you either think there's a sleeping for 100 or there isn't so
00:26:33 so i think what this does it gives the opportunity for crews to practice that linear premises risk assessment so in terms of do i think it's
00:26:44 so in terms of do i think it's satisfactory then i think it it works in terms of crews being able to apply this and then discuss their rationale after but in terms of uh telling them and
00:26:55 but in terms of uh telling them and training them as to how to go about in practical terms the 72d would you accept it's not quite achieving that aim
00:27:04 i accept your your earlier proposition that it doesn't
00:27:08 doesn't give guidance on how to complete the risk assessment but as i say i think that is straightforward and and linear and this gives you the opportunity to
00:27:19 and this gives you the opportunity to practice it so i wouldn't agree that it doesn't meet the objective of the 72d training package in that regard right let's now look at bab quadruple zero zero five
00:27:35 now as the front slide suggests these are trainer notes um for the training which give guidance on how to deliver the training now can you remember was this training delivered by staff at
00:27:47 this training delivered by staff at station level [Music]
00:27:51 [Music] i can't remember would that be the usual level at which this type of training is pitched if it was if it was a cbt training there's a fair chance that this would be
00:28:04 there's a fair chance that this would be delivered by the watch officer in charge of that particular watch at the station would the watch officers themselves have re received training on how to conduct some 2d visits
00:28:18 not over and above what they would have experienced as a firefighter
00:28:26 do you consider that to be a gap in the system in the sense there is a missed opportunity to ensure consistency of approach to 72d visits by ensuring all watch officers are trained in the
00:28:37 all watch officers are trained in the same way as to how to conduct them
00:28:42 i don't think it's a missed opportunity in terms of should we supply training over and above for watch officers as opposed to firefighters because i think the the process doesn't
00:28:53 because i think the the process doesn't distinguish between who it is that's carrying out a risk assessment i think it matters it matters not whether it's a firefighter or watch officer at the end of the day the inspection is the
00:29:04 of the day the inspection is the inspection so i don't see any any specific issue there i think we're i think we're an opportunity was overlooked in the past is the is is
00:29:15 was overlooked in the past is the is is the question about what training did we give staff to do seven two days prior to this training package and i think up to that point it was only initial training when joining the organisation and and on the job training
00:29:27 organisation and and on the job training learning uh as you did the inspection so so i think probably this hopefully rectified what maybe have been missed in the past but but i wouldn't uh i wouldn't i don't
00:29:39 but but i wouldn't uh i wouldn't i don't believe there needs to be any different training for watch officer as opposed to a firefighter on this particular issue just following on from the more procedural mechanics of the training program mr brown see how far you can
00:29:50 program mr brown see how far you can help us on this could we go to bab quadruple zero double zero three five forward slash two three
00:30:02 now if we look at the final box on that page under the heading final sign off there appears to be no final sign off now
00:30:12 now do you know whether the training and this
00:30:16 and this tcap concerns the 72d training program we've just been considering do you know whether the training was in fact provided notwithstanding the absence here or the apparent absence of any
00:30:28 here or the apparent absence of any final sign-off um i believe the training was provided yes what's the basis of that belief because well a number of things so firstly we've issued the publication
00:30:39 firstly we've issued the publication secondly we've issued the training package but crucially what i always would have done is
00:30:45 is seek to performance management the completion of that training so information management were able to supply me with reports in terms of how each watch were progressing we would
00:30:57 how each watch were progressing we would read amber and green it in terms of have they started it have they not started have they completed it and then i would report the outcomes of that suit ocdb to close that loop as it were to
00:31:08 to close that loop as it were to demonstrate that yes the training was required yes it's been provided and yes it's been completed now just in relation to training on on how to carry out section 72d visits sorry to label the
00:31:19 section 72d visits sorry to label the point but danny cotton when she gave evidence the inquirer at phase one um said that no training was provided to firefighters on how to go about conducting a visit is that consistent
00:31:30 conducting a visit is that consistent with your understanding of the position it is consistent with my understanding in terms of up and to up until this point but thereafter then no that's not
00:31:41 point but thereafter then no that's not the case and so you your position is that this training program remedied any previous deficiencies yes
00:31:54 can i now turn to a draft email from you in relation to stations regarding the recording of high-rise premises on the ord and for start this
00:32:06 and for start this line of questioning can we go to lfb double zero double one three five double nine
00:32:16 now what we can see here and if we go to the bottom half of page two
00:32:24 is an email chain from november 2012 so after the publication of policy 800 in july 2012 and around about the time i think you
00:32:35 and around about the time i think you thought but weren't entirely sure that your involvement in policy 800 started now what we have down here is an email from david lindrich to richard binder
00:32:46 from david lindrich to richard binder and first of all who was richard binder richard bina was a group manager who worked in central service delivery and would have worked for michellis now looking at this we have
00:32:58 now looking at this we have the first line this message from assistant commissioner ops prevention and response dave brown and it's for all station based managers and the
00:33:08 email was headed recording of residential high-rise on the operational risk database and i hope you don't mind i'll read it out so apologies to people having to listen to me this message has been sent to remind
00:33:19 this message has been sent to remind station based managers to review the risks on their station's ground with a particular focus on the recording of residential high-rise the quality of information held in the operational risk database is
00:33:31 operational risk database is instrumental in reducing the risk our crews and the members of the public are exposed to through use of the mobile data terminals mdts the publication of pn 800 information
00:33:43 the publication of pn 800 information gathering contingency plans earlier this year gives guidance on identifying and gathering operationally important site risk information sri and other supporting information and recording it
00:33:56 supporting information and recording it on the operational risk database this risk-based approach allows watch and station managers to prioritize the premises on their stations ground and familiarize their crews accordingly and
00:34:08 familiarize their crews accordingly and now the following section is emboldened and italicized in the text of the draft it might be useful to describe here which high-rise premises are expected to be recorded all question mark
00:34:21 be recorded all question mark only those presenting additional risk question mark only those above 149 on the scale described in pn 800 the latter will exclude most
00:34:32 the latter will exclude most when visiting residential high-rise premises
00:34:35 premises watch managers are encouraged to record details that would be of assistance to crews attending an incident with no prior knowledge of the building [Music]
00:34:45 [Music] this and if we turn over the page email is to remind visiting managers of the facility to add images to the ord which is ideal for delivering an initial understanding of the premises very
00:34:57 understanding of the premises very quickly the current use of this facility is not wisely used and does not always deliver sufficient detail now my first question is simple was that message drafted at your behest
00:35:12 i can't recall whether i asked dave lindbridge or whether dave lindrich suggested it but what i can recall is
00:35:20 is we both agreed it was a good idea and stop if we can stop there what was the reason what was your reason for having the message sent because of the number if we go back a slide if our mind
00:35:33 number if we go back a slide if our mind of course you want to go back to page two yes please excuse me
00:35:37 excuse me [Music]
00:35:40 [Music] it might be even earlier than this i've seen i've seen this email and uh i know what precedes it so i might have
00:35:51 i know what precedes it so i might have i might be thinking of what i've read in preparation for the inquiry but there was an email exchange with dave lindbridge that highlighted the fact that there was in the region of i think
00:36:03 that there was in the region of i think 250 260
00:36:05 250 260 premises on the ord high rise premises on the ord now that was uh unacceptable and uh this i believe was to
00:36:17 i believe was to uh
00:36:19 uh re-engage if indeed that's the right word to to push through what i wanted in terms of more premises is being put on the operationalist database i believe that was the emphasis
00:36:30 database i believe that was the emphasis for this is looking at the emboldened italicized words there that set out in the penultimate paragraph on that page about 10 suggests that even within your team
00:36:42 that even within your team in november 2012 there was still confusion or uncertainty about which high-rise premises were actually to be recorded on the ord would you accept that
00:36:52 that well david ridge wasn't in my team uh but not withstanding that i think no i wouldn't accept that i think what he's doing he's just giving me as the sender the option as to which i would
00:37:04 sender the option as to which i would want to include but which of itself given the
00:37:10 given the looking at the words actually used there is an absence of certainty as to what level of detail is to be included would you accept that
00:37:27 no no i wouldn't accept that there's is a confusion over it i think it's really just him given the option quite possibly because
00:37:34 because his final point only those above 149 on the scale described in pa pn800 and his comment the latter will exclude most which i don't agree with but uh maybe he just wants to remind me
00:37:47 but uh maybe he just wants to remind me that if we did follow his policy in his view it would exclude most and is that what i really wanted well it'd be for the panel in due course to make of that email sure what they make but
00:38:00 what was your response to this question what level of detail did you require to be recorded uh well i
00:38:10 uh well i unless i'm about to see an email that contradicts what i'm about to say i would have gone for the final option so uh only those above 149 and a
00:38:21 option so uh only those above 149 and a scale pres described in pn800 because a that's what we'd set out and b even if they were under 149 they still would have had a premises
00:38:33 they still would have had a premises information plate attached to them so there still would have been information about them available to arriving crews if there was an incident there around things such as
00:38:44 there around things such as how many stairways where they were where the fire lift was how many lengths of hose water suppliers number of floors in the building so it still would have been a useful
00:38:53 a useful exercise
00:38:54 exercise in terms of crews having on arrival information
00:39:01 and i think it flows from what you've just said that you'd ex well i think you've said explicitly that mr lindridge you accept his view that taking the latter approach i excluding those rather including those above 150 would
00:39:14 rather including those above 150 would exclude most high-rise buildings well no i don't accept that he's true i accept that that might be what he believed but i i don't accept that that's a
00:39:25 but i i don't accept that that's a statement of fact did you raise that point with him at the time do you remember i don't remember that
00:39:32 that now if we can uh go back uh to or further up in this email chain to the bottom half of page one
00:39:45 and here we go it's an email from mr binder himself to you
00:39:51 and it says as follows gov regarding the issues of recording high-rise info on the ord mdt pre-planning at residential high-rise fires
00:40:01 fires to include single-line diagrams showing number and location of individual flats i've spoken with dave wyatt and the consensus is that since that action was required there's been for good reasons a
00:40:13 required there's been for good reasons a more intelligent and risk-based approach in recording operational risks to firefighters on their station's ground this culminated in the information gathering note pn 800 and the matrix
00:40:24 gathering note pn 800 and the matrix used is specific in what should be added david lindrich has undertook a quick trawl of the brigade and approx 250 high-rise premises are recorded on the
00:40:35 high-rise premises are recorded on the lrd of which 61 have some limited information recorded via a plan or a picture with six having greater details including a simple plan drawing as it
00:40:46 including a simple plan drawing as it stands now this will not fulfill the action in increasing the level of pre-planning required now the high-rise database that you sent to station staff in april 2009 contained
00:40:59 to station staff in april 2009 contained over 1800 entries um are you able to help us as to why there are now comparatively uh so few ie 250 high-rise premises on the ord three years later
00:41:14 i i i don't i can't help with certainty i would uh don't if you if you don't know
00:41:20 know no i'm just going to use a professional opinion as to why it might be the case but no i don't know if it's certain now if we can go back to mr binder's email um which in its uh fifth paragraph says this the
00:41:31 in its uh fifth paragraph says this the comms message below from dl so that's david lindrich details how this may be achieved the problem is that personnel might with good reason decide that a high rise might not now be worthy of
00:41:42 high rise might not now be worthy of inclusion due to the score following use of the matrix which could then allow the premise to be removed from the or which turning over the page we would have to accept as part of this process however
00:41:54 accept as part of this process however this review will allow those that do attract inclusion will then have the single line drawings added to the premises information as is the intention of the comms message by approaching it in
00:42:06 by approaching it in by approaching it this way a review is carried out of all listed high-rise premises and where applicable where currently there are no single line drawings that are then added increasing
00:42:17 drawings that are then added increasing our numbers accepting that some premises will ultimately be removed it may be worth putting a review deadline date if in if this needs to look a lot healthier by january and sent
00:42:29 look a lot healthier by january and sent it to area dacs and bc's of barrack commanders to ensure this is actioned now this email there refers explicitly to quotes the problem that personnel
00:42:40 to quotes the problem that personnel might with good reason decide that a high-rise might not now be worthy of inclusion because the matrix when would you expect a high-rise building to receive a very low score on the matrix meaning that it would not be
00:42:51 the matrix meaning that it would not be included on the ord at all is this the paradigm
00:42:55 paradigm model you were talking about earlier that had
00:42:57 that had impressive fire suppression systems in the rest of it now the inquiry has not been able to find any evidence that the draft email that we started with was in fact sent
00:43:08 that we started with was in fact sent are you able to help us as to whether it was in fact sent
00:43:14 as far as i'm aware it was sent yes and the reason i say that is because i i remember being disappointed with those figures and wanted to uh
00:43:28 figures and wanted to uh to action it and make sure that we we we get we got on with increasing the numbers
00:43:35 numbers on the operational risk database can you remember now what if any guidance was given with the final version of this email
00:43:42 email to essentially advise station managers on which high-rise buildings were required to be recorded on the ord it would have it would have been to follow the guidance given in policy note
00:43:53 follow the guidance given in policy note 800. and therefore sorry if i can stop you there you've said in a number of answers today it would have been my uh my question was more direct was final guidance sent out with the
00:44:04 was final guidance sent out with the fight was guidance given with the final version of the email that was sent out can you are you able to remember whether that was done i can't categorically state but i can't imagine a situation where i wouldn't have sent it out and if
00:44:15 where i wouldn't have sent it out and if i did it and when i did it would have involved policy no 800. but
00:44:20 but your recollection is sure that it would have been yes now can i turn to a separate but um related topic which is the lfb's
00:44:32 related topic which is the lfb's response to porous guidance that's p o r p-o-r-i-s
00:44:37 now the porous guidance was published in 2012 is that correct yes can you help the panel and anyone watching or may not be familiar what is was the porous guidance it's the
00:44:49 was the porous guidance it's the provision of operational risk information system and it was a document that was provided by
00:44:59 by the uh
00:45:02 the uh bus
00:45:03 bus effectively central government really in response to a health and safety risk assessment that had been carried out on the uk fire service nationally so this this gave guidance that fire and
00:45:16 so this this gave guidance that fire and rescue services should follow in terms of the kind of information that they should be collecting and how they should collect it thank you now can we start this line of
00:45:27 thank you now can we start this line of questioning going to a report produced for the corporate management board on the 27th of february 2013 that can be found at lfb 00917
00:45:38 00917 85
00:45:40 85 as you can see it's entitled operational risk information lfb response to national operational guidance and the report summary on the front page we can see here
00:45:51 on the front page we can see here towards the bottom of the screen it says this dclg so that's the fund of communities and local government as was issued operational guidance on operational risk information in april
00:46:02 operational risk information in april 2012.
00:46:03 2012. this paper considers the con the content of that guidance and the extent to which lfb is compliant with the guidance now
00:46:13 now as you've um adverted to the national guidance in uh introduced a model approach which was called the provision of operational risk information system and if we can look in broad terms at the
00:46:26 and if we can look in broad terms at the substance of that model and if we could turn to h o m
00:46:32 h o m zero four five three six four
00:46:41 and if we could turn to page 48 first of all
00:46:49 now mr brown the five stages of the porus model are described between pages 48 and 49 here what i'd like to do is just discuss these very briefly in headline terms
00:47:00 headline terms so that the panel is excuse me familiar with them and the first one we have at page 48 is stage one which describes itself as the initial site risk analysis process
00:47:13 initial site risk analysis process in broad terms am i right in thinking that this is a review of the existing information about our premises in order to determine whether a visit is required at all
00:47:43 so the reason i'm i'm just pausing is certainly
00:47:46 certainly it covers what you've said i'm just trying to determine in my mind whether it goes beyond just that initial decision we're just talking in broad terms here headline points about the stage i just want to
00:47:57 points about the stage i just want to identify them because there are complexities to it but just to give people some it certainly covers what you've said thank you now if we can turn to page fifty five zero
00:48:07 and here we have stage two which is the data gathering process again broad term summary uh mr brown see whether you agree with it this is the site visit in those cases where one has
00:48:19 site visit in those cases where one has been deemed necessary
00:48:25 yes thank you turn over the page to page 51 we find stage three which is the detailed site risk analysis process
00:48:36 process this involves in broad terms again assessment of the data that is collected during the visit at stage two in broad terms is that right
00:48:47 terms is that right [Music]
00:48:49 [Music] yes and then the model certainly the model at this stage provides various templates as appendices that are there to assist the assessment process itself yes thank you
00:49:02 yes thank you from the lay perspective mr brown please shout if this is an undue simplification this looks like the most important stage of the five-stage process is that a an
00:49:14 of the five-stage process is that a an accurate or sensible summary
00:49:19 [Music]
00:49:23 it's a sensible summary yes could we now turn onto page 54.
00:49:32 here we have stage four which is the risk management process i'm i'm pushing this really simply and i hopefully not at the expense of accuracy but this is what you do with
00:49:44 accuracy but this is what you do with the risk information and the assessment of risk once it's been collected is that fair yes and finally can we turn to page 58
00:49:56 which is the fifth and final stage which is the incident information distribution process
00:50:01 process again in broad terms this relates to how risk information should be distributed to instant commanders for use incidents is that fair yes thank you
00:50:12 is that fair yes thank you could we turn briefly over the page to page 59
00:50:16 page 59 and paragraph 10.44
00:50:20 i'll just let you familiarize yourself with that
00:50:34 so
00:50:43 okay thank you in general terms that suggests that there may be different layers of information that are required at different stages of the incident is that a fair overview
00:50:55 a fair overview yes
00:50:56 yes and also the information applying to the arrival of resources at various stages of the incident as well thank you now if we can put uh porous itself to
00:51:09 now if we can put uh porous itself to one side and go back to the lfb report of february 2013 which can be found at lfb
00:51:17 0091785 forward five
00:51:25 now just to help you you may not have seen this document for some time but the report is structured in tabular form setting at the substantive point made by key paragraphs of the national guidance
00:51:36 key paragraphs of the national guidance in the middle column and the lfb's position is in the column on the far right hand side now if we could skip to page 20 and paragraph 33
00:51:50 uh we see here the conclusion and
00:51:53 and again apologies for reading this out but it's probably easier paragraph 33 says this
00:51:59 this lfb arrangements in place for the gathering of risk information appear to be robust
00:52:04 be robust and largely in compliance with the national operational guidance issued in april 2012 it is not considered necessary or practical to make significant adjustments to current arrangements a
00:52:15 adjustments to current arrangements a few issues are highlighted for some further action and recommendations are made
00:52:21 made now before we turn to those recommendations themselves what process did the lfb follow in arriving at the conclusion that its existing arrangements for the management of operational risk did not require
00:52:32 operational risk did not require a significant amendment so this was a report completed by information management so david wyatt would have been instrumental in this my understanding is what was presented
00:52:44 my understanding is what was presented at the corporate management board was uh as we saw in the previous page a list of the
00:52:51 the areas of uh provisional provision of operational risk information and then comparisons with uh the various parts of our process and opera protein
00:53:03 parts of our process and opera protein 800
00:53:04 800 so it would have been a desk-based research that would involve discussion with those who apply the policy uh in terms of just you know gathering information and triangulating understanding of the way
00:53:17 triangulating understanding of the way the process works uh you say my understanding is what was presented at corporate mountain board were you a member of the corporate management board i was there for this paper i was
00:53:28 i was there for this paper i was ultimately a member of the corporate management board i can't recall exactly when i became a member but i certainly would have been here for this paper were discussions held with station bus station based staff to assess the
00:53:40 station based staff to assess the practice of those on the ground my understanding of this is yes it was for the purposes of this paper was an audit of the ord carried out
00:53:54 i don't know on that one
00:53:59 sorry when you say an audit of the ord what do you mean exactly what more targeted forensically targeted review to see whether the information recorded on the
00:54:10 whether the information recorded on the ord for example in respect of high rises was accurate or not oh i'll see i i don't know i can't imagine what that would have added to this
00:54:22 added to this paper because this was about process if we could go to page three in this paper and the box at the top of that page
00:54:37 now the report notes that
00:54:43 you were consulted and gave comments on an earlier version together with a number of your colleagues um can you help us now can you remember the extent of your contribution uh to the drafting of this report
00:54:57 the drafting of this report i i i can't remember it just it would have been on on process but i can't remember exactly what comments i would have made
00:55:07 i can say though however richard binder as we've just uh discussed was uh a key part of this in terms of central server delivery and john elwell
00:55:18 delivery and john elwell was a borough commander who was the lead for our service standard on contingency planning so he was uh
00:55:26 uh he was
00:55:28 he was would have would have had some useful and valuable comments in regards to this so i would have been i've been comforted by the fact that john and richard both commented on this paper we'll be coming on to mr elwell in due course as you can
00:55:40 on to mr elwell in due course as you can imagine but did you agree with the overall conclusion that a significant amendment was not required to the lfb's processes yeah i agree it was broadly compliant there were one or two issues but uh but it was broadly
00:55:52 two issues but uh but it was broadly compliant
00:55:54 compliant now the report's recommendations are set out at pages uh one and two of this report and if we can go to page two it's just a limited number of
00:56:05 it's just a limited number of recommendations i briefly like to discuss with you now the first one is recommendation g and if that could be amplified please thank you and that provided agree that an operational assurance
00:56:16 agree that an operational assurance audit review take place to identify the consistency with which stations identify sites buildings that might present an operational risk or hazard and compliance with policy 800 and the risk
00:56:28 compliance with policy 800 and the risk matrix the audit review to take place after new section 72d training has been put in place and is delivered and if we go to
00:56:37 go to page 14
00:56:39 page 14 on the bottom row on that page
00:56:46 and what that says there is that is this one of the challenges is how to process a very large number of sites in order to identify those where the availability of accurate relevant and timely information
00:56:58 accurate relevant and timely information may be of value at any reasonably foreseeable incident many buildings or risks may not require detailed site-specific information in order to expect a safe and successful
00:57:09 order to expect a safe and successful outcome to operational interventions now if we look rightwards we see the lfe's response
00:57:15 response which was as follows the current process as outlined in lfb policy 800 is regarded as adequate to identify the key buildings that are likely to present operational risks the
00:57:26 likely to present operational risks the onus is on stations to identify risks on the station ground and to schedule regular visits if required the risk matrix in policy 800 provides a way of determining if a site building
00:57:38 way of determining if a site building should appear on the ord and the frequency of revisits operational news in february 2013 will also include a specific article on recording information relating to complex buildings that are likely to
00:57:50 complex buildings that are likely to cause difficulties to operational staff in the event of an emergency now
00:57:56 now the key question here is do you agree with the conclusion that the lfb's process was quote adequate to identify the key buildings that are likely to present operational risks giving given the problems you'd experience over
00:58:08 given the problems you'd experience over the preceding years achieving that aim [Music]
00:58:11 [Music] i think the process was adequate but undoubtedly there were issues in terms of achieving the outcome we were looking for
00:58:24 in the sense you hadn't yet achieved the outcome yes could we go to page 15 please and again the bottom row [Music]
00:58:35 [Music] and here it deals with paragraph 8.28 of the of the porous guidance and it summarizes that thus periodic audit is a useful means to enable a deeper and more critical appraisal of
00:58:46 deeper and more critical appraisal of the operational risk information systems and whether the system has been properly implemented and maintained and is effective in meeting organizational policies
00:58:55 policies now looking at the far right column the lfb responded as follows there are inconsistencies in the approach taken by stations about what is included on the ord
00:59:07 what is included on the ord and the quality of data capture and usage is variable policy 800 and the risk matrix within it is designed to improve this over time it will be useful for the head of
00:59:18 will be useful for the head of operational assurance to review audit how stations identify sites buildings that might present a risk or hazard and the consistency of approach against policy 800
00:59:30 against policy 800 such an audit review should take place once the new training is in place and has been delivered on what basis did the report conclude
00:59:41 on what basis did the report conclude that there are inconsistencies in the approach taken by stations about what is included on the lrd and the quality of date data capture and usage is variable
00:59:54 that would have been based on the general understanding that prior to the premises risk assessment there were premises on the central risk database
01:00:07 premises on the central risk database which became the operational risk database which when considering risk in its purest form really shouldn't have been there and there were other premises
01:00:18 other premises uh that clearly should have been there just but then and that's obvious by the basis of how many uh premises were on the database now given the reports finding that there
01:00:29 given the reports finding that there were inconsistencies in approach and the recommendations for review to investigate further mindful of that further investigation um how could the lfb or how did the lfb
01:00:41 um how could the lfb or how did the lfb conclude before that review had in fact been carried out that its processes were nonetheless adequate
01:00:52 because because the process as it says here uh policy so in the third line on the far right column posi 800 and the risk matrix within it is designed to improve
01:01:03 matrix within it is designed to improve this over time so because of that and we were satisfied that we had a system in place to increase the numbers of inspections and we had a consistent and standardized
01:01:15 and we had a consistent and standardized system to make sure that the appropriate premises were recorded on the ord we felt that the process was accurate and and and fit for purpose well bearing
01:01:27 and and and fit for purpose well bearing that in mind can we go back to page 15 which is on the screen and looking at the column on the far right hand side and roughly two-thirds of the way down
01:01:39 and roughly two-thirds of the way down that last box this form of words which i've quoted but i'll take you to again such an audit review should take place once the new training is in place and has been delivered
01:01:52 has been delivered is the training that's been referred to here the tcap double zero five five that we were discussing earlier on yes why was it recommended that the audit review take place after the new section
01:02:04 review take place after the new section 72d training had been put in place and delivered
01:02:09 delivered uh
01:02:09 uh because
01:02:11 because because this was probably the first time that we'd
01:02:16 that we'd formally trained staff in seven two days or certainly for some considerable time then to allow that to bed in and allow staff to
01:02:28 that to bed in and allow staff to understand that training and and and to enhance what they're already doing so i don't want to run away with the idea that staff didn't know how to do a 72d they did
01:02:37 they did but this was this was formal training so to allow that to bed in and then along with policy note 800 and the pra
01:02:45 pra that would be an appropriate time then to carry out this brigade-wide audit could i put the point more directly haven't you put the cut before the horse here ought you to have carried out the
01:02:56 here ought you to have carried out the review audit first to identify what deficiencies the training need to address
01:03:06 we could we could have done that but i think we we accepted uh following the lack of house action plan we accepted that there were gaps in the provision of information and training
01:03:18 provision of information and training were given to our crews so i think we we we accepted that we needed to start afresh with training so i don't think i really wanted to get involved in finding out what the gaps are we was
01:03:30 finding out what the gaps are we was just doing a belt and braces approach to seven two ds albeit in the knowledge that there was a lot of organizational knowledge at stations in terms of how to do a 72d
01:03:40 do a 72d but also thinking of new entrants as well so how do you deal with the problem what happens if the audit review had identified yet further gaps or deficiencies in training
01:03:51 deficiencies in training that would have to be remedied uh well then that's when the dynamic intelligent operational training kicks in because we would find that out
01:04:02 kicks in because we would find that out and we're continually looking to improve our training so if we did find that there were further gaps we would have mended the training course and reissued it but if you are to take a belt braces approach isn't it best done on the basis
01:04:13 approach isn't it best done on the basis of a thorough review before any remedial training is rolled out as personnel
01:04:21 except for the fact that we we accepted after the lack of house uh coroner's inquiry and the and the pre-inquest actions that we've put in place that it was
01:04:32 place that it was on reflection it was an omission that this hadn't been done earlier so we felt there was no need to carry out review because we was going to start start from from square one if you like in terms of 72d training so they said the only thing
01:04:44 72d training so they said the only thing we we risked was training some people in things that they knew exactly what to do already but but that would be a better approach in in our view than it would be to potentially miss something
01:04:56 miss something i think we probably exhausted that topic can we look at a separate document now lfb trouble zero four one three six five
01:05:07 now this is an email exchange you would not have seen because it post dates by nine months your retirement it is an email exchange from december 2017 between danny cotton and adrian
01:05:18 2017 between danny cotton and adrian bevan
01:05:19 bevan and you'll see that adrian bevan says this and the second email on that page sorry to bother as part of my review of lachnal actions i've come across this and i have no recollection
01:05:30 across this and i have no recollection of it myself do you remember it mr bevin's email then sets out what appears to be an extract of the action plan relating to x dash 0 r 1 7 or o r 1 7 which replicates the
01:05:44 0 r 1 7 or o r 1 7 which replicates the text of recommendation g set out in the 2013 report which we've just been looking at i the audit review to identify consistency of station
01:05:55 to identify consistency of station identification of sites now in the middle column your name is crossed out replaced with that of danny cotton and the right far right column says this
01:06:08 and the right far right column says this work by head of operational assurance to validate the work at stations to identify and record operational risks will need to await the embedding and outcome of work by the third officer
01:06:19 outcome of work by the third officer to increase the number of visits and premises on the ord which has outlined an item ori 4 above the lead for this action should be
01:06:30 action should be head of operational assurance then if we could look at the email ahead of this chain from danny cotton and she says hiya no i don't think i've ever seen this
01:06:41 no i don't think i've ever seen this before and dave brown would definitely not have allowed us to do this now
01:06:49 now the language of that email chain is clear
01:06:53 clear that suggests that the recommended audit was never carried out now is that right there's a couple of issues here uh well if we can start off with an answer to
01:07:05 if we can start off with an answer to the question is it right that the audit review was not carried out i don't believe the audit review by operational assurance was ever carried out
01:07:17 out and your answer suggests it was carried out by someone else yes who so
01:07:22 so the service standards that i introduced in 2014 had a specific service standard for contingency planning and we had structured approaches to be
01:07:33 and we had structured approaches to be able to audit what was going on with regards
01:07:37 regards uh seven two days and and operational uh contingency planning in general so my service standard support officers would certainly have carried out audits in this regard
01:07:48 have carried out audits in this regard on an annual basis from 2014 onwards were those service standards designed or were they use actually take it down in stages were they designed to discharge the
01:08:00 they designed to discharge the recommendation gi to carry out the audit review no
01:08:06 do you believe or do you know whether the audit review was in fact carried out under the umbrella of the service standard audit that you referred to
01:08:18 in my opinion that would have would have addressed this particular issue yes i'm sorry to pressure i'm not interested and we don't hear from your your opinion
01:08:30 your opinion was the audit review carried out that's a fact or not was the auditor review carried out envisaged by recommendation g under the umbrella of the service standard audit
01:08:41 umbrella of the service standard audit procedures that you just referred to i never offered that up as a
01:08:47 an outcome for that particular action now
01:08:50 now so when you sought to qualify your answer earlier on by saying the review audit was not carried out by ops or assurance
01:08:59 assurance is it right therefore to take it from the evidence you've given that you don't know whether your department carried out an audit or review in following recommendation g oh no sorry i've misrepresented myself then so i
01:09:12 i've misrepresented myself then so i know that my service down support officers did regularly audit on an annual basis a range of issues and this would have been one of them what i'm not suggesting is
01:09:24 what i'm not suggesting is i then went forward and said hey
01:09:27 hey that particular action in this action plan we can tick that one off now because i've dealt with it i never said that i never did that that that was for operational assurance to do
01:09:38 operational assurance to do and and this comment in the far right column in terms of being suspended awaiting the outcome of further work by me in terms of increasing the number
01:09:49 increasing the number of premises on there is accurate but at some point it would have been for the head of operational assurance to say it's now my turn to pick this up and get
01:10:00 it's now my turn to pick this up and get on with this audit and the reason we're both on there is because we both owned the action me to get the training done me to build up the numbers on the database and then the head of operations
01:10:11 database and then the head of operations to take over and use her staff to do the audit for which her staff were all deters
01:10:18 deters that's a very long answer can i just take us back to what recommendation g was because i think there's a danger here of generality obscuring the particular okay if we go back to lfb trouble zero nine one seven eight five
01:10:30 trouble zero nine one seven eight five forward slash two
01:10:33 and if we'd amplify recommendation g
01:10:40 it was a specific recommendation mr brown
01:10:43 brown operational assurance audit review take place to identify the consistency with which stations identify sites buildings that might present an operational risk or hazard so the focus
01:10:55 or hazard so the focus was on
01:10:57 was on the consistency or otherwise of the approach adopted by stations to operational risk or hazard was there a particular audit or review that answered
01:11:09 particular audit or review that answered that specific recommendation
01:11:13 carried out by your department as part of normal business as part of this service standards then yes but that
01:11:23 but that particular recommendation refers to joint work between head of operations prevention response noa and on that respect no that wasn't okay thank you
01:11:34 okay thank you could we go back to the cotton beven email correspondent lfb lfb0041365
01:11:45 danny cotton's email at the top dave brown would definitely not have allowed us to do this
01:11:54 can you help us to why she'd formed the view that you would not have allowed us either lfb or operational assurance to do this well first of all there's a really
01:12:06 well first of all there's a really disappointing comment to read and i work closely with operational assurance
01:12:12 assurance who did lots of audits in terms of senior accident investigations and performance reviews of command at fire stations without without anything other than full
01:12:23 without anything other than full cooperation for me so i've got no idea why uh danny would have suggested such a thing
01:12:29 thing and indeed there's nothing in the february 2013 report on paris to suggest that you
01:12:36 that you disagreed with or wasn't willing to implement recommendation g no and and and even if even if i had for some bizarre reason wanted to stand in the way of this which
01:12:48 wanted to stand in the way of this which i didn't this is a corporate action and there was no way that i'm going to stand in way of a corporate action agreed at cnb for which i was i was uh present
01:12:59 cnb for which i was i was uh present thank you can we now turn to a separate topic which is the lachnal rule 43 actions
01:13:05 actions now excuse me if we can go back to your first statement first of all lfb treble 0 321 6 page 7
01:13:16 page 7 and starting with paragraph 16.
01:13:21 now here you set out at the bottom of the page in paragraph 16 the following in 2013 inquests were held into the death of the six people who died as a result of the fire at lachnal
01:13:33 died as a result of the fire at lachnal house on 28 march 2013 her honor frances kirkham cbe assistant deputy coroner sent a letter to the commissioner setting out her five recommendations for action by the lfb
01:13:45 action by the lfb rule 43 recommendations in my capacities the lfb's head of operations prevention and response i was allocated the role of lead officer for recommendation 2 which concerned visits
01:13:57 recommendation 2 which concerned visits made pursuant to section 72d of the fire and rescue services act 2004 and recommendation for regarding brigade control
01:14:07 control i also had an involvement in recommendation one in relation to public awareness and recommendations three involving incident commanders now
01:14:16 now in your evidence of module three mr brown at module five rather i'd like to comment concentrate on recommendation two so section seven two d visits okay now the then commissioner robin dobson
01:14:27 now the then commissioner robin dobson wrote to the coroner on the 23rd of may setting out the lfb's response to her recommendations and we can find that lfb travel zero four two zero eight nine
01:14:44 uh if we go to page four and the second paragraph
01:14:49 we see there the response in relation to recommendation two on which you led
01:14:56 and really it's the second paragraph at the top of that page says this it is recommended that the brigade review procedures for sharing information gained as a result of section 72d
01:15:08 gained as a result of section 72d familiarization and home fire safety visits with crews both within the station in question and at other local stations
01:15:16 stations now in response the commissioner wrote the third paragraph under the heading response
01:15:22 response this the brigade's policies concerning the gathering of operational knowledge are under regular review and many have been modified to reflect the lessons learned in the latino house
01:15:33 the lessons learned in the latino house fires
01:15:34 fires he then continues under the heading proposed action this
01:15:40 this to further enhance current systems the brigade will undertake a review of the existing policy relating to information gathering and contingency plans this review will aim to optimize all of
01:15:51 this review will aim to optimize all of the brigade's pre-planning activities to ensure the effective sharing of information gained as a result of section 72d familiarization and home fire safety visits it will aim to
01:16:03 fire safety visits it will aim to maximize the use and availability of this information when operational personnel respond to emergencies create an inspection regime that targets high priority residential and non-residential buildings with a view to
01:16:15 non-residential buildings with a view to increasing the number of premises records which are available to the brigades
01:16:20 brigades operational staff on the operational risk database develop guidance to assist staff to create consistent tactical tactical plans
01:16:30 plans focused on improving speed of firefighting and life-saving interventions develop a new policy guidance to address known outstanding risks through the brigade's home fire safety visits and
01:16:41 brigade's home fire safety visits and other engagement activities establish a corporate mechanism by which targets for the brigade section 72d activities are set now that as we understand it formed the
01:16:54 now that as we understand it formed the basis for the actions that are referred to as actions 2a 2b 2c and 2d in the lachnal assurance review a document to which you've clearly had regard in reaching your statement is that correct
01:17:06 reaching your statement is that correct that's true yeah thank you now i'd like to take a moment to identify each of the actions um as described in the lachnal assurance review and um if i could ask the trial
01:17:17 review and um if i could ask the trial director to bring up the before we do that mr kenya can you just help me with this because i want to understand where we're going
01:17:26 going the recommendation doesn't address concerns about this system for obtaining information it's concerned with sharing information
01:17:38 concerned with sharing information gained as a result of section 72d and so on visits is there anything in this that actually deals with sharing of information when you say this you mean the response yes um not
01:17:51 yes um not not especially no this doesn't actually address the recommendation at all no right
01:17:56 right that's the point which will be um covered with mr dobson right thank you very much if we go to the assurance review itself which is lfb quadruple zero four eight
01:18:07 which is lfb quadruple zero four eight zero one
01:18:14 and if we could put page four of the commissioner's letter so lfb double zero four two zero eight nine four side by side thank you
01:18:24 now in the the coroner's recommendation 2 is set out on page 25 of the assurance review so if we could look at page 25 thank you and it's in the left column
01:18:37 and it's in the left column bold blue text
01:18:42 and action 2a is then identified on the same page in the right hand column
01:18:53 [Music] okay
01:19:08 thank you as we see two a's they're identified do you have it mr brown oh yes
01:19:14 oh yes and it's so it's um it says review existing policy related to information gathering contingency plans
01:19:20 plans excuse me that corresponds to the first bullet point in the commissioner's letter to the coroner would you agree yes now if we can apologize to the trial director for this
01:19:31 apologize to the trial director for this but if we can go to page 27 in the assurance review
01:19:37 looking at the left hand column on the bold red text identifies action 2b which is to create an inspection regime
01:19:48 which is to create an inspection regime targeted high priority buildings would you agree that 2b corresponds to the second bullet point in the commissioner's response letter yes
01:19:58 action 2c is also on page 27 of the assurance review and you'll see that is entitled develop new policy guidance to address no outstanding risks
01:20:09 to address no outstanding risks identified through home fire safety visits
01:20:11 visits that corresponds to the fourth bullet point in the commissioner's response yes thank you and finally action 2 d d for delta
01:20:22 action 2 d d for delta is also on page 27 and that
01:20:26 and that is entitled set corporate targets for 72d activities would you agree that that corresponds to the fifth bullet point in the commissioner's response letter yes thank
01:20:37 commissioner's response letter yes thank you
01:20:41 now just to add administrative complexity action two and its four component parts were also known as action 18
01:20:51 action 18 a to d
01:20:53 a to d in the context of the lfb's internal lachnal house action plan do you remember that level of detail yes uh yeah and it wasn't particularly helpful that was a an action plan being
01:21:04 that was a an action plan being incorporated with another action plan and being renumbered but uh but yes yeah and if we could just um just so people know what we're talking about if we can go if we can put with apologies again to the trial director we
01:21:16 apologies again to the trial director we can put both of those documents down and put another one up which is lfb trouble zero
01:21:22 zero two nine three zero seven
01:21:31 now this is the lfbs rule 43 monitoring report we can see its date in the top right corner november 2013 and for people who are watching
01:21:43 and for people who are watching proceedings these documents were produced regularly following the lack of housed inquests for the purpose of monitoring the lfb's uh progress in implementing the actions identified to
01:21:54 implementing the actions identified to satisfy the coroner's recommendations is that a fair and accurate summary mr brown yes
01:22:00 brown yes now we can see from the top of the first page that this was a consolidated action plan
01:22:07 plan arising from actions arising at lachnal as well as those arising from another inquest which was shirley towers in hampshire is that right
01:22:16 right yes shirley towers happened not long after lack and all and we was minded to look at the issues out of that and see whether there's any that apply to our own organization so we combine them together
01:22:28 together thank you if we can turn to page 17
01:22:32 and here we find the entries for action 18 parts a to b
01:22:40 and if we could look very briefly at the text in the third column ie the middle one i think under the heading lfb action a review existing policy related to
01:22:53 a review existing policy related to information gathering b create an inspection regime targeting high priority buildings c develop new policy to address outstanding risks from home fire safety visits and if we turn over the page
01:23:08 d set corporate targets for seven 2d activities [Music]
01:23:14 [Music] just to bring everything full circle these are what you and the latino assurance review referred to as action two parts a to d is that right yes thank you
01:23:25 you now we can also see here in the far right oh sorry in the fourth column under the heading lead that you were allocated as the sole lead officer for each component part of
01:23:37 officer for each component part of action 18. is that right apart from action 18a yes but i was a joint lead yes and you were joint lead with ac fire safety and regulation who was steve
01:23:49 fire safety and regulation who was steve chirek at the time yes thank you now apologies for that somewhat pedantic painful trawl through the bureaucracy can we go back to page four of the
01:24:00 can we go back to page four of the commissioner's letter to the coroner which is lfb travel zero thank you for two eight nine four four
01:24:10 now can you help us how was the coroner's recommendation that the brigade quotes review procedures for sharing information gained as a result of section 72d visits converted into the
01:24:21 of section 72d visits converted into the five actions proposed by the commissioner in this letter
01:24:27 so as a senior management group we discussed each of the recommendations from the coroner and uh and discussed ways that we could achieve them so we broke them down into
01:24:39 achieve them so we broke them down into component parts that we felt added to the completion of each of the recommendation and this and these were the issues that we agreed as a group
01:24:51 we agreed as a group that would uh address the coroner's recommendation what was your the extent of your involvement as joint lead in respect of
01:25:03 involvement as joint lead in respect of a
01:25:04 a and sole lead in respect of the other three actions that were required [Music]
01:25:10 [Music] well the joint lead on a uh was because we
01:25:15 we used premises information plates uh we we incorporated that into uh into this particular action to a and the
01:25:26 this particular action to a and the premises information plates were plates that were allocated to the uh to high-rise uh residential buildings and on that regard we needed input from regulator regulatory fire safety which
01:25:38 regulator regulatory fire safety which is where the joint lead come in with regulatory fire safety it was probably because my question was unclear what was the extent of your involvement what did you do what were you doing or say to lead the work or jointly lead the
01:25:49 to lead the work or jointly lead the work to implement these recommendations
01:25:54 so it it it varies uh so overall what i would have done is allocated members of staff to deal with each of these and then they would have reported back
01:26:06 and then they would have reported back to me
01:26:07 to me i had i had more to do with some than others
01:26:11 others but but overall yes i would be allocating members of staff to complete each of these leads and then report back by a dedicated time did anyone during the course of this work asked the question that the
01:26:22 work asked the question that the chairman asked which was the recommendation is focused on sharing what are these recommendations doing to meet the concerns the coroner obviously had in
01:26:33 concerns the coroner obviously had in respect of sharing of information no they didn't can you help us as to why
01:26:43 i think that the uh
01:26:45 uh two-way the first one i don't take a review of this existing policy
01:26:50 policy so by
01:26:52 so by by using that policy and by collecting the information and rolling out mobile data terminals so we were operational staff were collecting information feeding it into the operational risk
01:27:03 feeding it into the operational risk database the appropriate information and that information would then be regurgitational crews ie shared as in when they arrived the incidents so although it's not articulated
01:27:14 so although it's not articulated anywhere the assumption was that the mdt was the mechanism by which improvements would be made to the sharing of information is that a fair summary yes and i think to to varying degrees each
01:27:27 and i think to to varying degrees each of the five make sure that we've got the appropriate information to be shared and it enhances that sharing so i i totally understand the chair's question in that regard
01:27:38 the chair's question in that regard looking at it now i can see that it isn't clear but we were satisfied that it was dealing with sharing the information within the organisation to the appropriate people at the right time
01:27:49 the appropriate people at the right time now looking to at the extent to which the actions implemented the response the recommendation the third bullet point set out in the
01:28:01 the third bullet point set out in the commissioner's response i developed guidance to assist staff to create consistent technical plans focused on improving speed of firefighting and life-saving interventions that isn't covered in any of the four
01:28:14 that isn't covered in any of the four actions that purported to implement these actions do you accept that
01:28:22 i i i feel that that third bullet point is effectively a subset of the first bullet point but but in terms of individually highlighting it and reporting against it yes i'd accept that
01:28:34 reporting against it yes i'd accept that that's missing
01:28:38 why does action 2a or 18a not specifically address the third bullet point
01:28:50 [Music]
01:28:55 i suggest it's because of uh an over familiarization with uh what policy note 800 was all about so obviously it was about uh hazard information and it was about tactical
01:29:07 information and it was about tactical plans of which is that third bullet point
01:29:11 point so i think it was just an an unhelpful assumption on our part that the third bullet point is part of the first bullet point but in terms of reporting then clearly that's not clear now
01:29:25 then clearly that's not clear now let's look at action 2a 18a which is the review of existing policy related to information gathering and contingency plans now
01:29:36 now [Music]
01:29:37 [Music] we know it deals with those matters can we now turn to your first witness statement which is lfb trouble zero three two one double six forward slash 22
01:29:49 22 and paragraph 71
01:29:56 here you say this the this action was shared with the ac fire safety regulation steve turek my involvement in this action was limited to providing operational insight
01:30:08 limited to providing operational insight into the feasibility and practicalities of obtaining useful information i was also involved in the initiative to introduce e-pips now in his statement
01:30:22 now in his statement and probably useful to go to it so you can see it it can be found lfb trouble zero three two one two eight forward slash eleven
01:30:37 in his statement of paragraph 34 ac turek said this action 2a the third officer so that's you had primary responsibility for the execution of this action again i provided support
01:30:50 of this action again i provided support of a technical nature namely to advise on our responsibilities under fire safety legislation now you can't both be right um
01:31:02 having gone through the relevant documents having seen mr turek's recollection are you wrong or is he wrong can you just remind me please of exactly what i said in yes we can go back to
01:31:14 what i said in yes we can go back to your witness statement which is at lfb trouble zero three two one double six forward slash twenty two so it's there on the page and paragraph seventy one
01:31:30 [Music] i don't think i don't think i was wrong i think it's just in the uh in the terminology we've used i think my phrase limited to providing i guess suggests it
01:31:42 limited to providing i guess suggests it was a minor role i didn't mean it in that regard if we was to do a percentage split between the two of us i guess i would have had a greater percentage responsibility and so mr turip was right in the sense
01:31:54 and so mr turip was right in the sense that you had primary responsibility well primary suggests one is more important than the other i don't think that but i would accept that i i took a larger share of responsibility yes in
01:32:07 larger share of responsibility yes in fairness and he said primary responsibility for the execution of this action yes because it very much would have been
01:32:14 have been my staff that were involved in collecting information it would have been the technical know-how of uh steve turret that would have been key to this now we've got that um cleared up can we look at a later version of the lachnal
01:32:26 look at a later version of the lachnal and shirley towers rule 43 action plan and that can be found at lfb trouble003106
01:32:36 and this is dated march 2016. [Music]
01:32:43 there we see the date in the top right corner
01:32:45 corner and if we turn to page 22 which deals with action 18 a also known as action 2a
01:32:54 2a and we can see that 18 is at the bottom and just reading across from the left to the right the first entry in the action update column of the far right hand side
01:33:07 column of the far right hand side says this
01:33:08 says this 4th of july 2013 a review of pn 800 has been completed and has been recommended to include 72d guidance in pn 800 rather than create a new and separate policy
01:33:21 than create a new and separate policy who carried out the review of policy 800
01:33:26 uh that would have that would have been my
01:33:29 my department i think it was
01:33:34 a group manager uh andrew bell i think who would have led on it is he
01:33:42 is he now ac andy bell yes what is the section 72d guidance referred to here there was discussion over but because of
01:33:54 there was discussion over but because of the the the prominence of 72d there was discussion over whether there should be a separate standalone policy on 72d but on the basis that we we were also
01:34:05 but on the basis that we we were also organizationally keen to keep things as straightforward as possible and not increase the number of policies rather amalgamate we decided that uh
01:34:17 amalgamate we decided that uh note 800 was an appropriate place to use 72d
01:34:21 72d guidance so we'd incorporate it there why there
01:34:24 why there rather than say for example uh appendix one of 633 as well that's a good question uh i think the the reason is because
01:34:36 i think the the reason is because policy note 633 is all about high-rise firefighting so whilst there's clearly uh
01:34:42 uh uh
01:34:44 uh essential that we've got the appropriate information in terms of on arrival tactics policy note 800 is a better fit because this is all about information gathering before the incident so we felt
01:34:57 gathering before the incident so we felt that's where it better sat thank you so it's just after quarter past three this is a convenient place well then we better have a break now haven't we thanks sir yes well mr brown i think this is a good time for us to have the
01:35:08 this is a good time for us to have the afternoon break we'll stop uh we'll resume half past three please and as usual please don't talk to anyone about your evidence while you're out of the room thank you sir all right thank you very much would you go to the ocean
01:35:19 you very much would you go to the ocean please
01:35:26 [Music]
01:35:30 thank you uh mr kenya half past three then
01:50:33 would you ask mr brown to come back in please
01:50:46 all right mr brown yes thank you for carry on good yes mr kenneth can we go back to the march 2016 action plan
01:50:54 plan which can be found at lfb trouble zero three one zero double six forward slash two two
01:51:04 now that's the page that we were discussing just before the afternoon break if i could ask us to turn over the page to page 23
01:51:14 and looking at that far right column mr brown
01:51:18 brown what we see there in broad terms is a iterative process of amendment and consultations relating to pn 800 and if we turn over the page to 24
01:51:30 the page to 24 [Music]
01:51:32 [Music] that process ended on the 27th of august uh sorry i should say 25th of august 2015
01:51:44 when the process ended now can you help us as to why it took over two years for the iterative process of amendment and consultation to take place and before the policy was finally
01:51:57 place and before the policy was finally published on the 25th of august 2015. can we go back please uh where would you like to go back to page 22 or 23. oh sorry just just so i can quickly remind myself of some of the iterations in this
01:52:08 myself of some of the iterations in this action update if we go to 23 it's probably the easiest
01:52:14 thank you
01:52:19 [Music]
01:52:36 okay well two things i'm i'm i'm slightly surprised to see that because i thought
01:52:43 i thought there'd been uh uh an issue of the policy in 2013 which is why i just wanted to read that but but clearly that doesn't uh support what i thought was the case
01:52:54 uh support what i thought was the case so in terms of the second issue as to why it took so long uh this this this was a a key policy and we had a
01:53:05 we had a long and arduous path to go to through in terms of consultation there was there was two uh staff side arenas industrial relations and health and safety
01:53:18 relations and health and safety and it was a process that we needed to go all the way through one process industrial relations and then start all over again at health and safety we we tried in the past with a staff side to
01:53:30 tried in the past with a staff side to have a a one-stop shop where we had one set of uh discussions and consultations but we weren't successful unfortunately this was in the backdrop of difficult
01:53:41 this was in the backdrop of difficult industrial relations with staffside and things tended to take a long time so not wishing to apportion blame but uh but clearly this got caught up in
01:53:52 but uh but clearly this got caught up in long discussions with staffside but from industrial relations perspective and a health and safety perspective can you just tell us mr brown what is bjc hsw
01:54:03 just tell us mr brown what is bjc hsw that's a brigade joint committee for health and safety because it seems to have got stuck there between june or july and november and maybe a bit even beyond yes
01:54:17 november and maybe a bit even beyond yes yes it was uh health and safety of the two would be the more difficult in terms of uh of satisfying staff side and there was al it was also uh you know a difference in
01:54:29 it was also uh you know a difference in opinion whether these documents were what we call consultative i.e we we are staff side's opinion and we do our best to achieve it but we can do it anyway or negotiation where we cannot
01:54:42 anyway or negotiation where we cannot move forward without their agreement and because issues were so difficult we would invariably opt for the negotiation type because what we didn't want to do was cause any
01:54:54 what we didn't want to do was cause any more
01:54:55 more challenges with staff side than already existed
01:54:58 existed so what that meant was sometimes things were being requested by staff side which were which were difficult to achieve and we spent time trying to to
01:55:09 spent time trying to to weed our way through it i i was involved in industrial relations consultations it would have been a different set of people
01:55:16 people i think danny cotton at some point in uh bjc hsnw the health and safety side of it
01:55:23 it just taking the step back from this as the chairman observed about nine months out of this process seems to be consumed by discussions with the bjchsw
01:55:35 with the bjchsw out of a period roughly of two years is that
01:55:40 is that the norm that the process where a policy change bites on or touches health and safety that the process of amendment consultation would take something in the order of two years not nine months no
01:55:51 order of two years not nine months no was that exceptional that it would take this long yes
01:55:56 yes [Music]
01:56:00 can you remember now what the particular concerns were that had been raised in the forum the bj chsw that consumed so much time uh no i can't i'm afraid
01:56:11 so much time uh no i can't i'm afraid i would have had nothing whatsoever to do with the health and safety consultations mine would have been purely the industrial relation consultations even in terms of
01:56:23 even in terms of office discussions can you remember whether the concerns raised um staff side concerned the subject matter the substance of the policy or was it sort of
01:56:34 policy or was it sort of other issues that uh caused the delay i'm sure
01:56:38 i'm sure i'd be speculating if i was to try to guess i'm sorry
01:56:45 do you recall if as part of the the review and consultation process there's any discussion of any of the concerns in relation to 72d visits that we've been discussing today for example
01:56:57 discussing today for example inconsistent approach of crews to identifying buildings in need of visits that that certainly was an issue that was discussed and and staff side
01:57:08 was discussed and and staff side to their credit always would have been seeking appropriate training for their members ie our firefighters in terms of achieving a new policy do you remember whether there was much
01:57:19 do you remember whether there was much substantive discussion if any about concerns about the quality of entries on the ord and their inconsistency that that would have that was an issue that that we raised uh management side
01:57:32 that that we raised uh management side in terms of why we wanted such a policy and a risk assessment process uh but but to my to my memory staff side hadn't raised that issue that was one of our issues uh looked at more generally
01:57:45 our issues uh looked at more generally did anyone raise that that particular concern
01:57:49 concern outside the management team yeah not that i can recall now um can you remember whether there was much discussion whether in the management team or staff side of the question whether all financial operational crews properly understood
01:58:01 operational crews properly understood what was required of them when carrying out section 72d visits
01:58:07 there wasn't when we was consulting on this policy from the
01:58:12 from the management side we were
01:58:15 we were we were satisfied that the training would address that issue i don't recall staff side raising any issues in that regard okay
01:58:26 raising any issues in that regard okay mr brown can we now turn on to action 2b or 18 b
01:58:31 or 18 b which was creation of an inspection regime targeted at high priority buildings
01:58:37 buildings can we start first of all with what your understanding was of what this action required first of all what did you understand high priority buildings to encompass
01:58:54 high priority buildings was uh was a phrase that that got into discussions i'm not quite sure where it came from
01:59:05 where it came from but but we could translate it across really to uh high-risk buildings did people this phrase emerge did people understand what it meant was everyone
01:59:16 understand what it meant was everyone talking to the same definition
01:59:19 i don't think it was a phrase that was corporately used but but certainly in the exchanges on this particular action it it found its way into the correspondence between us
01:59:31 way into the correspondence between us and i think it calls at least for a period of time some unnecessary confusion
01:59:36 confusion but eventually did those involved in the review uh understand that it meant it was a synonym for high risk yes who brought clarity to the confusion
01:59:47 who brought clarity to the confusion did you knock heads together or uh
01:59:51 uh no i think it just i think in correspondence it just became clear what was what was meant and the higher priority
02:00:02 the higher priority phrase just disappeared how did you understand that the proposed inspection regime would relate to the existing regime for carrying out 72d visits under policy
02:00:13 for carrying out 72d visits under policy 800.
02:00:14 800. well so the so the existing regime was about
02:00:19 was about staff
02:00:21 staff of i finding buildings that currently have never been assessed and b once they had been assessed following the risk matrix in terms of frequency so it was the bit about
02:00:33 so it was the bit about getting buildings if i can call let's call them unknown buildings so if getting unknown buildings onto the operational risk database so the inspection regime was about giving some
02:00:44 inspection regime was about giving some guidance as to where to focus your efforts to get those unknown buildings onto the operational risk database because without that guidance there was the danger that uh the buildings
02:00:57 the danger that uh the buildings of a lower risk shall we say might be being visited and of a higher risk of just sitting there waiting to be visited so to try and give some structure around that
02:01:09 around that inertia of getting more premises onto the ord
02:01:14 the ord [Music]
02:01:16 [Music] i suppose one thing that's telling about that answer is that it begs the question how do you define high risk and to what extent did the discussion seek to identify that concept
02:01:27 discussion seek to identify that concept first as a means of providing context for the new proposed regime
02:01:33 so this was a 2b or 18b was a task that i asked tom george who was a deputy assistant commissioner to undertake for me
02:01:45 undertake for me and tom then sought the assistance of one of his borough commanders within his area john l will who also happened to be the lead for the service standard that
02:01:58 the lead for the service standard that dealt with this kind of thing so that was that was a wise choice and it was it was between the three of us i think there was some initial uh clarification required but we resolved
02:02:09 clarification required but we resolved that
02:02:10 that so when um thinking back we can go to if you want but when mr dobson responded to the coroner that the creation of this new inspection regime was specifically quotes with a view to increasing the
02:02:21 quotes with a view to increasing the number of premises records which were available to the brigade's operational staff on the ord that appears to have been your understanding also about the aim of the exercise yeah it was to get more on there but also make sure it was the
02:02:33 there but also make sure it was the right ones in the right order and it was not confined to high-rise buildings it was buildings generally from
02:02:40 from yes i'd make from your evidence yes yeah there was there was a bounding process and high rises was one of the priority bones
02:02:47 bones now just flowing on from the evidence you gave from respect to tom george can we go to his statement which can be found at lfb travel zero three two eight two three four slash
02:02:58 two three four slash seventeen and paragraph 69
02:03:04 [Music] thank you and we see there at paragraph 69 mr george said this in november 2013 the third officer instructed me to carry
02:03:15 the third officer instructed me to carry out some work on a particular action from the lachnal house action plan namely to create an inspection regime targeted at high priority buildings one of my borough commanders barrack commander for kingston was already the
02:03:27 commander for kingston was already the lead officer for service standard 7 operational contingency planning with the third officers agreement i therefore asked the borough commander for kingston to consider the action and
02:03:38 for kingston to consider the action and put forward a proposal on what could be achieved
02:03:42 achieved now just to get some understanding of the hierarchy uh tom george at this stage was a deputy assistant commissioner he reported to you is that right that's correct the borrower commander from kingston that's john elwald is that right that's
02:03:54 that's john elwald is that right that's correct
02:03:58 can you help us mr elwell's role as the lead officer for service standard seven what did that role entail so service standards was something that was in the brigade some considerable
02:04:09 was in the brigade some considerable time ago and for whatever reason it fell by the wayside and it was something that i always thought was it was a shame and it should be
02:04:20 was it was a shame and it should be reintroduced because it helps standardize issues across the brigade so i sought to reintroduce those
02:04:27 those after i managed to consolidate the north and south of london together i then set up i think they were i think there was
02:04:35 there was 10 service standards and then we sought to
02:04:40 sought to provide a lead for each one of those service standards in terms of creating those service stands all over again
02:04:49 again coming up with common standards that every borough across the brigade could use performance indicators that cross-reference with them and advice and guidance really so
02:05:01 a new borough commander could look at these and he or she could be following the same process as a very experienced borough commander so i had the same thing going on and
02:05:12 thing going on and this one service down the seven operational contingency planning covered amongst other things seven two days so john elwell's role was to uh was to arrange the standards and the performance indicators etc uh to to
02:05:25 performance indicators etc uh to to bring that up to fruition that the whole brigade could use i think there are now 11 service
02:05:33 but download it be fair to say that the weight of those standards is concerned with measuring performance in a manner akin to kpis
02:05:44 that's part of the role but it's also to to give guidance on on what should be done and how it should be done which which together leads into a performance indicator
02:05:55 indicator um
02:05:56 um can you help us as to what about the particular role of lead officer for service standard seven operational contingency planning made mr l well appropriate for
02:06:07 appropriate for leading the work on action 2b
02:06:11 well because because a whole issue of two ds is about information gathering so effectively creating contingency plans for
02:06:22 creating contingency plans for uh for operations i.e incidents so it felt squarely within service standard seven the whole issue of information gathering seven two days uh can we now turn to an email chain
02:06:34 uh can we now turn to an email chain which can be found at lfb trouble zero four double two five two now this is an email chain from november 2013 between dac tom george and john elwell um if we can go
02:06:48 george and john elwell um if we can go to the bottom of page two
02:06:54 which is an email from tom george to john elwell and it says this john as you're the service standards lead officer for operational contingency planning dave brown has
02:07:05 planning dave brown has given out a piece of work that i'd like you to think about and put some suggestions to me please the coroner's rule 43 letter monitoring report following shirley towers and lachnal house includes an action action
02:07:17 lachnal house includes an action action 18 the brigade reviews procedures for sharing
02:07:20 sharing information gained as a result of section 72d visits with crews both within the station in question and other local stations as a result of this pn 800 has been
02:07:31 as a result of this pn 800 has been reviewed action 18a as you know also attached to this action is to create an inspection regime targeted at high priority buildings action 18 b and is this that dave and i
02:07:42 action 18 b and is this that dave and i would like you to review please there are currently only 7 000 ord entries and the third officer feels there should be more he wants us to beef up our inspection program can you please have a
02:07:54 inspection program can you please have a think on this and put a proposal to me on what would be more appropriate than what is done currently and how this could be achieved dave has asked for a response asap so could i ask for your thoughts within two weeks if possible
02:08:06 thoughts within two weeks if possible many thanks much appreciated now
02:08:11 now tom george has taken your name in vain there oh he's certainly taking your name
02:08:18 is he doing justice your intentions when he says that you wanted two quotes beef up close quotes the inspection program i don't recall making that comment uh but
02:08:31 does it convey the tenor of your aspirations for the work i would have said
02:08:35 said i may well have said that uh but but it was far more than just beef up the inspection program uh i had regular meetings with the deputy assistant commissioners and
02:08:46 deputy assistant commissioners and probably spoke with them almost daily as well by telephone or otherwise certainly had numerous email conversations with them
02:08:53 them and uh and that's i've made it clear to tom that i want an inspection program that ie leads to more ord entries and b gets the right ones on there if that is
02:09:04 gets the right ones on there if that is interpreted as beef up i think that oversimplifies it but it's uh it's not an unreasonable way to describe part of it it seems on the base of that that he's fairly summarized your intentions in
02:09:15 fairly summarized your intentions in terms of getting more yes premises details on the ord yes but but also making sure that we get the right ones on there as well at least to start off with can you help us the reference to 7000 properties in that
02:09:28 reference to 7000 properties in that quote but was that a reference to high-rise properties specifically or just properties generally no that was the total number of buildings that are on the operational risk database so the operationalist database is is really any
02:09:41 operationalist database is is really any could be any non-commercial building or indeed as in high-rise for example it could be residential buildings so there's a whole range of different buildings
02:09:50 buildings that could effectively be on the ord
02:09:55 tom george sent this email can we now look at john elwell's response which starts at the bottom of page one of the chain
02:10:02 chain [Music]
02:10:06 he asks first of all for a copy of the monitoring report and then goes on to ask this in the bottom of the page could you also confirm the use definition of the term
02:10:17 confirm the use definition of the term high priority buildings in action 18 b as turning over the page currently this does not accord with any terminology in pn 800 based on the premise's risk assessments
02:10:29 based on the premise's risk assessments appendix 2 premises are rated as high risk is this the same concept or does the action plan refer or allude to a different grading model now mr george replied at the top of page
02:10:42 now mr george replied at the top of page one in the second paragraph
02:10:48 and he answers candidly i have no other detail other than this have a look and if i still need to seek guidance on high priority buildings i will do but i'd read this as those that present the
02:10:59 read this as those that present the greatest risk to firefighters
02:11:03 now did mr george discuss the definition of high priority buildings with you as part of the iterative process of clarification that you referred to earlier on
02:11:14 certainly tom did come back to me i can't recall the conversations but what i do know is that we eventually got to the
02:11:23 the a great position that we're talking about high risk as defined by the action plan
02:11:30 here high risk is more specific is that which presents the greatest risk to firefighters was that your understanding of what the term meant at the time
02:11:45 i wouldn't i wouldn't describe it in in that way necessarily we were obviously always
02:11:52 always massively concerned about the risk to our staff in emergency incidents and one could argue that those sites that are the highest risk
02:12:03 that are the highest risk to the public also are of great risk to firefighters but i wouldn't i wouldn't simplify in those terms so did mr george say to you gov have i got the right definition
02:12:16 the right definition i can't recall exact details of our conversation but but i do know we got to the position in the end where it was about high risk as per the the action plan
02:12:28 i.e greatest risk to both firefighters and residents of those buildings absolutely [Music]
02:12:50 can we now turn to a briefing paper which is the initial paper that mr elworld produced which can be found at lfb trouble zero three two eight two five
02:13:05 and page one of the paper which is entitled action 18b london fire brigade consolidated action plan following coroner's recommendations the third paragraph under the heading
02:13:17 the third paragraph under the heading background sets out a number of issues which mr elwell identified as quotes implicit within the concern on numbers of ord entries and if we could just go through these
02:13:28 and if we could just go through these simply because the importance of the document a is the existing guidance pn800 fit for purpose to achieve the desired outcomes b
02:13:38 b what other brigade data could be deployed to identify relevant premises for inclusion on the ord c
02:13:45 c are the 7 000 we have all relevant and in compliance with the guidance in pn 800
02:13:51 800 d
02:13:52 d which premises are missing from the ord given the guidance pn 800 e
02:13:59 e what is the capacity of a station watch in terms of the number of ord entries that can be effectively entered and revisited with the existing guidance a pertinent point given the disparity of
02:14:11 a pertinent point given the disparity of the numbers risk and types of premises on different stations grant f is the quality of existing ord entries providing data to underpin safe systems of work
02:14:22 of work g
02:14:23 g are our staff competent to carry out the 72d visits and enter meaningful data and professional tactical plans h
02:14:32 h what are the existing performance evaluation tools to monitor performance i what service standard is in place to quality assure the relevant extant policies
02:14:43 policies as these issues start to be effectively defined addressed and monitored i would suggest that an improvement in the quality and quantity of oid entries will be observed note the term high priority buildings
02:14:54 note the term high priority buildings used in action 18 b does not accord with the definitions in the extant policy note 800 or draft policy note 800. this term is therefore taken to mean high risk in line with the
02:15:07 taken to mean high risk in line with the terminology currently in use in both versions of pn800 now taking the step back there's that's a summary rich in detail and complexity
02:15:18 a summary rich in detail and complexity mr elwell was proposing a fundamental review of the basic adequacy of the brigade's existing operational risk management systems would you agree with that description
02:15:29 that description yes
02:15:31 yes can we now look at another email chain which can be found at lfb trouble zero four one three six zero
02:15:45 i'm afraid this is a long chain and could we go to page ten from the bottom of that page [Music]
02:15:52 [Music] we can see there that on the 13th of december 2013 mr elwell lodged his report both with you and tom george do you recall receiving
02:16:03 do you recall receiving mr elworth's report yes
02:16:07 now mr george followed up with the following email to you the next day and that can be found at the bottom of page nine
02:16:13 nine [Music]
02:16:16 [Music] mr elwell has not copied in uh to this email
02:16:20 email and again apologies for reading it out dave following the action given to me at pmb regarding action 18 from the rule 43 letter following the shirley towers and lachmal house incidents specifically to
02:16:32 lachmal house incidents specifically to create an inspection regime targeted at high priority buildings i asked john elwell
02:16:38 elwell lead officer for ss7 to look into this and provide me with some suggestions which i was going to review collate with other observations and report back to you at or before the next pmb
02:16:50 next pmb john has been extremely thorough and produced a 16 page report attached and already forwarded to you from john this report is actually only five pages long and it's well worth a read the
02:17:01 long and it's well worth a read the following pages are associated appendices john has made some recommendations which i've listed below although they really need to be read in context you asked me to think about how we can
02:17:12 you asked me to think about how we can improve on our 72d inspection program particularly for high-risk premises i believe john's report does exactly that and each recommendation should therefore be carefully considered in my opinion
02:17:23 be carefully considered in my opinion please let me know how you wish for this to be taken forward or i'll leave it to you to raise at pmb unfortunately i'm not there on wednesday as i'm on leave mr george then listed the
02:17:34 mr george then listed the recommendations from the report in the latter half of his email recommendation one that the ongoing review of pn800 provides explicit detail of the types of risk that should be present the layout
02:17:46 risk that should be present the layout of the note should be user friendly and be a one-stop shop for all guidance pertaining to the ord system including the gap analysis undertaken during the service standard process
02:17:59 recommendation 2 if an immediate focus is required on the completion of the ord to enhance the quantity of entries then face-to-face meetings should take place between the appropriate managers
02:18:11 between the appropriate managers that's deputy assistant commissioner and borough commander borough commander and station manager station manager and watch manager to reinforce the provisions of pn 800 and the expectations required this can be
02:18:22 expectations required this can be undertaken as part of the performance management review cycle or if required in a more urgent manner as a bespoke meeting specifically for this purpose recommendation three when the revised
02:18:33 recommendation three when the revised pn800 is promulgated the publication is carried out simultaneously with a series of face-to-face workshops with station and borough commanders these workshops should provide a detailed explanation
02:18:44 should provide a detailed explanation and expectations of the content of pn800 the current practice of entering new policy notes onto the station circulation folder or announcing the policy by email will not be sufficient
02:18:55 policy by email will not be sufficient to effectively explain the expectations required
02:18:58 required with apologies it continues turning over the page
02:19:03 recommendation 4 of feasibility study is undertaken into the use of existing brigade data recommendation 5 a review is undertaken of the disparity of risks across
02:19:14 of the disparity of risks across different station grounds and a methodology developed to determine the optimum number of ord entries for stations with high numbers of applicable premises
02:19:23 premises recommendation 6 further training is provided to all personnel with a role in the ord process to ensure they have the skills to meet the competencies required recommendation 7 consideration is given
02:19:34 recommendation 7 consideration is given to redefining the kpis in service standard 7 to include measurement of the quantity and quality of ord entries recommendation 8 the service standard board finalizes the arrangements in a
02:19:46 board finalizes the arrangements in a timely manner for the publication of agreed service standards associated systems and policies with particular reference to service standards seven the timely publication will provide a further performance
02:19:58 will provide a further performance assurance process to improve ord entries both in quantity and quality now it's a very long run run up to enough one final email before i actually ask a question if we go to the
02:20:09 actually ask a question if we go to the top of page nine
02:20:12 and you responded on the 16th of december 2013 so just two days later tom this is interesting and helpful and i'm sure we can use some of john's recommendations however it doesn't feel
02:20:24 recommendations however it doesn't feel to me that any of the recommendations actually deals with the requirement to quotes create an inspection regime targeted high priority buildings or am i missing something well that's a very long run up to one
02:20:37 well that's a very long run up to one short question was your view that mr elwell's report did not fulfill the brief of creating an inspection regime targeting high priority buildings that's correct yes do you accept that mr elwell's report
02:20:49 do you accept that mr elwell's report raised some significant broader concerns though about the adequacy of the lfb's current arrangements
02:20:58 yes however i do need to qualify that because some of the recommendations that he raised
02:21:04 he raised uh
02:21:06 uh had been dealt with already were being dealt with with or within john's uh sphere of influence to deal with by virtue of the fact that he was contributing to the uh policy note 800
02:21:19 contributing to the uh policy note 800 and he was also lead service standard seven and there were one or two that were
02:21:27 were were very aspirational and uh in an ideal world yes great but the reality just didn't work well let's look at some of the
02:21:35 of the the black and white of some of these recommendations and could we go to lfb trouble zero three two eight two five forward slash two
02:21:48 now looking at recommendations two and three
02:21:51 three which on the top half of this page both those recommendations emphasize the importance of face-to-face meetings and workshop between crews and their managers do you accept that
02:22:13 recommendation two and three ask for for that kind of interaction yes yes and
02:22:21 yes and recommendation two uh i don't think there's any serious doubt but you accept and you agree and endorse the aim to enhance the quantity of some of the end
02:22:32 enhance the quantity of some of the end the quality and quantity of the entries uh on the ord is that fair
02:22:39 yes and would you agree that in order to achieve the improvements in both quality and quantity what was required was more face-to-face time between operational staff and their managers to explain what
02:22:50 staff and their managers to explain what was required of them and for the purpose of the process do you accept that i accept it but then i also expect that was normal business
02:23:00 given it was the subject of recommendation isn't that a warning or at least a suggestion to you that it wasn't routinely part of normal business across the lfb's operations
02:23:12 no because because i i know that it was the case i mean so so john for example is
02:23:19 is is was a borough commander so and i knew and i knew john for example had regular meetings with the dak and i knew john had regular meetings with his station manager so this to me seemed to be
02:23:32 manager so this to me seemed to be stating it it's a it's it's the correct thing to do but it was already happening this is normal business isn't that the problem haven't you inadvertently put your finger on the
02:23:43 inadvertently put your finger on the problem though you've got a borough commander who is the lead on service standard seven he's making a recommendation to you that there should be
02:23:53 be more or face-to-face meetings that ten suggests it isn't happening because he felt the need to make the recommendation why isn't that a reasonable supposition based on what he's setting
02:24:05 supposition based on what he's setting out here
02:24:09 i i can only use so my knowledge of of the brigade having so by this time this is 2013. so i had been in post now for
02:24:21 so i had been in post now for seven years nearly and my experience in them seven years
02:24:26 years is that actually there was an abundance of meetings and i and i could use my knowledge in terms of i was aware of what was going on all over london in every single borough and i knew
02:24:39 every single borough and i knew that dax met with their borough commanders and borough commanders with their station managers i knew that for a fact
02:24:44 fact so
02:24:46 so let's look at the level below you've keenly emphasized those discussions what about the most pertinent discussions between crews and their managers
02:24:59 again from my experience this is something that that was happening i mean what i would want to emphasize is recommendation two is a sound
02:25:10 recommendation two is a sound recommendation it's absolutely right this should be discussion between crews and managers and
02:25:16 and watch managing stations et cetera et cetera is absolutely right but it's something that is already happening so my understanding of why the recommendation is being put in there is
02:25:28 recommendation is being put in there is because it's the right thing to do it shouldn't necessarily be drawn to inclusion it's not happening there's other recommendations in here as well the right thing to do but also we're already having
02:25:39 already having can we look at recommendation three in relation to things that are already happening and look at the last three lines which says the current practice of entering new policy notes onto the station circulation folder or announcing
02:25:51 station circulation folder or announcing the policy by email will not be sufficient to effectively explain the expectations required now was
02:25:58 now was were those means of communication consistent with your experience were new policies usually introduced simply by insertion in a folder or circulation by email without accompanying workshops or training that
02:26:10 accompanying workshops or training that was the case sometimes yes sometimes
02:26:14 sometimes that formula of words there suggests it was
02:26:17 was generally the case it depends on it depends on what the policy was about the prior knowledge so the issue that we would always consider and we did this in training
02:26:28 consider and we did this in training packages as well is what is what is the gap what is the need in terms of what staff need to know and then we would think to ourselves how do we address that need do we address that need for a training package or
02:26:39 that need for a training package or through face-to-face meetings or by a an email announcement or just by a policy being sent out for staff to read through that there was there was a desire for
02:26:50 that there was there was a desire for staff to always have uh some kind of training package or uh or extended uh explanation but that isn't always practical or necessary now can we go
02:27:02 practical or necessary now can we go back and look at recommendation five which can be found at page three and the second paragraph on that page
02:27:12 now the report recommended there at five a review is undertaken of the disparity of risk across different station grounds and a methodology developed to determine the optimum number of ord
02:27:25 to determine the optimum number of ord entries for stations with high numbers of applicable premises now that's an issue you refer to in paragraph 40 of your second statement and probably be useful if we go to it
02:27:37 and probably be useful if we go to it lfb trouble zero eight four zero two zero forward slash one five and if we look at paragraph 40 at the bottom of the page
02:27:49 bottom of the page you say that there are 33 boroughs across london there is significant variation between the built environment in each london borough some boroughs will have a large number of large amount of commercial buildings whereas others
02:28:00 of commercial buildings whereas others with will have a high percentage of residential buildings and some will have both all of which require an awareness of by fire station staff accordingly it was impractical to set
02:28:11 accordingly it was impractical to set fixed targets for the number of section 72d visits that staff at each fire station should complete in high-rise residential buildings as it would place an equitable workload on some fire
02:28:22 an equitable workload on some fire station staff that was not placed on others especially when taking into account a range of other commitments such as training and community safety again apologies for long run up to a
02:28:34 again apologies for long run up to a short question did a review of disparity of risks that was recommended by mr elwell take place
02:28:44 a review no
02:28:49 no but a recognition that that was a an accurate summary of an issue to be resolved and i'll put in place a method to resolve it
02:29:00 a method to resolve it why was the review not carried out
02:29:06 because because i think we we were both in agreement that that there was a disparity so the review would only have confirmed what we already knew and agreed about and so the
02:29:18 already knew and agreed about and so the recognition was on your part you referred to oh yes absolutely it was something that uh i was fully aware of anyway and and and john quite rightly also underlined the
02:29:29 john quite rightly also underlined the point and what method did you put in place to resolve it so
02:29:34 so there's a lot been mentioned about crews on their own station's ground and there is where the inequity lies so we had a method called strategic results and what that effectively did
02:29:45 results and what that effectively did was it allowed us to take a fire engine off the run i make it unavailable for a shift and in that time that the crew on that fire engine could go anywhere they liked in london
02:29:57 liked in london to do training or community safety activities and so strategic results had been developed so that we could take a large number of fire engines off the run on
02:30:08 number of fire engines off the run on particular shifts so then what i did was knowing which boroughs had a higher prevalence of high-rise buildings and other buildings that needed to go on the operational
02:30:19 that needed to go on the operational risk database we put systems in place where we would flood for one of a better expression certain areas with a number of appliances and fire engines and say to them you need to go out and in line with
02:30:31 them you need to go out and in line with what the station manager of that station is giving you go and inspect these buildings and get them on the operational risk database so that would assist
02:30:40 assist that's like for example the city it's got one fire engine in it the city of london but yet has got as one would imagine an incredible amount of high-rise they could never do it on their own so it's another appliances in
02:30:52 their own so it's another appliances in and i would always use the analogy because it wasn't popular people didn't like the idea of this and i would use the analogy that if there was a large fire in the city you'd have no problem coming from from havering in the east to
02:31:05 coming from from havering in the east to help out with that fire in the middle so equally you should have no problem coming in the middle and helping out with doing some inspections that needed to go on beforehand and i use that same philosophy with home fire safety visits and things where it required a large
02:31:17 and things where it required a large number of personnel in an area where we wouldn't normally have a large number of personnel
02:31:22 personnel so that that was that was my approach to dealing with john's recommendation although to be fair that was something that that was in my mind to do anyway john just quite rightly underlined the need for it
02:31:33 need for it the recommendation is number five is in two parts
02:31:37 two parts the first part is a review of disparity of risks the second part is development of a methodology to determine the optimum number of ord entries for stations now as i understand the evidence you've just given
02:31:49 evidence you've just given the method you put in place did not involve
02:31:53 involve developing a methodology to determine the optimum number of ord entries is that right in terms of if what you mean by that is how many exist on that station's ground
02:32:04 how many exist on that station's ground so when we know it's complete no it no it didn't because we were still struggling at that time to determine how many there actually were was it methodology ever developed no no why not
02:32:16 why not because we just didn't know how many there were there so the idea was that we were just we knew
02:32:23 knew we knew what areas they would be in uh in terms of if you look at london as as three rings is the inner ring and then the second ring is where most of them will be the inner ring mostly commercial
02:32:34 will be the inner ring mostly commercial the second ring mostly residential the outer ring you know the more suburbs far less of either so we knew where to place our resources but we just didn't know
02:32:45 our resources but we just didn't know at that time whether the brigade knows now i'm not sure but we didn't know that time exactly when that pot will be exhausted
02:32:56 but we also felt that we were we were so far away from exhausting the pot that there was a little point in in putting too much effort into it because we weren't near the finishing line on that one we just needed to
02:33:08 one we just needed to it was a front to earth common sense we knew there was there was so many missing and we needed to get them on there thank you could we go to back to mr elwell's report and look at recommendations six which we found at lfb trouble zero three
02:33:21 which we found at lfb trouble zero three two eight two five forward slash three that's the bottom of page three
02:33:30 where he said this or recommended this further training is provided to all personnel with a role in the ord process to ensure they have the skills to meet the competencies required the paragraph at the bottom of page
02:33:42 the paragraph at the bottom of page three
02:33:42 three immediately above this recommendation says this
02:33:45 says this during the development of the service standard presumably seven and at recent instance a number of existing ord entries have been examined a number of substandard examples were found this
02:33:56 substandard examples were found this could indicate a poor understanding of the rationale and a lack of competency based on the above list in recording relevant risk and tactical planning information at all levels of the process
02:34:07 information at all levels of the process watch manager station manager borough commander
02:34:10 commander district as deputy assistant commissioner was that reference to substandard ord entries
02:34:17 entries any cause of concern for you first of all oh absolutely yes of course yeah and were you already aware of the problem of substandard entries yes
02:34:28 yes which is i don't over play in terms of substance entries but in my view one substandard entry is one too many we can have no flexibility on this
02:34:39 have no flexibility on this so yes i was aware there were examples but then that was that was part of the reason why we were doing what we were doing with policy note 800 and also with the training that had probably only just
02:34:50 training that had probably only just been rolled out some seven months before john made this recommendation
02:34:59 you don't want to overplay the problem about substandard entries and respect the ord we already know the substandard nature of the entry in relation to grenfell that's the subject of findings
02:35:10 grenfell that's the subject of findings could we look at another one which is rather can we look at the ord entry for grenfell which is lfb quadruple zero three double one six [Music]
02:35:22 [Music] it's something we've touched on earlier but it's probably useful to go back onto to remind people the ord entry was considered in phase one and a number of deficiencies were identified
02:35:33 identified and take you through them first of all there were no plans of the tower on the ord despite the fact that nicholas davis the station manager noted that plans are required
02:35:43 required and we see that on the entry for the 10th of may which is in the fifth row in the main table on page one secondly the only photograph of the tower was a small aerial image which
02:35:55 tower was a small aerial image which gave no information about the building or access to that building and that can be seen at page seven thirdly
02:36:03 thirdly the incorrect number of flaws was recorded 20 is stated on page 3 under hazards
02:36:12 and under the heading tactical plan on page 4
02:36:17 page 4 the subheading operational contingency plan contains simply a blank box dated the 30th of october 2009.
02:36:28 are you familiar with the ord entry for grenfell tower no
02:36:35 i've i've become aware of it clearly since the inquiry but but prior to that now were you aware of the extent of the findings in relation to the deficiencies
02:36:47 findings in relation to the deficiencies of that ord that was made by the chairman and the phase one report yes
02:36:52 yes was the standard of ord entry as exemplified by grenfell typical of the quality of rd entries generally in your experience no
02:37:06 did you agree with mr elwell that the problem was substandard entries could indicate a poor understanding of the rationale and a lack of competency on the part of personnel who made those entries
02:37:19 not a poor understanding i think staff did understand i think what it does indicate is that there's
02:37:30 there's some somewhere along the line there's clearly a
02:37:34 clearly a gap
02:37:35 gap in the process and and this entry on grenfell is he's clearly poor and uh and and and wrong and when i found out about this yes it was
02:37:46 found out about this yes it was something that i reflected on and thought
02:37:49 thought how how could this happen did you reflect upon it to the extent of actually taking action for example requiring further training to remedy the potential problems identified by mr elwell poor understanding of the
02:38:01 elwell poor understanding of the rationale and the lack of competency well when i saw this entry obviously i left the brigade but at the time in terms of john's recommendation back in
02:38:12 back in 2013 more training yeah it's it was a valid point but my my position on that was we had only just rolled out the training uh some six or
02:38:24 rolled out the training uh some six or seven months prior to that so the the need for further training i took the position that what we needed to do is what we do with all training we roll it out and then we monitor
02:38:35 roll it out and then we monitor performance in terms of entries into the operational management performance database and if we find evidence that it's not working and also in focal fire reviews and in training exercises and in
02:38:48 reviews and in training exercises and in performance reviews of commands if there's evidence coming through that despite that training it's still not working then yes we would revisit it but with the with the greatest respect to john or or any other borough come on
02:38:59 john or or any other borough come on that makes that recommendation we need to follow due process in terms of determining whether the training has worked or not so it's 20 past four yes the next match
02:39:11 so it's 20 past four yes the next match that i wish to turn to i won't get done in 10 minutes i'm mindful it's been a long day also for mr brown and it would be useful to start at a logical starting point first
02:39:22 start at a logical starting point first thing tomorrow morning well i just suppose mr brown will object to an early afternoon um how are you getting on with his examination i mean in time-wise just as a general
02:39:33 in time-wise just as a general indication can he hope to be free tomorrow yes [Music]
02:39:39 [Music] can he put his hopes higher i would never wish to overestimate anyone's hopes in terms of time management here but um i'm confident that mr brown's
02:39:50 confident that mr brown's examination will be complete tomorrow yes well that's very helpful because i think he'd like to know that well mr brown it is slightly earlier than usual but i think we'll stop at that point for the day um i'm going to have to ask you to come back to
02:40:02 going to have to ask you to come back to continue tomorrow but i think you were expecting that but it sounds as though you can hope to finish tomorrow thank you sir so thank you very much indeed um we'll resume at ten o'clock tomorrow
02:40:13 we'll resume at ten o'clock tomorrow please and uh as before please don't talk to anyone about your evidence or anything relating to it thank you very much
02:40:21 much all right thank you very much indeed thank you yes you could go with the usher please
02:40:35 thank you very much mr kenya well 10 o'clock tomorrow thanks thank you
02:40:52 you