Module 5 opening statements addressing London Fire Brigade's training, management, culture, and response to the Grenfell Tower fire. Legal representatives for bereaved, survivors and residents deliver devastating critiques of the LFB's systemic failures, cultural resistance to change, and lack of contrition.
00:21:01 good morning everyone welcome to today's hearing
00:21:04 hearing today we're going to embark upon module 5 of
00:21:08 5 of phase 2 in which we're going to investigate aspects of training and management of the london fire brigade which we were not able to investigate in phase one
00:21:20 phase one today we're going to hear opening statements from various core participants but before we come to them we're going to hear first from council to the inquiry mr richard millett green's council yes mr village mr chairman thank you very
00:21:32 mr village mr chairman thank you very much good morning to you good morning to members of the panel mr stefan and mr akbar
00:21:37 akbar today's opening addresses mark the start of module 5 during which we will investigate the remaining matters concerning the london
00:21:48 remaining matters concerning the london fire brigade's response to the grenfell tower fire on the 14th of june 2017 that could not be addressed in phase one we will also investigate three other
00:22:00 we will also investigate three other specific topics that arise from the chairman's findings in the phase one report
00:22:05 report those specific topics are as follows first the adequacy and effectiveness of visits carried out by the lfb under section 72d of the fire and rescue
00:22:16 under section 72d of the fire and rescue services act 2004 to obtain information which is necessary to discharge the lfb's statutory function to extinguish fires
00:22:27 fires secondly training and with particular focus on the training provided by the lfb to incident commanders and in relation in particular there to
00:22:38 and in relation in particular there to evacuation and thirdly alternative firefighting strategies in high-rise buildings as to the structure of module 5 we are going to start with opening statements
00:22:49 going to start with opening statements by certain of the core participants today
00:22:53 today starting from tomorrow we will hear evidence from past and present senior lfb officers on the topics that i've mentioned
00:23:01 mentioned you will recall that at phase one the inquiry called evidence from some 88 lfb employees
00:23:08 employees and the statements of a further 262 lfb witnesses were read into the record in this module 5 the inquiry will not therefore be calling any further factual
00:23:20 therefore be calling any further factual evidence about the events on the night of the fire on the 14th of june 2017 those events have been the subject of detailed analysis and findings in the phase 1 report
00:23:32 phase 1 report the inquiry currently expects the factual evidence of this module 5 to take 14 or say sitting days following the factual evidence we will then hear from three of the four experts
00:23:44 then hear from three of the four experts retained by the inquiry for the purposes of this module those experts are as follows one professor chris johnson who has examined the effectiveness of the lfb's communication systems
00:23:56 communication systems to mr steve mcguck who will deal in broad terms with firefighting on the night
00:24:02 night and three professor jose torreira who will consider general issues arising from the firefighting response we expect that that evidence the evidence of each expert will take one
00:24:13 evidence of each expert will take one day a piece dr ivan stoyanov has addressed certain issues relating to water on the night of the fire in the light of some of the points made by thames water and the lfb
00:24:25 points made by thames water and the lfb very recently in their opening submissions the inquiry team has decided to call dr stoynov's evidence later in module 7
00:24:34 module 7 to allow him to consider the points that have been raised finally i should make it clear that the first part of module 6 will be concerned with further questions for the lfb and others such as the sufficiency of the
00:24:47 others such as the sufficiency of the lfb's policy arrangements for the management of fire survival guidance calls
00:24:52 calls mhclg's policy document gra 3.2 and evacuation the translation of knowledge within the lfb of risks presented by cladding fires in high-rise buildings into operational
00:25:04 in high-rise buildings into operational policy and practice and the lessons learned and arising from the latino house fire and other relevant fires in this country and abroad we intend to examine those matters uh in
00:25:17 we intend to examine those matters uh in module six but also to some extent in this module five i should also make it clear that in module six the inquiry will hear evidence from the present london fire commissioner and his two immediate
00:25:28 commissioner and his two immediate predecessors mr chairman that is all i propose to say by way of opening statement thank you very much mr millet we're now the first of the core participants
00:25:40 participants legal representatives to address as is mr friedman queen's council and uh since he's in the room he's ready to go slightly earlier than we suggested we might be able to hear him good morning mr friedman good good morning
00:25:51 morning mr friedman good good morning samantha see you are you ready to make your statement i i i i am and um we are grateful to the arrangements that have been made for the remote hearings but but also happy to see you here this
00:26:02 but but also happy to see you here this morning and good morning to miss esteban and mr akbar too
00:26:10 firefighters don't cause fires they respond to the threats of other people's making but that does not insulate fire services
00:26:21 but that does not insulate fire services from the need to achieve competency in what they do and at grenfell tower the london fire brigade confronted the limits of its competency the depth of its deficiencies
00:26:33 the depth of its deficiencies exposed an organization that could not cope with an emergency beyond the normal or standard fire although unusual the catastrophic consequences of high-rise building
00:26:44 consequences of high-rise building failure were foreseeable and foretold still
00:26:47 still the lfb remained dangerously unprepared the inescapable function of fire services
00:26:54 services is to compensate for the errors of architecture design and other control systems which once failed will lead to disaster if not responded to effectively
00:27:05 responded to effectively that is why we say to all the fire fighting parties at this inquiry that the gross negligence of the contractors the hijacking of regulations by companies and the economics of
00:27:17 companies and the economics of successive governments cannot serve as full excuses there are aspects of the lfb's undoing at grenfell tower that were caused by the culture of the organization
00:27:29 organization caught in its traditions fiercely cared for by its unions its heroic status makes it rare for it to face public criticism but that in turn makes it hard to honestly assess its
00:27:42 makes it hard to honestly assess its deeper limitations all these things have burdened the lfb in making change and for reasons i now turn to the lfb is unlikely to reimagine itself to correct
00:27:55 unlikely to reimagine itself to correct the deficiencies exposed by this exact disaster without outside intervention our starting point is management capability the generation that led the lfb in its
00:28:08 the generation that led the lfb in its period up to grenfell tower had largely entered as young adults at watch station level
00:28:13 level mostly during the 1980s and worked their way up through the ranks to middle and senior officer roles it was normal for them to have no relevant university qualifications
00:28:25 relevant university qualifications and they appear to have had little training in leadership and management skills
00:28:29 skills with some notable exceptions like paul grimwood and sabrina cohen hatton who the inquiry is about to hear from through few leaders of operational firefighters have developed
00:28:40 firefighters have developed understanding of management fire engineering or behavioral psychology in turn these managers promoted those coming up behind them without what would
00:28:51 coming up behind them without what would now be regarded as transparent and fair procedures with little fast tracking of talent or competitive lateral hires from other services or sectors in our written document we've summarized
00:29:03 in our written document we've summarized the findings of 20 years of independent reviews and that have repeatedly said the same thing from the audit commission in 1995 the bain review in 2002 the night review
00:29:16 the bain review in 2002 the night review in 2013 and the thomas review in 2015 the constant refrain has been that fire services are heavily managed but insufficiently led
00:29:27 insufficiently led because its leadership does not have the training development or competitive recruitment to do better these criticisms are relevant to the lfb
00:29:38 these criticisms are relevant to the lfb the brigade had advice from babcock in 2014
00:29:42 2014 to introduce mandatory formal management accreditation into each level of leadership a peer review by representatives from other services in 2015
00:29:53 other services in 2015 underscored the need for a change in leadership style and better connection with staff at all levels after the grenfell tower the internal people services review
00:30:04 people services review completed in 2017 december by then assistant commissioner rowe acknowledged for the fight that uh for the first time in anything we have seen that the brigade lack quote
00:30:16 that the brigade lack quote a clear structured program of change encompassing in particular leadership and performance management this would need it said external multi-disciplinary support and better
00:30:27 multi-disciplinary support and better leadership development and recruitment to combat what it described as stagnation and a lack of new thinking for more than a decade central government had ceased inspection of fire
00:30:40 government had ceased inspection of fire services
00:30:41 services but when her majesty's inspectorate investigated the lfb in 2019 it found that processes for selecting developing and promoting middle and senior management lack effective recording and
00:30:52 management lack effective recording and openness and there were few opportunities for staff to develop leadership capabilities when this inspector returned to assess the lfb in 2020 just after your phase
00:31:04 the lfb in 2020 just after your phase one recommendation sir it's still found that the basic building blocks of program and change management are only now being established if that was the finding in 2020
00:31:17 if that was the finding in 2020 the lfb not only lacked those basic arrangements to manage lead and assure its service in june 2017 but we say no one in the organization's leadership had urgently identified how
00:31:29 leadership had urgently identified how lacking it was in its capacity to do so the consequence was a management system that was highly resistant to change the inquiry will need to consider how
00:31:41 the inquiry will need to consider how funding reductions contributed to lack of innovation especially after 2010. yet the shortcomings of the lfb at grenfell tower have roots long before
00:31:54 grenfell tower have roots long before austerity and are to do with a considerable consensus across all ranks of fire services that are unwilling to transform the nature of what they do
00:32:06 the nature of what they do firefighting despite its courageous values and high level of comradeship and public service remains a conservative vocation it has a problem with progressive
00:32:18 it has a problem with progressive organizational thinking at various levels and not just at the top
00:32:24 top firefighters find it difficult to transform when transformation is due in terms of understanding what went wrong at grenfell tower a pertinent focus is that both the
00:32:36 a pertinent focus is that both the management and the crews grew out of the watch and shift culture and its drilled approaches to particular forms of standard fire fighting responses and very significant demands
00:32:49 responses and very significant demands for peer group conformity indeed
00:32:52 indeed those who climb to the heights of leadership will often have excelled within that culture and part of its related self-reinforcing cycle again since the turn of the century reports
00:33:04 since the turn of the century reports have repeatedly focused on this problem in 1999 hermaggi's majesty's inspectorate found that quote the watch is a closed culture which takes on the
00:33:15 is a closed culture which takes on the character of a family rather than a team where the emphasis is on fitting in not on tolerating diversity 20 years later the renewed hm
00:33:26 20 years later the renewed hm inspectorate still describes some watches as having created their own subcultures which are contrary to service values and have proved impenetrable for new staff and where teams have worked together for many
00:33:38 teams have worked together for many years
00:33:39 years working practices haven't yet modernized the lfb has a well-documented difficulty in this area its peer review in 2015 described a them
00:33:50 its peer review in 2015 described a them and us culture affecting trust openness and respect that went well beyond the division between management and union adrian thomas in the same year felt that
00:34:01 adrian thomas in the same year felt that distance from london was by no means a rule
00:34:05 rule but distance did seem to allow a greater degree of independent thinking more flexible thinking and acceptance of change from the employee representatives the hm inspection of the lfb in 2019
00:34:19 the hm inspection of the lfb in 2019 equally found that changes understood to be required after grenfell tower were quote slow to implement which is typical of the brigade's approach to organizational change and in recent years innovation has stifled and staff
00:34:32 years innovation has stifled and staff reported a lack of organizational desire for church sir
00:34:37 sir all of that begs the question why this conservative and quite fearful workplace culture continues to prevail in what is
00:34:48 continues to prevail in what is otherwise a courageous community of people
00:34:52 people there is an insider's answer to that question in dave badgett's study entitled one more last working class hero a cultural audit of the uk fire service
00:35:03 service the author is an academic sociologist who was previously a member of the lfb and the fbu he describes three features of firefighting life
00:35:15 three features of firefighting life first the heroic and still highly male gendered need to get into the fire second the need to get on and fit in
00:35:26 second the need to get on and fit in with watch colleagues and third the tendency to see an us and them divide between management and station
00:35:34 station but also between the heroism of the notional front line and those non-operational theorists who focus on prevention and policy badget's work
00:35:45 badget's work is going to no doubt have its opponents but dr cohen hatton has spoken about the toxicity and fearfulness of the dominant male heroic model that both men and
00:35:56 male heroic model that both men and women who work in the services feel that they have to live up to this analysis also strongly resonates with those bsr who told the inquiry at the end of phase one hearings that what
00:36:07 the end of phase one hearings that what they wanted was not heroes but well-trained professionals working to a well-structured plan what incurred instead was the flooding of the building
00:36:18 was the flooding of the building and firefighters and equipment all going in
00:36:21 in without conceptual tools or adequate training to do things differently for the bsr
00:36:30 there were agonizing failures of training on the night of the fire so many firefighters with so much experience could not recognize an event of complete
00:36:42 could not recognize an event of complete building failure unfolding before their eyes
00:36:46 eyes and consequently when and how to evacuate it we know that evacuation happened in melbourne in 2014 and it happened just recently in milan
00:36:58 and it happened just recently in milan why didn't it happen in london in 2017 the difficult truth is that previous experience of firefighters turned out to be their greatest impediment
00:37:09 impediment they could not see what they did not know
00:37:12 know they could not do what they had never experienced professor torreira's root cause explanation for their knowledge deficit
00:37:23 knowledge deficit is that operational firefighters are intentionally trained to achieve proficiency in planned or set fire fighting methods as opposed to encouraging developmental learning skill
00:37:35 encouraging developmental learning skill and psychology they cannot work effectively beyond unexperienced events torreira's key point is that training is presently underdeveloped for anything
00:37:47 presently underdeveloped for anything other than what he calls design anticipated fires the essential features of the design are one
00:37:54 one the presumption that compartmentation will hold
00:37:58 will hold two a default position to favor direct interaction with fire as opposed to considering other options such as evacuation and three
00:38:08 and three the predisposition to act out the internal heroic image of the responder who fights the fire in torreira's view the presently trained personnel can discharge firefighting
00:38:20 personnel can discharge firefighting plans but they are not proficient in formulating new ones the presumption of regulatory compliance including having stay put as the emergency plan has caused the training
00:38:31 emergency plan has caused the training to deliver standardized operational tactics and excused firefighters from needing any proper understanding of building behavior all of that came unstuck at grenfell
00:38:42 all of that came unstuck at grenfell tower
00:38:43 tower torreira primarily puts the course down to the fact that in all areas government private and fire service competency in fire engineering has not kept up with the complexities of modern design that
00:38:56 the complexities of modern design that he says is to do with the lower status of fire engineering as an academic and vocational discipline as against other forms of engineering causing it still to resemble a regulated trade as opposed to
00:39:09 resemble a regulated trade as opposed to a profession the lack of competency of those who led on fire engineering within the fire services is particularly damaging twice over
00:39:19 over it cannot hold the responsible persons under the fire safety order to account and at the same time cannot obtain enough influence within the fire services to qualify the operational
00:39:30 services to qualify the operational protocols relating to standardized design firefighting whatever the grounds to criticize the outsourcing of training to babcock that issue should not detract from the
00:39:43 that issue should not detract from the primary blockages caused by the educational traditions in which the lfb operational responders are trained they are still taught by instructors who are largely previous or current serving
00:39:54 largely previous or current serving members of the brigade who were themselves firefighters in the traditional image and mold and lfb managers
00:40:02 managers are the ones that commission and audit the training and they also tend to be from the same background the bsr will look to the inquiry to establish whether the training provided
00:40:13 establish whether the training provided by babcock was worse than its predecessor but their major concern is that it didn't get any better despite the industrial relation sensitivities
00:40:25 sensitivities we are also bound to observe that whatever the continuing advantages of a strict watch shift system it is inconsistent with delivering training that will fundamentally
00:40:36 training that will fundamentally transform the competency of the service the shift
00:40:40 the shift with its two days and two nights on and four days off limits available time it ill-fits co-training with non-operational experts it is particularly difficult to quality
00:40:52 it is particularly difficult to quality assure
00:40:53 assure especially if the watch managers have to be trainees trainers and supervisors of the training during shift hours without the training to do so
00:41:04 the training to do so overall
00:41:05 overall it makes significant change in the way things are done particularly cumbersome to achieve taking all these matters together the lfb remained a depressed learning
00:41:16 lfb remained a depressed learning environment before grenfell it was not an auspicious forum for change makers or particularly welcoming to blue sky thinking you saw that in phase one with peter johnson's exercise that tested the
00:41:28 johnson's exercise that tested the readiness of compound command units to deal with multiple fire survivor calls you will see a similar problem in this module with regard to research on the psychology of incident command
00:41:41 psychology of incident command modern organizations need to be places of ideas that is the case even when and indeed especially when those organizations manage risk to life
00:41:53 manage risk to life projects for change were not so much rejected
00:41:56 rejected as default dampened down or stalled in the system the bsr therefore in consideration of these impediments of culture and training
00:42:06 training they provide important root cause explanations as to why the lfb defaulted in its competencies in such a significant way at grenfell tower and it is those deficiencies as established in
00:42:17 is those deficiencies as established in phase one that i now turn to the first efficiency operational firefighters could not identify a cladding fire even though it
00:42:28 identify a cladding fire even though it was long understood to pose potentially catastrophic risks the evidence suggests a genuinely perverse disconnect between the identified and identification of cladding systems being recognized as a
00:42:40 cladding systems being recognized as a high-rise fire danger for more than 30 years
00:42:44 years but no one ever seriously suggesting that operational firefighters ought to be trained on the subject witnesses core participants and a note of counsel to the inquiry have set out
00:42:55 of counsel to the inquiry have set out the multiple references to the issue over time
00:42:58 over time we particularly mention the select committee report in 1999 the various versions of generic risk assessment 3.2 in 2008 and 2014.
00:43:10 assessment 3.2 in 2008 and 2014. the guidelines on the provision of operational risk information otherwise known as porous in 2013
00:43:19 in 2013 and the 2014 national operational guidance program paper on fires in the built environment environment that highlighted external wall finish
00:43:30 highlighted external wall finish cladding and describe the potential for external fire spread with combustible cladding systems so it could be debated whether more should have been done by central government
00:43:41 government but the hazard of cladding and other forms of external fire spread was identified in the national documents but were never mainstreamed into lfb capability
00:43:53 capability phase 2 disclosure shows that discussion of cladding fires took place in different sections of the lfb but was never transferred to operational firefighters whose knowledge of the risk
00:44:04 firefighters whose knowledge of the risk counted most chief amongst those failings was the various slide presentations on tour building facades that were adapted by members of the fire safety and enforcement department in 2015 to be
00:44:17 enforcement department in 2015 to be delivered in training only to themselves without anyone apparently thinking to translate the slides into a station based package for fellow firefighters
00:44:28 based package for fellow firefighters during 2015 the leaders of operational policy having completed gra 3.2 in its revision and its translation into
00:44:39 in its revision and its translation into an updated local policy 633 attended various high-rise building sector conferences and emailed one another during which the terrible
00:44:50 another during which the terrible examples of cladding fires were mentioned but still not circulated to the organization it is an awful indictment of a fire service that its training and dialogue
00:45:01 service that its training and dialogue was so disjointed that this pocketed awareness of bad case scenarios was never joined up the explanation of officers who knew about these cladding fires but did not educate their workplace about them is
00:45:13 educate their workplace about them is equally disappointing even if revealing they say that the details of the fires were too limited to learn anything from but in an age of internet emails and
00:45:25 but in an age of internet emails and video conferencing they did nothing to research their facts they then say that they assumed without actually knowing that the regulatory framework and compliance cultures in these other
00:45:36 compliance cultures in these other countries would be less exacting than the uk and therefore little was thought to be gained if these explanations are genuine they amount to an admission of unacceptable
00:45:48 amount to an admission of unacceptable closed-mindedness and constitute a facial breach of health and safety obligations to inform train and prepare the lfb
00:45:58 the lfb repeatedly presents itself as a world leader but on this the largest brigade in a significant global capital city it is incongruously isolationist and
00:46:09 is incongruously isolationist and parochial
00:46:11 parochial the second deficiency at grenfell tower was that the lfb visits to the building before the fire woefully understands the risks it posed and the basic features of layout that needed to be known
00:46:23 layout that needed to be known since 1947 fire services have been under a statutory duty to make arrangements to cree gather information to enable the discharge of their function
00:46:34 discharge of their function the terms of section 72d of the fire and rescue services act 2004 do not change that requirement albeit that for the first time they explicitly state that the duty relates to both the
00:46:46 state that the duty relates to both the putting out of fires as well as the protection of life and property from fire
00:46:52 fire nevertheless the duty erroneously remains downgraded in fire fighting parlance as familiarization visits in fact it ought to combine two things
00:47:05 in fact it ought to combine two things first preventative risk assessment and second the preparatory stage of operational response such as to enable incident command and crews if ever deployed
00:47:16 deployed to have access to the right information when they need it the content of the operational risk database or ord filled in by north
00:47:27 database or ord filled in by north kensington station for grenfell was so inadequate that it is difficult to believe that its flaws were not more widespread the inquiry has already established the various gaps in the database as well as
00:47:40 various gaps in the database as well as the follow-up actions that were never completed
00:47:42 completed the incident command at grenfell tower julie had insufficient wrong or no information as to the number of floors building plans
00:47:53 building plans riser mains lifts control ventilation radio testing emergency contacts and residence the recent inquiry expert report on
00:48:04 the recent inquiry expert report on water has disclosed that available fire hydrants which would have made a difference in water flow were missing from the ord are never used based on the standardized lfb risk
00:48:15 based on the standardized lfb risk assessment system that prevailed at the time grenfell tower scored the lowest possible category this absolutely should not have been the case
00:48:26 case after the latina house fire in 2009 the lfb became aware that the organization was exposed its research acknowledged that degrees of building failure were relatively common and that the protection of
00:48:38 common and that the protection of building control under the building regulations and risk assessments under the fire safety order were insufficiently robust in 2010 a national study known as future
00:48:49 in 2010 a national study known as future fires described securing compliance with fire safety as the biggest single concern to the sector the lfb leadership therefore knew that the instability of the regulatory system
00:49:01 the instability of the regulatory system was itself a generic hazard particularly in relation to high-rise firefighting and arguably its greatest threat a report of december 2013
00:49:14 a report of december 2013 commissioned to comply with the lachnal house action plan showed stations to be lacking in training or commitment to comply with the requirement of either the national or internal premises risk
00:49:25 the national or internal premises risk assessment policies the problem was so great that the study advocated alteration of the service standards in order to sufficiently compel greater station compliance with
00:49:36 compel greater station compliance with the statutory duty the brigade's third officer in command assistant commissioner brown effectively shelved that report and its recommendations despite having previously informed the latino house
00:49:48 previously informed the latino house working group that the lfb was compliant with the relevant policies and it met its lachnal house action plan the commitments relating to section 7 2 d of the act
00:49:59 the act it obviously had not on this issue the lfb demonstrates a profound ambivalence about what it expects of its members
00:50:10 about what it expects of its members the various lfb policies acknowledged the necessary connection between competent prior inspection and construction literate incident command
00:50:20 command however commissioner cotton's phase one evidence chose to disavow the expectations of the policies because in our words
00:50:28 our words front line firefighters don't have the technical knowledge or ability to be able to do those things to which the obvious responses are if not why and whose fault is that
00:50:40 not why and whose fault is that whatever the success of preventative and preparatory measures in london witnesses will tell this inquiry that premises assessment remained a perceived paperwork chore to be tolerated rather
00:50:52 paperwork chore to be tolerated rather than lauded as an essential feature of the firefighting job firefighters likely got by without better information and knowledge because during standard fires they did not need
00:51:03 during standard fires they did not need it
00:51:04 it radical solutions including altering the shift system to prioritize inspection or transforming the structure of the organization to truly realign its prevention function was seen as too controversial to be pursued
00:51:17 controversial to be pursued can i turn then to the third deficiency in the lfb response on the night and that is the insecurities of the incident command system
00:51:29 incident command system we agree with others that without sufficient training preparation and policy the failings of the individual incident commanders were the failings of the organization but there is one particular aspect of
00:51:42 but there is one particular aspect of those failings that demands real attention and it concerns the extent to which the unusual but not unexpected features of the fire overwhelmed the commanders who looked at
00:51:53 overwhelmed the commanders who looked at it
00:51:55 it we want to suggest that the attempt by the lfb and other fire service corps participants to find only technical explanations for that failure will never work and the reason for that
00:52:06 and the reason for that is that the errors partly lie in human psychology and the over tendency of the brain to compute what is experienced and recognizable and to overlook information that is not
00:52:18 that is not for more than 50 years behavioral psychologists have described this essential editing feature of the mind
00:52:25 mind it causes error when making decisions especially under extreme pressure it has been studied for the preparation of military battlefields and launch pads airline cockpits surgeons operating
00:52:38 airline cockpits surgeons operating tables and other high-risk stress-related disciplines it has become central to north american armed services doctrine especially since the mistaken shooting down of an iranian commercial airline flight by the uss mansans in
00:52:51 airline flight by the uss mansans in 1988 and some of its central insights were achieved by research done on u.s fire ground commanders in the 1990s and yet
00:53:01 yet the lfb is still reluctant to recognize this as a core part of its own incident command training and doctrine instead it stands by the decision making
00:53:13 instead it stands by the decision making model or dmm contained in its policy three four one the model assumes that in the heat of the moment
00:53:24 that in the heat of the moment a commander is able to analyze in a form of straight reasoning that gathers and thinks about information identifies objectives plans their execution communicates and
00:53:36 their execution communicates and controls the plan evaluates the outcome upon execution and then starts to cycle again
00:53:43 the problem with the model is that is just not how people think under pressure especially during emergency incidents in real world settings experimental
00:53:55 in real world settings experimental research shows that their thinking is more reflexive than reflective they rely on generalized appraisals and biases rather than optimum or exact judgments in their situational awareness
00:54:07 judgments in their situational awareness and especially so when the situation is dynamic complex and stressful and consequently they do not generate and compare options asking watch manager dowden to rely on
00:54:20 asking watch manager dowden to rely on this orthodox model of decision making that was designed by business consultants in the 1940s for people sitting at desks with the luxury to contemplate solutions set him up not
00:54:31 contemplate solutions set him up not only to fail but disabled him in his capacity to succeed
00:54:37 succeed the evidence of chief officer dr sabrina cohan hatton will show that by 2015 national guidance come to accept that the older decision-making model was dangerous because it was
00:54:48 dangerous because it was counter-intuitive and wrong it advocated thereafter a new approach that controls the human tendency to simplify and prompts against our natural
00:54:59 simplify and prompts against our natural bias towards the familiar hence its name the decision control process or dcp dcp contains three questions one why am i doing this
00:55:11 why am i doing this two
00:55:12 two what do i think will happen and three
00:55:15 and three is the benefit proportionate to the risk the dcp has been the subject of internationally peer-reviewed published research studies by cardiff university that show it to produce five times
00:55:27 that show it to produce five times greater effectiveness in command decision making than the traditional lfb model
00:55:32 model the authors of that research include cohen hatton and group manager phil butler
00:55:38 butler both of these peoples were pioneer in their pioneers in this country to the great benefit of the lfb both these career firefighters were working for the organization in the years before
00:55:49 for the organization in the years before grenfell tower still their nationally adopted ideas were deemed by the brigade leadership to be too transformational too much too soon the lfb is the only fire service in the
00:56:02 the lfb is the only fire service in the country that did not adopt the dcp model it is now used by all other london blue light services even when it has national guidance and the country's leading experts available
00:56:13 the country's leading experts available to make change happen this is an organization that still finds it extremely difficult to do anything other than remain the same the fourth deficiency
00:56:24 the fourth deficiency evacuation
00:56:27 the basics still warrant repeating stay put is a principle of construction designed to limit the need to evacuate residents from tall buildings when it is unnecessary to do so no more no less
00:56:41 unnecessary to do so no more no less however the phase one report found that the principle had been allowed over time by the lfb to transform into an article of faith
00:56:50 of faith the inquiry has now seen the foundation documents of the 1960s and 1970s through to the present bsi and pass guidance as long as stay put has existed as a
00:57:03 as long as stay put has existed as a concept so has its limitations it is reliant on effective compartmentation and envisages in any event that once affected by fire or smoke residents need to get out through
00:57:14 smoke residents need to get out through unencumbered means of escape bsi
00:57:18 bsi 9991
00:57:20 9991 also makes clear that the numbers profile and disabilities of the resident population we will be relevant to how long it takes to get out it is ludicrous to operate under a
00:57:32 it is ludicrous to operate under a default assumption that this will never happen
00:57:35 happen compartmentation fails doors don't close works are not competent contractors break the law and so smoke and fire spread
00:57:45 spread the inquiry has already seen that the requirement for incident commanders to consider the need for evacuation was contained in national and local policy but that the efficacy of the requirement
00:57:56 but that the efficacy of the requirement was fatally compromised by the fact that there was no guidance as to how in practical terms this should be done as far as the lfb was concerned the how remained a chronically
00:58:09 the how remained a chronically undeveloped doctrine and practice the inquiry will hear from dr grimwood about the alternative approach that was taught by kent fire services to incident commanders from 2010 onward which
00:58:22 commanders from 2010 onward which included the so-called ice later rice technique
00:58:26 technique rice stands for rescue intervention containment escape its central premise is that it does not assume that compartmentation will hold
00:58:37 assume that compartmentation will hold or that residents will not self-evacuate it also counsels against default engagement with the fire deploying straight to intervention before establishing by rapid reconnaissance of
00:58:48 establishing by rapid reconnaissance of the staircase that compartmentation can be operationally relied upon by 2014 a group of southeastern regional fire services had developed joint
00:58:59 fire services had developed joint operating procedure that identified four factors to consider when re-evaluating the pre-planned stay put strategy these are one fire development two smoke
00:59:11 these are one fire development two smoke travel three self-evacuation and four compromised staircase all of which were witnessed we should add within the first minutes of the grenfell fire
00:59:23 grenfell fire by the commanders the kent trainer also envisages that the stairwell can split into sectors so as to fill estate facilitate conveyor belt staged evacuation
00:59:34 staged evacuation lfb has been developed since the grenfell tower fire to incorporate aspects of the kent southeast approach including stairwell protection and dedicated monitoring and identifying a
00:59:45 dedicated monitoring and identifying a set of triggers that would justify considered departure from stay put the question is why was that thinking not there previously brought a way to look at it is why was a
00:59:58 brought a way to look at it is why was a technique that had been developed in training assessment and firefighting in kent since 2010 and before that in malaysia and then shared across other services was so
01:00:10 shared across other services was so underappreciated by the lfb before the grenfell tower buyer given that it could have made a significant difference on the night
01:00:19 the night the evidence in phase one included repeated assertions that evacuees evacuees would have been panic and endanger themselves and firefighters
01:00:31 and endanger themselves and firefighters several years on no evidence has been disclosed to establish the solid empirical foundation to justify that fear the likely reasons
01:00:42 to justify that fear the likely reasons for that is that for several decades those who have studied cried psychology during disasters including during fires and explosions such as the summerland resort the king's crossfire and the
01:00:54 resort the king's crossfire and the collapse of the world trade center have established that in moments of crisis people tend to act in an unusually collaborative and bonded way even with strangers
01:01:04 strangers but especially when they are in familiar surroundings and with people who are known to them we have cited a range of articles that
01:01:15 we have cited a range of articles that emphatically make these points clear including a research study of world trade center survivors led by professor ed galea that was footnoted at the end of gra 3.2 on high-rise firefighting
01:01:30 of gra 3.2 on high-rise firefighting what is striking is how the phase one evidence adds to that body of research even in great fear people did not exhibit extreme uncontrollable reactions
01:01:42 uncontrollable reactions despite the conditions neither residents nor firefighters were physically hurt as a result of the evacuation they may not have fought it at the time but the evidence of survivors and even
01:01:54 but the evidence of survivors and even the recordings and texts of those who died overwhelmingly show them as prone to creative cooperative and life-saving initiative
01:02:06 initiative this is the body of data that the initiative in this process is collected and it is extraordinarily add item with the conventional wisdom that now
01:02:19 with the conventional wisdom that now exists in the academic research on behavioral psychology
01:02:25 underneath its technical construction origins and policy justifications we therefore want the inquiry to test an ostensibly more difficult
01:02:36 to test an ostensibly more difficult contention about stay put that this article of faith has developed as such because it is up because it is underpinned by a continuing fear and
01:02:47 underpinned by a continuing fear and mythology
01:02:49 mythology about the panicking crowd the consequences is that the firefighters see themselves as the rescuers in the story rather than facilitators of residents being the co-respondents in their own
01:03:01 being the co-respondents in their own escape
01:03:05 now it is inevitable inevitable for a range of reasons reasons that some buildings will need to be evacuated on that
01:03:15 on that there existed a further unacceptable gap in doctrine as steve mcgurk accepts that there has never been any dedicated thinking around how to evac evacuate residents whose mobility is impaired and
01:03:28 residents whose mobility is impaired and there is still nothing of meaningful substance contained in the amended policies
01:03:34 policies that is the case even though the overall significant percentage of mobility impaired people in high-rise social housing buildings is well known and it's also well known that it's growing giving given the aging
01:03:46 growing giving given the aging population without wishing to dilute the responsibility of the landlord to profile and better arrange for resident evacuation from its building it cannot be right for the fire service to remain
01:03:58 be right for the fire service to remain aloof from planning how they will facilitate a building evacuation if the emergency need arises by virtue of their duties under section 72d fire services must also establish
01:04:10 72d fire services must also establish what plans are responsible per person has made for vulnerable residents and consider taking enforcement action when there are none the further deficiencies in the response
01:04:22 the further deficiencies in the response to grenfell tower concern the communication system the problem was not just the equipment but the way in which it was used in the manner in which incident command the fire ground sectors and the coal control
01:04:33 fire ground sectors and the coal control room communicated all parts of the system were overwhelmed the issues relating to the controlled room and fireside first fire survival guidance will be dealt with in module
01:04:44 guidance will be dealt with in module six
01:04:45 six professor johnson has also provided the inquiry with an in-depth description of the technical deficiencies of the available radio equipment especially the ba radios
01:04:55 ba radios we want to draw your attention to professor johnson's emphasis that the effectiveness of communications is not about the equipment alone but the overall quality of the communication system and the organizational culture
01:05:08 system and the organizational culture that procures and utilizes the equipment what is at stake for a communication system at a fire ground is the achievement of situational awareness johnson provides a general definition as
01:05:20 johnson provides a general definition as the ability of individuals and teams to perceive information in their environment to interpret and comprehend the meaning of that information and then use it in a way that helps anticipate
01:05:31 use it in a way that helps anticipate future events and hence informs their subsequent actions the conclusion of the expert is that the lfb put up with and makes do with the
01:05:42 lfb put up with and makes do with the defective radio equipment because most of the time they don't need it crews are deployed they put out the fire and they say what they've done
01:05:53 and they say what they've done that is until the incident becomes huge and complex those who witnessed the faith witness the phase one evidence will recall the profound lack of situational awareness
01:06:05 profound lack of situational awareness especially by incident and sector commanders throughout the night the problem lay in part with the equipment but it also lay in the quality of the interpersonal communications at
01:06:16 of the interpersonal communications at the fire ground and with the control room
01:06:19 room there is an important emergency concept called crew resource management or crm it places a premium on interpersonal communications amongst teams in high
01:06:32 communications amongst teams in high stress situations the absence of developed crm organizational culture within the lfb is relevant to the failure at the grenfell incident ground
01:06:43 incident ground there were points especially in the window of opportunity before 2 am
01:06:48 2 am when experienced firefighters like station station manager eagan did not speak up when they believed that the building needed to be evacuated and when they did speak up they were not
01:07:00 and when they did speak up they were not heard as appears to have been the case with much management harrison speaking up for those in support roles and listening up for those in leadership
01:07:11 and listening up for those in leadership are skills the failings in this area including that the airlift b doesn't teach these skills are likely to relate to the extent to which the organization remains inflexibly against speaking up in its
01:07:23 inflexibly against speaking up in its hierarchies even though other disciplined vocations including the cockpit the operating room and military launch pads have made it professionally safe and indeed a duty to do so
01:07:36 there is now a real question as to whether the final deficiency in the lfb response
01:07:43 response concerns the competency in the use of water
01:07:47 water it is important that the bsr wait for the informed explanation of others and yet it is equally right that they should articulate their concerns at this stage until the recent service of dr ivan
01:07:58 until the recent service of dr ivan stoinovs reported it was thought that the non-availability of the taller 42 meter ladder was the critical issue as to the absent water equipment during most of the fire
01:08:09 most of the fire it is now suggested that there was equipment present that might have made a difference but for the lack of institutional knowledge on how best to use it
01:08:20 use it if the expert is correct then water from the ground monitor situated on grenfell walk was capable of reaching the 15th floor
01:08:29 floor and all the available aerial pumps were capable of launching water to the top of the building both of these things are said not to have happened because of a fundamental
01:08:40 have happened because of a fundamental misunderstanding of the technical features of water supply and the consequential failure to alter incident strategies to secure greater water flow this is an extraordinary possibility for
01:08:53 this is an extraordinary possibility for the bsr to have to contemplate four years after the fire the phase one evidence tragically indicates that it is unlikely that greater water
01:09:04 that it is unlikely that greater water supply and more aerial pumps and monitors would have prevented the upward vertical spread of the fire or its horizontal spread across the crown at
01:09:15 horizontal spread across the crown at the top of the building yet the evidence of the success achieved by the ground monitor on the ray section of grenfell walk does suggest that there was a strong
01:09:27 does suggest that there was a strong correlation between water supply and containment of downward fire spread this is what happened with the partial containment of the flies of fires on floor 10 and 11.
01:09:39 floor 10 and 11. it enabled the late rescues of antonio roncalata from flat 72 at 605 in the morning and el pidio bonifacio from flat 83 at 807.
01:09:52 flat 83 at 807. the fact that the families of natasha elcock from flat 82 and anne chance from flat 73 also survived until rescue in the later hours of the fire attested the combination that external water provided
01:10:05 combination that external water provided as a containment function until ba crews arrived
01:10:11 arrived that is why we are bound to raise again the fate of flat 113 three floors above on the same side of the building where there was proof of life until 406 a.m
01:10:24 life until 406 a.m just before the flat became engulfed in fire at 409 the inquiry is well aware of missed opportunities earlier in the night to rescue those who took shelter in flat 113.
01:10:36 113. this new evidence on water adds a potential additional reason as to why this flat and this floor stand out as the paradigm of preventable death
01:10:47 panel we are moving into the final modules of this inquiry there is considerable evidence now that britain currently has an unstable
01:10:59 that britain currently has an unstable fire regulatory system but it also has a fire service that is incompetent to meet contemporary challenges both of those matters need fixing
01:11:11 both of those matters need fixing and until that happens those who live in high rise social housing will continue to be at significant risk grenfell tower showed them least likely to be protected in fire off from fire
01:11:23 to be protected in fire off from fire and most likely to be dependent on effective fire service response the lfb was brave at grenfell tower but it was not effective
01:11:34 it was not effective there is a time and a place in this inquiry to deal with deregulation and austerity
01:11:39 austerity but the fire service leadership and the fire brigade union need to be far more introspective than they currently are and in in acknowledging how they can be more part of the solution
01:11:51 more part of the solution rather than the problem professor torreira's opinion is that without a radical change in structure culture and competency then things will remain the same
01:12:03 remain the same what he says brings into question that the present model the fire response is an unqualified heroic good in particular he can test society's traditional comfort in neighborhood fire
01:12:14 traditional comfort in neighborhood fire stations and the retention of an orthodox frontline shift system the evidence of decades of reviews tells us that the sector will never lead itself out of these current deficiencies
01:12:26 itself out of these current deficiencies and therefore what is required is a long-term ongoing multi-disciplinary national transformation process it should include fire service personnel but must be led by others
01:12:39 but must be led by others for the bsr the question of reform can no longer be a closed conversation the panel will have to decide how much it will prompt these endeavors but with as with other aspects of this
01:12:51 but with as with other aspects of this once in a generation inquiry if not now when
01:12:58 thank you very much indeed mr friedman
01:13:03 now the next statement is going to be made by professor thomas queen's council on behalf of other bereaved survivors and residents
01:13:23 [Music]
01:13:48 good morning mr thomas morningsix morning panel
01:13:55 it's been said that you um rise above your fears by facing them not ignoring them
01:14:04 in our society we've been brought up to respect and to be grateful for fire fighters for what they do for us it does not come naturally to us to criticize their actions
01:14:17 to us to criticize their actions they are held in high esteem by the public as frontline workers who bravely put their lives at risk for others
01:14:27 others and who are here to protect and serve us they act with impressive selflessness so
01:14:37 so our criticism of the london fire brigade not detract from the individual acts of bravery of firefighters nor does it detract from the solidarity
01:14:50 nor does it detract from the solidarity of individual firefighters with the brave resident survivors of the grenfell community
01:14:57 community but
01:14:58 but grenfell
01:15:00 grenfell is not just a story of individual heroism
01:15:03 heroism and bravery it is a tragedy fraught with neglect systemic a culture of organization of fusification
01:15:16 individuals may have been brave but was the lfb wise
01:15:24 lfb wise the lfb as a public body has a duty of accountability and should act with candor in its response responses to this inquiry
01:15:34 inquiry indeed
01:15:35 indeed it is only through acknowledging the causes and consequences of its failings can the lfb make meaningful change
01:15:46 the london fire commissioners open in submissions on behalf of the lfb lack the contrition and introspection needed to truly rise above and learn
01:15:58 needed to truly rise above and learn from the lfb's failings on the 14th of june 2017 which as we have seen and heard during phase one
01:16:09 during phase one are reflective of systemic failings the failure of the lfb to appropriately be critical of its response to the fire at grenfell tower
01:16:21 response to the fire at grenfell tower constitutes a great disservice to those who lost their lives those who lost loved ones those who lost their homes and indeed the wider grenfell community
01:16:35 and indeed the wider grenfell community the lfb's failure to adequately address their organization's failings is
01:16:43 is disappointing to the bsrs who view this as an attempt to ignore fault
01:16:53 so how can i assist you we ask
01:16:59 we ask the questions as grenfell tower burnt before the world's eyes action
01:17:08 action and in some quarters radical action was needed and well overdue
01:17:16 we hope that during the course of this module this inquiry will investigate how it came to be that the lfb
01:17:27 that the lfb was so ill-equipped to respond to the fire at grenfell and why the lfb abjectly failed in its dynamic risk assessment
01:17:39 we say that there are at least at least eight questions that need to be answered by the lfb number one
01:17:49 why was there a failure to learn lessons from lack of house
01:17:56 number two were there deficiencies in the training across the lfb and was this systemic
01:18:06 number three
01:18:09 what was the impact of austerity cuts and deregulation on the lfb in the years preceding grenfell fire
01:18:20 grenfell fire and the lfb's response to this number four why were the section 72d visits to
01:18:31 why were the section 72d visits to grenfell tower so deficient
01:18:36 number five how did
01:18:40 how did essential communications fail
01:18:44 fail at grenfell tower and why was the technology so inadequate
01:18:51 number six why did the london fire brigade fail to follow its own policies
01:19:01 number seven
01:19:06 were there systemic failings within the lfb that impacted on their response to the grenfell tower fire
01:19:14 fire and number eight
01:19:17 why did incident commanders fail to recognize that the grenfell tower was a failing building and that the stay put advice was untenable
01:19:29 untenable now
01:19:30 now those are eight broad questions we've come up with i'm sure your team will have questions of its own
01:19:41 structure of our submissions
01:19:45 in these oral submissions we intend to address
01:19:49 address the points raised by the other cps in their opening written submissions you'll be pleased to know that we do not intend to repeat our written submissions
01:20:02 i might touch upon them just on occasion to refer to their content as we outlined in our written submissions for this module there are
01:20:13 submissions for this module there are central themes that pervade all the topics to be addressed most notably
01:20:20 notably the lfb's culture the lfb's failure to learn lessons austerity and deregulation in our submission it is essential to
01:20:32 in our submission it is essential to fairly contextualize the lfb's failings at grenfell prior to
01:20:38 prior to and on the night the specter of austerity and massive cuts to the lfb's budget retrenchment and closures of fire stations loomed
01:20:49 and closures of fire stations loomed large over the organization and undoubtedly negatively impacted on equipment resources training and the failures to learn lessons from previous fires and incidents
01:21:02 previous fires and incidents matters were further compounded by a deep rooted and
01:21:07 and pervasive culture of intransigence and an unwillingness to change and develop
01:21:16 culture my learned friend mr friedman of queen's council has spoken at length about the issue of culture and the manner in which it
01:21:27 culture and the manner in which it affected the lfb's ability to prepare for a fire like the one at grenfell tower
01:21:33 tower sir
01:21:34 sir we agree wholeheartedly with those submissions and we agree that the lfb's culture permeates all strands of its
01:21:45 permeates all strands of its unpreparedness
01:21:49 its blinkered response to the fire resulted in the failure of the instant commanders pry two
01:21:59 now commissioner andy rowe to consider the earlier abandonment of stay put and the failure to engage with or consider an evacuation plan
01:22:10 consider an evacuation plan this is in our respectful submission evidence of the brigade's cultural resistance to change and the technical and technical knowledge and innovation
01:22:21 and technical knowledge and innovation as well as an embedded weakness in the organizational training and structure it's of no surprise that the brigade's response was woefully deficient
01:22:33 response was woefully deficient both on the instant ground and in the control room we agree and adopt professor torreira's opinion on the issue namely
01:22:44 opinion on the issue namely that
01:22:45 that at the heart of the inadequate dynamic risk assessment conducted during the grenfell tower fire was a quote fundamental misunderstanding among all
01:22:56 fundamental misunderstanding among all command ranks that the primary role of the fire and rescue services is to fight fires and that if a fire cannot be fought there is no alternative path of action
01:23:09 there is no alternative path of action or role that professor torreira notes that this misconception is a quote key weakness
01:23:20 key weakness of the training and structure of the london fire brigade it is important to note that our clients and the public do not expect perfection
01:23:33 do not expect perfection for we are we are not perfect beings we make mistakes we make mistakes all of the time but
01:23:45 but all we can do is try to learn from our mistakes
01:23:50 mistakes take responsibility for them and do a better job tomorrow the question here is whether the fire service is exempt
01:24:01 is whether the fire service is exempt from that standard which we hold to ourselves
01:24:06 ourselves i fear the answer is a resounding no
01:24:11 deflection of responsibility
01:24:17 vika runwall once said
01:24:21 once said honest self-reflection opens the door to reprogramming change success and freedom end quote
01:24:33 dear panel the written submissions of the lfb make for very disappointing reading in this regard the lfb repeatedly stated in
01:24:45 regard the lfb repeatedly stated in their written submissions that ultimately it was not responsible for the causes of the fire or the manner in which it developed
01:24:56 in which it developed the lfb points to finger at the building contractors product manufacturers as well as the tmo and building control of course we do not dispute
01:25:09 of course we do not dispute responsibility of those involved in the refurbishment and the management of grenfell tower the evidence from modules one to three has indeed been shocking
01:25:21 has indeed been shocking and damning nor do we say that the lfb in any way caused the fire however
01:25:29 however the fact that others played the primary role in the causes of the fire does not absolve the lfb of its responsibility and obligations
01:25:42 responsibility and obligations its response to the fire and its preparation for a fire at grenfell tower have to be held up to the cold light of scrutiny and
01:25:54 scrutiny and where want in those deficiencies must be exposed and thereafter acknowledged and rectified by the brigade
01:26:05 rectified by the brigade joining in the chorus of disapproval of the egregious behavior of the corporate core participants does not make the lfb's failings disappear
01:26:17 disappear the organization must apply some critical thinking and introspection in order to ameliorate
01:26:28 ameliorate its own ills lest we forget as we start this module that inquiry phase one report was incredibly critical
01:26:40 phase one report was incredibly critical of the lfb for the manner in which it prepared for and its response to the fire at grenfell tower yet
01:26:48 yet almost two years on from that report the london fire commissioner's open statement contains limited acknowledgement and acceptance
01:26:59 and acceptance of the lfb's failings one would have thought that an organization whose actions were so heavily criticized
01:27:11 whose actions were so heavily criticized would be humbled and be prepared to take ownership of mistakes
01:27:17 mistakes the nfb's deflection of responsibility despite the weight of the evidence to the country further illuminates how the lfb came to not implementing any substantial
01:27:29 came to not implementing any substantial lessons from previous fires and in high-rise buildings it also raises real public safety concerns about the willingness
01:27:40 concerns about the willingness of the london fire brigade to learn lessons from the grenfell tower fire as well as its commitment to the safety of londoners
01:27:50 londoners the lack of contrition is frankly insulting to the brief residents
01:27:57 residents survivors of the grenfell community we know
01:28:03 we know that the lfb is not a monolith there were some alternative voices raised that challenged the orthodox and accepted lfb positions as evidenced by some in the fire
01:28:15 as evidenced by some in the fire fighting testimony in phase one however
01:28:20 however the prevailing lack of self-reflection and self-awareness of the lfb is quite frankly a kick in the teeth to the rank
01:28:31 to the rank and file firefighters who risked all to go up
01:28:34 go up several fight flights of smoke-filled stairwells as the fire raged and enveloped the tower the stance adopted
01:28:45 the stance adopted in the lfb's opening submission risks long-term damage to the reputation of its organization it is because of the good will
01:28:57 it is because of the good will and the high regard in which the london fire brigade is held in the public conscience that we expect better from them rather than empty platitudes
01:29:09 platitudes how can the public have faith in the institution if it's unwilling to accept responsibility for widely acknowledged mistakes and failings
01:29:22 acknowledged mistakes and failings accepting and understanding mistakes is a key feature of learning lessons and we agree with the mayor of london who said in his opening submissions namely quote
01:29:33 namely quote the most important outcome for the bereave survives in residence and indeed for all londoners is that the lessons of grenfell are learnt and progress quickly
01:29:44 grenfell are learnt and progress quickly so that they can be reassured that the terrible events of that night will not be repeated end quote can the bsrs be confident that lessons are being learned
01:29:56 lessons are being learned once again the answer must be a resounding no the written submissions of the london fire brigade alarmingly demonstrate that
01:30:07 fire brigade alarmingly demonstrate that it is not an organization that is undertaking meaningful introspection in response to the fire and the phase one findings not withstanding the fact that the lfb
01:30:20 not withstanding the fact that the lfb and their written submissions say that they have been involved in the process of quote assessing lfb policy procedure and training to reflect
01:30:32 training to reflect the learning from the grenfell tower fire
01:30:35 fire end of quote and that this is being done recognizing the need to demonstrate that the lfb is a learning organization committed to continuous improvement
01:30:46 committed to continuous improvement their unwillingness to accept their own failings renders this hollow that passage could have been cut and pasted from the myriad declarations policy documents circulars
01:30:59 declarations policy documents circulars generated post lachanol however the hand-ringing mameya koppers are no substitute for decisive action
01:31:11 substitute for decisive action you see
01:31:12 you see our clients and the grenfell community have not forgotten the evidence of ex-commissioner cotton who infamously stated that even with the benefit of
01:31:25 stated that even with the benefit of hindsight she would not have done anything differently on the night of the fire and that she would not train firefighters for a cladding fire any more that she would train them quote
01:31:39 any more that she would train them quote for a space shuttle landing on the shard
01:31:45 many of the beer's arts said in their evidence to this inquiry that they wanted change to make sure that what happened to them and their families never happened again
01:31:59 whose brother and his wife and three children died in the fight said quote it was very upsetting to hear danny cotton say that she would not have done anything different on the night this is
01:32:10 anything different on the night this is like saying there are no lessons to be learned
01:32:13 learned i know that people tried their best but mistakes were made saying that they wouldn't would not do anything differently cannot be an acceptable response if we are serious about learning
01:32:25 about learning 72 people passed away and we can't can't bring our loved ones back
01:32:32 that public bodies are unwilling to engage in meaningful retrospection it's not surprising to us lawyers who work in this field there's a long history of public bodies
01:32:44 there's a long history of public bodies resisting such introspection until forced to do so and when forced to do so drag in their feet to meet recommendations
01:32:55 feet to meet recommendations it is for this very reason that families have pressed for public officials in those organizations acting in the public interest to act with candor
01:33:07 interest to act with candor the reticence is emblematic of a culture that professor torreira describes as incapable of reform from within we know that change can sometimes mean
01:33:19 we know that change can sometimes mean venturing into the unknown and leaving behind that which is comfortable familiar and routine the fear of the new
01:33:31 the fear of the new this can be problematic in an individual but catastrophic in a large public organization cultural inertia within a public organization such as the lfb
01:33:44 organization such as the lfb is short-sighted and dangerous
01:33:48 as professor torreira astutely succinctly opines quote the creation of a culture that rebalances priorities is necessary to promote acquisition of skills and
01:33:59 promote acquisition of skills and attributes essential for the vice and rescue services to operate in a modern built environment the new culture requires a profound reformulation of hierarchy within the
01:34:10 reformulation of hierarchy within the lfb that enables those with the appropriate skills and attributes to conduct plan formulation to progress in the command structure currently
01:34:20 currently this culture does not exist and the lfb command shows a strong bias towards those individuals who have demonstrable skills and attributes when it comes to the consistent repetition of pre-defined
01:34:35 the consistent repetition of pre-defined protocol
01:34:38 that lessons will be learned as a phrase so often used and abused after tragedies and disasters when the public gaze is still bright and hand ringing and platitudes are
01:34:49 hand ringing and platitudes are plentiful however its meaning has become diminished and treated with often justifiable skepticism
01:35:00 often justifiable skepticism it is a phrase which sadly history has shown
01:35:04 shown often shown to be hollow far from being learned lessons are ignored disregarded and failings ultimately repeated
01:35:16 ultimately repeated lucknow
01:35:20 one of the most shocking aspects of the
01:35:23 of the lfb's failure of preparedness for the grenfell fire is that lesson should have taken should have been learned from the lack of house fire in 2009 which if addressed properly and taken
01:35:36 which if addressed properly and taken seriously
01:35:37 seriously may have prevented this disaster although not like for like the similarities between the two fires are striking
01:35:48 are striking on the 3rd of july 2009 a faulty television caused the fire to break out on the ninth floor of lacanal house in campbellwell in south london
01:35:58 london the building was a high-rise residential block
01:36:01 block some 42 meters tall contain 98 flats and masonettes spread over 14 floors the flies the fire spread by the exterior
01:36:12 flies the fire spread by the exterior cladding
01:36:13 cladding made up of hpl composite panels which were found to be non-compliant with building regulations six people died in that fight including
01:36:24 six people died in that fight including three children inquests were held and at their conclusion in march 2013 assistant deputy coroner hirono francis kirkham cbs sent recommendations in a
01:36:36 kirkham cbs sent recommendations in a rule in a row 43 letter to mr ron dobson the then
01:36:41 the then fire commissioner these recommendations covered section 72d visits fire safety awareness for the public
01:36:52 fire safety awareness for the public incident commanders brigade control and communications at major incidents the inquiries phase one report found quote
01:37:03 quote the evidence heard in the inquiry at phase one shows that despite changes to certain lfb organizational policies and the introduction of new training packages
01:37:15 packages few if any lessons were learned by the lfb
01:37:20 the evidence concerning the lfb's failure to learn the lessons of lachnal house will be heard across modules five and six
01:37:28 and six in module five the inquiry will hear how the lfb failed to implement the recommendations relating to the section 72d visits instant the command policies and procedures and radio communications
01:37:40 and procedures and radio communications the inquiry will explore the failure to demons
01:37:44 demons disseminate knowledge of these changes through appropriate training
01:37:49 training in module 6 inquiry will hear evidence about the changes to national guidance following lachnal and the lfb's failure to fully incorporate these provisions into their own local policies
01:38:00 into their own local policies about the introduction of the fire survival guidance policy and the failure to regulate regularly refresh the train of control staff and handling of important calls and the missed opportunities to introduce
01:38:12 opportunities to introduce fire safety measures in high-rise buildings through the retro fitting of sprinklers the common themes in the failure to learn these lessons
01:38:25 learn these lessons are a defensive culture within the lfb's top tier management who had batten down the hatching when thatcher's when faced with criticisms from the coroner's court and the dc-lg
01:38:38 from the coroner's court and the dc-lg following lachanol and a fire and rescue service whose workers are stretched to breaking point by chronic underfunding staff shortages
01:38:49 by chronic underfunding staff shortages ineffective training and threats of privatization
01:38:54 stay put and the failure following that
01:39:02 given that around 150 people were self-evacuated during lucknow house fire a review of the attachment to the stay put doctrine was necessary
01:39:14 put doctrine was necessary further given that the vast majority of the occupants of grenfell tower who self-evacuated on the night of the fire did so before the state put advice was abandoned at
01:39:27 the state put advice was abandoned at 0247
01:39:29 0247 and that the vast majority of those who died at grenfell did so after being advised directly or indirectly to stay put
01:39:37 put it is rather astonishing and to compound insult to the families and the grenfell community that in their written opening
01:39:48 written opening submissions both the uh
01:39:51 uh lfb and the fbu defend the decisions of the first instant fire commanders not to revoke stay put
01:40:01 stay put this is despite the finding of you sir in phase one to the country this position reflects a lack of appreciation that sometimes the tried
01:40:13 appreciation that sometimes the tried and tested methods need to be changed it also reflects organizational inertia and stagnation that the lfb has not accepted the failings of the instant command on the
01:40:25 failings of the instant command on the night which contributed to the loss of life
01:40:30 in effect instead of facing its fear it's chosen to ignore it it is clear that the stay put remains an article of faith for the
01:40:41 remains an article of faith for the london fire brigade it is unclear that though how this marries up with the lfb supposedly newfound appreciation of the risk of
01:40:53 newfound appreciation of the risk of compartmentation failures and the risk of combustible cladding in high-rise buildings
01:41:00 buildings there is a disconnect here on the 12th of february of this
01:41:07 of this of 2020
01:41:09 of 2020 andy rowe agreed the revised high-rise fire fighting policy
01:41:15 policy 633
01:41:16 633 for the lfb statin quote the lfc has a legal obligation to equip and train its firefighters so far as reasonably practicable for what is now a
01:41:27 reasonably practicable for what is now a foreseeable risk as well as an obligation to londoners to provide a service that will make all reasonable attempts to save lives including in circumstances as extreme as
01:41:38 including in circumstances as extreme as those experienced on the night of the grenfell tower fire end quote
01:41:43 the risk of external fire spread was a foreseeable risk by
01:41:50 by 2017 before 2017 which the london fire brigade was fully aware of however
01:41:59 however they fail to take make or have any adequate plans or training in place to respond to cladding fires once again the lfb comes across as an organization
01:42:11 the lfb comes across as an organization reluctant to take ownership of its own lack of preparedness for the grenfell tower fire this time in relation to its own knowledge of the risk posed by the
01:42:22 own knowledge of the risk posed by the cladding and the failures of compartmentation the saying goes that failing to prepare is
01:42:31 is preparing to fail one simply cannot hope for the best without planning for the worst once again the findings of the lack of
01:42:43 once again the findings of the lack of house inquest are prisian
01:42:46 prisian on the
01:42:47 on the 28th of march 2013
01:42:51 2013 the lack of house coroner wrote to mr ron dobson and emphasized amongst other things that consideration be given to training of incident commanders to enhance their performance in relation to the following
01:43:03 performance in relation to the following the dynamic risk assessment model other management tools to enable commanders to analyze the situation and recognize and react quickly to the changing circumstances to anticipate that the fire might behave
01:43:15 to anticipate that the fire might behave in a manner that is inconsistent with the
01:43:19 with the compartmentation principle in 2007 before the findings of the lack of house inquest the home office document fighting fires in high-rise
01:43:30 document fighting fires in high-rise building version 1.8 referred to the development of contingency plans for a range of foreseeable events including fire spread beyond the compartment of
01:43:41 fire spread beyond the compartment of origin
01:43:43 origin communication failure and lift failure you see there's evidence to suggest that the london fire brigade knew that there was more than a negligible risk of
01:43:54 there was more than a negligible risk of a serious fire in a high-rise building with a cladding system at the very least the london fire brigade ought to have known about the risk posed by combustible cladding due
01:44:05 risk posed by combustible cladding due to an awareness of cladding fires in the uk and abroad so you concluded in phase one quote notwithstanding the history of fires
01:44:17 notwithstanding the history of fires involving cladding systems the lfb's experienced an assessment of the shepherd's court fire in august 2016 and the letter to the chief executives of the london boroughs
01:44:28 of the london boroughs very few if any of the incident commanders or senior officers who attended the fire at grenfell were aware of the risks posed by exterior cladding certainly none of them received any training in recognizing or assessing
01:44:40 training in recognizing or assessing risks of that kind or in the steps that should have been taken in response to a fire in the envelope of a high-rise building end of quote professor torreira reinforced your view
01:44:53 professor torreira reinforced your view sir by stating quote given the recent history of large facade fires the evolution of the fire at grenfell tower was a foreseeable was foreseeable and that there was an awareness within the
01:45:05 that there was an awareness within the london fire brigade of these fires and their potential consequences
01:45:13 dear panel this inquiry heard evidence during phase one about the tall building facades presentation which was discussed with previous cladding fires mechanisms of
01:45:25 previous cladding fires mechanisms of external fire spread regulations a shepherd caught fire and the need to understand what products was used in the facade system the all evidence in this module needs to
01:45:36 the all evidence in this module needs to explore
01:45:38 explore why
01:45:39 why why this presentation was only showed to a few
01:45:44 a few senior officers why wasn't this information shared across the board
01:45:51 at the time of the grenfell fire the london fire brigade's standing policy on high-rise building fight firefighting number 633 had not been amended to take into
01:46:03 had not been amended to take into account bre 135 nor was it amended to take into account the brigade's own tall building facades presentation or the la canal house coroner's report
01:46:16 canal house coroner's report this is a failing on the part of the lfb as an institution to equip its firefighters with the knowledge of the risk of cladding fires and train on
01:46:27 the risk of cladding fires and train on how to identify and respond to cladding fires
01:46:31 fires cladding fires an external fire spread from cladding was not a new phenomenon i repeat
01:46:38 repeat not a new phenomenon indeed there have been cladding fires in the uk and around the world before grenfell fire commissioner rose commented that cladding fires are now quote now a foreseeable risk after
01:46:51 quote now a foreseeable risk after grenfell
01:46:52 grenfell is inaccurate and misleading alarmingly a note appended to the revised policy 633 said that quote clearly a more
01:47:05 633 said that quote clearly a more detailed and dedicated thinking is required is still required within the brigade end quote it's astonishing that even after the deaths of 72 people in greenville town
01:47:16 deaths of 72 people in greenville town fire the lfb cannot clearly set out a detailed and unequivocal policy about this issue why
01:47:27 while the london fire commissioner acknowledges the need
01:47:32 the need for the lfb's policies and procedures to be informed by international fires in the modern high-rise buildings on the one hand it continues to justify its failings at grenfell fire by certain
01:47:45 failings at grenfell fire by certain that these fires were in different jurisdictions and operated under different regulatory regimes and you heard mr free friedman of queen's council on that point earlier on
01:47:56 council on that point earlier on this qualification once again rings hollow
01:47:59 hollow it is it is possible to appreciate that different regulatory context exists across different jurisdictions while simultaneously appreciating the obvious
01:48:10 simultaneously appreciating the obvious dangers posed by multiple cladding fires in the face of overwhelming evidence the london fire brigade cannot in good faith argue that it was unaware of the
01:48:21 argue that it was unaware of the cladding fires in the uk and abroad so that the only reasonable conclusion is that the london fire brigade did not deem it necessary to amend its existing
01:48:32 deem it necessary to amend its existing policy and training and response and we ask you to question why was that
01:48:44 let me come on to training phase one
01:48:48 phase one highlighted deficiencies in the lfb's training prior to the fire perhaps most egregiously in the case of the incident command training
01:48:58 training the phase one report was highly critical of the absence of any training for incident commanders on how to recognize the need for evacuation which in turn reflects a failure to recognize the
01:49:09 reflects a failure to recognize the risks of the fire taking hold on the outside of modern buildings the phase one report found that quote there was a failure to educate
01:49:20 quote there was a failure to educate five-fold fighters in the dangers associated with combustible cladding systems which was surprising given the long history of fires involving cladding on high-rise building both in this country and abroad with a history which
01:49:33 country and abroad with a history which some senior figures within the lfb were aware
01:49:38 the lfb have argued that it's essentially the lack of training in relation to the evacuation for its incident commanders was partly due to quote
01:49:48 quote despite the provisions of gra 3.2 there's never been any national operational guidance as to how to manage the full or partial
01:49:59 how to manage the full or partial evacuation of a high-rise building with a staple strategy or to deviate from any other planned evacuation strategies which might apply to high-rise buildings end quote
01:50:11 end quote whilst there may indeed have been an inadequate guidance from central government this absence of guidance cannot justify the absence of internal training
01:50:23 the absence of internal training surely the london fire brigade should have attempted to guide their own staff on the mata after all
01:50:30 after all gir 3.2 did contemplate evacuation did the london fire brigade raise their concerns of central government
01:50:41 concerns of central government about the lack of guidance if they didn't why didn't they the issues associated with training were not limited to evacuation of high-rise
01:50:53 not limited to evacuation of high-rise cladding fires the phase one report and the expert evidence since have found significant deficiencies in training in the control room section 72d visits and
01:51:04 the control room section 72d visits and communications however in their opening submissions the london fire brigade argue that quote following its refurbishment grenfell
01:51:15 following its refurbishment grenfell tower was a tragedy waiting to happen the stay put tragedy was fatally undermined as soon as the rainscreen cladding system was installed the building control in the london fire
01:51:26 building control in the london fire brigade should have been informed of the increased virus associated with rain screen cladding system and ultimately there should not have been any residents living in the resultant death trap
01:51:38 living in the resultant death trap firefighters and control staff should never have had to respond to a fire in the grenfell tower ignorant of these increased virus without the necessary policy preparation and training end
01:51:51 policy preparation and training end quote
01:51:52 quote we couldn't agree more it relates to what the expert steve mcguirk and professor torreira has identified as human error psychology
01:52:03 identified as human error psychology namely the inability to deal with something adequately that you do not recognize and again mr freeman has already touched upon this but
01:52:14 but the brigade bears significant responsibility for putting their own employees at considerable risk without the necessary knowledge and training to do the job because they had the
01:52:26 do the job because they had the information
01:52:32 we know that dr cohen hatton faced resistance within the brigade as she attempted to make improvements to the instant command training
01:52:42 training our clients would like to know the reasons behind this and whether the missed opportunities to learn from her best practice contributed to the failures of command and control on the night
01:52:54 on the night of the fire ultimately this inquiry will have to ask the question given the failures were there deaths which could have been avoided
01:53:05 avoided were their lives that could have been saved
01:53:10 cuts the link between cuts and austerity and the fire safety being compromised and eroded is real if an organization is understaffed and
01:53:21 if an organization is understaffed and underfunded its ability to act efficiently is likely to be compromised our clients find common ground with the fire brigades union on this point whose warnings went unheard in the decades
01:53:34 warnings went unheard in the decades before the disaster as the london fire brigade experienced the worst cuts imposed on any fire service in modern history
01:53:43 history one of the impacts of the cuts was the reduction in staffing and control room on the night of the fire there were fewer control room officers on duty to handle the 999 calls and the five
01:53:54 handle the 999 calls and the five survival guidance calls there were fewer supervisors able to monitor how these calls would be handled and to ensure that the information was passed to the on the ground
01:54:05 on the ground in some cases this meant that vital information about people who were trapped and could not self-evacuated was not passed on to firefighters at the tower with fatal consequences
01:54:16 tower with fatal consequences we echo the call of the fire brigades union that the inquiry must investigate the decisions made by the former mayor of london to impose stringent cuts
01:54:27 mayor of london to impose stringent cuts on the brigade during module six our clients are clear in their assertions that prime minister boris johnson when he was the mayor of london had a cruel agenda for cutting the fire
01:54:41 had a cruel agenda for cutting the fire brigade's budget firefighters numbers and stations let me remind you this was a man who showed contempt for fire safety and the lives of londoners
01:54:54 fire safety and the lives of londoners when in the face of legitimate political debate and criticism of his reckless policies he told labour assembly member andrew dismore to quote
01:55:05 quote get stuffed close quote his agenda directly impacted on the london fire brigade's ability to discharge its statutory duty
01:55:16 discharge its statutory duty sadiq khan commissioned a review in 2016 when he became mayor the review was unequivocal that the fire brigade could not sustain any more cuts
01:55:27 brigade could not sustain any more cuts if it was to have sufficient resources to meet the challenges of the future to keep londoners safe the mayor's module 5 written submissions state that he has been
01:55:38 state that he has been funding the london fire brigade at levels higher than those to which he is resourced by central government say it is alarming that he felt the need to use his own submissions to plead for
01:55:51 to use his own submissions to plead for further investment in the london fire brigade
01:55:56 brigade the fact is we have serious concerns about the attitude of central government the written submissions of the home office while acknowledging its overall responsibility for fire and rescue policy in england is silent
01:56:09 policy in england is silent on the issues of funding cuts and deregulation we urge
01:56:15 we urge this inquiry to return to this important issue in module 6 and to make recommendations to address what we consider to be an urgent issue further cuts of 15
01:56:26 further cuts of 15 of the london fire brigades budget to 2020 were set out in the local government settlement despite the grenfell tower fire no additional funding has been found for fire and rescue services
01:56:39 fire and rescue services we fear that the london fire brigade will not be in a position to learn lessons from the grenfell tower fire without the resources to implement the necessary
01:56:49 necessary changes above all else our clients don't want other families to go through what they have been through but without proper funding we fear the past
01:57:00 past may repeat itself
01:57:03 i've nearly finished communication communication is another aspect of the brigade's response that among other things was arguably impacted by lack of
01:57:15 things was arguably impacted by lack of resources
01:57:16 resources communications within the brigade broke down at the grenfell tower fire the ability of the firefighters to speak to each other the bridgehead and or the incident commander was severely
01:57:28 incident commander was severely compromised vital information from the fsg calls was left to the vagueries of paper notes being passed to runners to the bridgehead and presumably back to the
01:57:39 bridgehead and presumably back to the incident commands this is in spite of the lfb policy 488 on instrument instant communications which states quote effective communications are the key to
01:57:51 effective communications are the key to success a reliable communication network is essential for safe operation at instance and fundamental for securing the level of command required to manage operational resources effectively end
01:58:02 operational resources effectively end quote
01:58:04 quote in the opinion of professor expert witness professor johnson the significant communication problems on the night of the grenfell fire place lives
01:58:14 lives both of the firefighters and of the residents at risk it seems impossible to avoid the conclusion that costs save and cut in influence the brigade's
01:58:25 save and cut in influence the brigade's decision not to upgrade its communications equipment earlier in phase one ricky nuttle said quote i know there's better equipment out there and i understand it's all about costs
01:58:38 and i understand it's all about costs but in this situation cost shouldn't come into it close quote we endorse professor johnson's recommendation for the lfb namely the need for cultural change from
01:58:50 namely the need for cultural change from making do
01:58:52 making do with the legacy of information technologies to technical excellence with other aspects of the lfb's inadequate response to the grenfell tower the failure of communication seems
01:59:05 tower the failure of communication seems to be one affected by culture that is resistant to change and innovation we endorse professor johnson's recommendation to understand why so many innovative
01:59:17 to understand why so many innovative proposals from the brigade staff were dismissed and more generally the resistance to technical innovation by the brigade communication failure featured in
01:59:28 communication failure featured in lachnal house fire problems with radio coverage interference and congestion also affected the brigade's response to lacking house these problems were repeated on the
01:59:40 these problems were repeated on the night of the fire at grenfell and our clients would like to know why so let me conclude
01:59:48 we welcome the london fire brigades missions that they have been looking into evacuation stay put since grenfell town fire and we too are alarmed by the continued lack of
02:00:01 are alarmed by the continued lack of national guidance and consensus this is a matter that urgent that is urgent and needs to be addressed at a national level central government must not drag its feet
02:00:12 feet any longer the overall message we would wish to convey on behalf of our clients is that the evidence and disclosure to date in this inquiry demonstrates that the brigade is an
02:00:24 demonstrates that the brigade is an institution in urgent need of reform our clients are concerned that the london fire brigade is an institution incapable of reforming itself from within
02:00:35 within professor torreira argued that the quote the current culture of the fire brigade fire and rescue services does not allow for the required level of self-criticism
02:00:46 for the required level of self-criticism introspection end quote as such our clients ask that you sir and your panel keep under review the need for the overhaul of the london fire
02:00:58 for the overhaul of the london fire brigade from the outside given the implications for public safety this overhaul cannot wait our clients want to ensure that others do not experience what they went through
02:01:10 experience what they went through we all want and need a fire service that is fit for purpose in the 21st century this is not an insurmountable goal but it is one that requires more than
02:01:21 but it is one that requires more than just goodwill and paper policies there must be a genuine sea change in the culture of the lfb at governmental level there must be a realization that bodies such as the
02:01:33 realization that bodies such as the london fire brigade are public services not just businesses safety and lives cannot be sacrificed at the altar of austerity
02:01:44 the altar of austerity the london fire brigade must be properly funded and resourced in order to underpin those changes in training learning practice development that are so desperately needed
02:01:56 so desperately needed the structure and makeup of the leadership must change they need to listen
02:02:01 listen to be humble to understand that the righteous indignation of those who suffered as a result of this disaster the london fire brigade must and can do
02:02:12 the london fire brigade must and can do better for the sake of its members and the wide society the safety of londoners requires it the residents and survivors of grenfell tower demand it the memory of the
02:02:23 tower demand it the memory of the deceased deserve it i started
02:02:26 i started this addresser with these words you rise above your fears by facing them not ignoring them the lfb chose to ignore them
02:02:40 so let me finish with these words conan doyle once said it's easy to be wise after the event but
02:02:50 but this quote has absolutely no place or applicability here because this is not a case of critics being wise with hindsight
02:03:01 of critics being wise with hindsight the lfb
02:03:03 the lfb should have been much wiser before the grenfell tower fire but this organization chose or was incapable
02:03:13 incapable of doing otherwise we state clearly and unequivocally that in this case accordingly this inquiry should not allow
02:03:24 this inquiry should not allow the the excuse of hindsight to be used when everything that we have said was foreseeable all along thank you
02:03:35 thank you well thank you very much professor thomas
02:03:38 thomas at this stage we'll take the morning break and we'll resume at midday
02:03:44 midday with the next statement thank you very much
02:21:51 good thank you not uh the next statement we're going to hear is going to be made by mr imran khan queen's council on behalf of those whom he represents yes mr khan
02:22:10 uh good afternoon sir i'm recovering from
02:22:13 from a sore throat so if my voice fails me my apologies well take your own time and there is water there and if you need any more please just indicate we'll get some for you very grateful um good afternoon
02:22:24 for you very grateful um good afternoon sir good afternoon panel uh pleasure to be here um i make submissions opening submissions on behalf of our clients represented by imran khan and partners
02:22:35 chair it's often said that when tragedies occur they could have been avoided had we known then what we know now and in relation to the tragedy of the
02:22:47 and in relation to the tragedy of the grenfell tower fire our clients invite the inquiry to ask the question what did the london fire brigade know before and at the time of the fire grenfell that took the lives
02:22:59 of the fire grenfell that took the lives of 72 people and could that knowledge have saved lives
02:23:06 lives even one life in our submission we set out what we understand through the disclosure that the london fire brigade knew and should have known which might have
02:23:18 and should have known which might have assisted in saving the lives of those on the night of the fire we set out information which we consider was available to the london fire brigade the lfb
02:23:29 the lfb before the grenfell tower fire and we set out what the like the lfb failed to implement despite the information available to them
02:23:39 them and where possible how this related to the night of the fire
02:23:45 so the trading of firefighters what they need to be trained on is identified by a commission department within the lfb or by third party training provider babcock
02:23:56 babcock from 2012 the majority of lfb firefighters received their training from babcock borough commanders watch managers and station managers retain the
02:24:07 station managers retain the responsibility for ensuring that firefighters within their borough had sufficient training regardless of who identified the requirements for training it would proceed via the training commissioning
02:24:20 proceed via the training commissioning alteration process known as tcap which was then followed up to and including june 2017 once a training requirement had been identified
02:24:31 training requirement had been identified a tcap form was completed the operational directorate's coordination board bit of a mouthful also known as odcb
02:24:42 also known as odcb identified and agreed what further training was required for lfb operational staff and those needs would be communicated staff through their operational news
02:24:53 staff through their operational news publication so sir panel members that was in very brief the system in place for the training of firefighters
02:25:04 firefighters so i go back to the original question so what did the lfb know through its training what is established in phase one of the inquiry the senior staff within the lfb
02:25:15 inquiry the senior staff within the lfb were aware of previous fires involving combustible cladding systems but
02:25:21 but it would seem it failed to adequately train operational staff to recognize or assess the risks that they posed and the steps that should have been taken
02:25:32 taken by way of response well then from mr thomas queen's council has already mentioned the lachenal house fire
02:25:40 fire the lachlan house fire and the subsequent recommendations made by the coroner in that case will be dealt with in detail in module six
02:25:49 six however the fire illustrates a specific example of the failure of the lfb to educate and train its operational staff on the hazards of external cladding systems on high-rise buildings
02:26:01 high-rise buildings despite its knowledge on the subject the lfb were aware of the role of the external panels in the fire and we have seen considerable evidence
02:26:12 and we have seen considerable evidence to indicate this and we've addressed it in detail in our written submissions we don't intend to repeat it here we know that mr david crowder of the building research establishment prepared
02:26:23 building research establishment prepared a presentation on the lachlan house fire which referred to the use of composite external wall panels the presentation was produced in collaboration former deputy assistant
02:26:34 collaboration former deputy assistant commissioner gary reason former commissioner ron dobson and assistant commissioner steve turek of the lfb
02:26:42 the lfb ms rita dexter who was deputy commissioner of the lfb stated in her witness name to the inquiry that the presentation made and i quote a very significant
02:26:53 and i quote a very significant impression end quote on her as a detailed refurbishment project we'd have which heard quote the unintended consequence of diminishing fire safety protections of
02:27:05 diminishing fire safety protections of the building in 2014 as part of the lfb's response to the lack of house coroner's recommendations they raised a teacup number zero one five three it
02:27:18 a teacup number zero one five three it was called the lachlan house training case study the lfb
02:27:23 the lfb draft powerpoint presentation however made no reference to the clouding for exterior wall panels the babcock training guide entitled lachlan house case study does not refer
02:27:35 lachlan house case study does not refer to cladding or exterior wall panels and the lfb powerpoint presentation does not refer to them either in addition to lacking
02:27:46 in addition to lacking there were national and international cladding fires of which senior staff in the lfb were aware as demonstrated through a consideration of their correspondence
02:27:58 of their correspondence these fires took place after the lack of horse house fire in 2009 and before the shepherds caught fire in 2016 which we deal with separately
02:28:09 in 2016 which we deal with separately in our written submissions were dealt in detail with the following cladding files maddingly durrington point sainsbury's distribution center
02:28:20 sainsbury's distribution center balearic capital east apartments andrew reed house and the fatal fire at atherstone industrial estate we don't intend to repeat it here and now
02:28:31 now the lfb was also aware of the following international clouding fires the lacrosse docklands in melbourne as well as the address and the torch both of which were in dubai these fires are also referred to in
02:28:43 these fires are also referred to in greater detail in our written submissions and we don't intend to repeat it here we now come to the extent of training to operational staff on the risks associated with cladding systems
02:28:55 associated with cladding systems and despite the lfb's knowledge of the previously stated fires we submit that there was only very limited training delivered to operational crews on the hazards of planting systems and combustible
02:29:06 of planting systems and combustible sandwich panels particularly in high-rise residential buildings
02:29:12 buildings it was established in phase one of this inquiry the following senior firefighters present on the nightfire did not receive training on how to fight cladding fires watch manager dowden
02:29:24 cladding fires watch manager dowden watch manager brian o'keefe crew managers charles batterby david davies charles secret and jamal stern and the following is a list of training
02:29:35 and the following is a list of training materials that has been disclosed in the inquiry which were available to operational crews before the night of the fire
02:29:42 the fire and this of course excludes lack of house case study an article in the lfb publication operational news entitled quote insulating sandwich panels end quote did
02:29:53 insulating sandwich panels end quote did refer to insulating sandwich panels but not in relation to high-rise buildings the article stated and i quote the incident commander must react very
02:30:04 the incident commander must react very quickly
02:30:06 quickly and be responsible to new information and evidence of changing conditions but did not provide any further guidance the firefighter training program entitled op002 building construction
02:30:20 entitled op002 building construction was disclosed to the inquiry by third party training provider babcock it was part of the core skills firefighter development program in november 2014.
02:30:32 november 2014. the program had a single page entitled sandwich panels used in construction but
02:30:39 but it did not relate to use in high-rise residential buildings nor the specific hazards associated with compartmented high-rise buildings
02:30:50 compartmented high-rise buildings it stated and i quote they are often used in conjunction with lightweight steel to provide exterior walls and roofing for large retail outlets and warehouses
02:31:01 warehouses it listed some houses to firefighters including rapid fire spread toxic smoke and the possibility that quote sandwich panels involved in fire may fail suddenly
02:31:14 fail suddenly a firefighting training program entitled op23
02:31:18 op23 firefighting in buildings one was also part of the core skills development course in february 2015. under the heading construction
02:31:29 under the heading construction it stated quote age materials use and system of buildings will greatly affect fire development and influence the firefighting tactics used op001 building construction deals with
02:31:42 op001 building construction deals with this subject in more detail we note how that op001 building construction did not refer to cladding materials or sandwich panels
02:31:53 materials or sandwich panels an overview of a back to basics firefighter tactical decision exercise produced by the lfb in 2016 included a scenario for a high-rise training science
02:32:04 training science this involved quote intense fire conditions in the flat of origin with vertical smoke and fire spread up exterior cladding or fascia in a high in a residential high-rise
02:32:15 in a high in a residential high-rise building
02:32:16 building the inquiry legal team has already noted that the scenario did not look for firefighters to identify the cladding as a means of fire spread nor did it address the risk associated
02:32:28 nor did it address the risk associated specifically with cladding or combustible materials now paragraph 38 of his second witness statement
02:32:36 statement lfb's current assistant director of training
02:32:39 training peter groves referred to training document tcap0212 entitled highly insulated building this was intended to raise training which would address houses associated
02:32:51 which would address houses associated with combustible insulation rather than sandwich panels and cladding this was raised in october 2015 and related to computer-based packages linked to the lfb publication
02:33:03 linked to the lfb publication operational news issue 30. we refer to training document tcap0212 in greater detail in our written submissions and again we don't intend to repeat that
02:33:15 and again we don't intend to repeat that detail here what we do note here is that tcap0212 requested training that ensured that firefighters should and i quote be aware of the implications
02:33:27 and i quote be aware of the implications on their firefighting tactics of the increasing use of highly insulated sealed compartments fire development in these compartments and the hazards associated with modern
02:33:38 and the hazards associated with modern methods of construction under the section entitled quote what do you want eve end quote
02:33:45 end quote the tcap training document stated that the computer-based training package intended to reference quote technologies that are used to make this happen celtics and kingspan etc
02:33:57 celtics and kingspan etc it noted
02:33:59 it noted that quote this technology is highly highly interdependent if one aspect fails it can undermine the entire designed solution and it recommended that the training
02:34:11 and it recommended that the training should address quote what a perfect response should look like consideration of compartment failure and effects crews can anticipate on the compartment fire
02:34:22 can anticipate on the compartment fire conditions in his second witness statement to the inquiry mr groves that the lfb stated that the computer-based training which arose from this training document was withdrawn
02:34:33 was withdrawn due to i.t issues and it was intended that it would be relaunched in operational news issue 40 which was to be issued after the grenfell tower of fire
02:34:45 grenfell tower of fire mr groves does not mention why the training was not re-launched until half the after the fire in her witness statement inquired ms kara kelly of training provided babcock
02:34:56 kara kelly of training provided babcock say the babcock did not receive a new tcap request from the lfb in relation to the same
02:35:04 this is important because it was the only tcap training document exhibited which addressed the specific hazards of combustible insulation in such level of detail
02:35:15 detail and it was not relaunched until after grenfell
02:35:20 grenfell on the 19th of august 2016 the lfb attended an external cladding fire in a 20-story residential block in shepherd's bush
02:35:29 bush approximately 50 occupants were evacuated
02:35:33 evacuated on the 30th of august 2016 the cladding panels from the shepherds called fire were tested by testing company euro veritas with staff from the lfb's fire engineering department
02:35:46 engineering department the
02:35:47 the consequent report produced by bureau veritas
02:35:50 veritas indicates the panels were quote likely to have assisted the fire in spreading up the outside of the building
02:35:59 in april 2017 some months later lfb's senior communications officer martin simpson emailed the bergray's current head of fire safety assistant
02:36:10 current head of fire safety assistant commissioner daniel dadey as well as the head of regulatory enforcement andy jack and assistant commissioner andy hearn about an article from inside housing the publication this article addressed the role of
02:36:21 this article addressed the role of external cladding in the shepherd's call fire
02:36:25 fire mr simpson's email highlighted a quote in the article from a chart surveyor and fire safety expert which stated quote this kind of spread can be catastrophic
02:36:36 this kind of spread can be catastrophic particularly where flames can get through windows and if they stay put policies in place for residents
02:36:44 the lfb produced a powerpoint presentation setting out information about the shepherds called fire and the conclusions of bureau veritas cladding panel testing
02:36:55 cladding panel testing according to the witness statement of lfb fire engineer mr david green who produced the presentation it was given to lfb fire engineering liaison officers and senior fire safety officers
02:37:07 senior fire safety officers in october 2016.
02:37:12 the lfb did not disseminate the presentation to operational crews in her oral evidence the inquiry former lfp commissioner miss cotton was not familiar with the presentation and
02:37:24 not familiar with the presentation and could not explain why the circulation of the presentation was only restricted to a limited group of lfb fire engineers in addition in his witness statement the
02:37:35 in addition in his witness statement the inquiry assistant commissioner daley stated that in his view the incident has similarities with the lack of house fire and as such quote
02:37:44 quote it did not appear to be a new hazard as an awareness of external fire spread is referenced in lfb high-rise firefighting policy
02:37:55 firefighting policy he stated that the effectiveness of firefighting actions in arresting the fire spread of the building led him to believe that quote there was no need for additional messages to operational crews
02:38:07 messages to operational crews in his statement to the metropolitan police assistant commissioner daley explained that he raised the shepherd's court fire as an issue internally for inclusion in the lfb's publication
02:38:18 inclusion in the lfb's publication but i've already referred to operation news
02:38:21 news he said that he was fairly certain that the issue did not feature operational news until after he explained quote in fairness i imagine there is always a long queue of material waiting to be featured
02:38:33 waiting to be featured you can't send out and document every bit of learning required as people can only absorb so much in a period of time he noted that there was in his words
02:38:44 he noted that there was in his words quote something end quote in operational news in august 2018 about high-rise firefighting which addressed the withdrawal stay put in favor of evacuation
02:38:56 favor of evacuation the lfb were aware of cladding fires that resulted in the evacuation of residents often from buildings with a stapled policy in place in particular the fires at maddingly
02:39:08 in particular the fires at maddingly durrington point in shepherds court evidence has also been disclosed inquiry of other high-rise fires that london fire brigade attended which resulted in evacuation
02:39:19 evacuation and in our written submissions we refer to the following files the adair towel fire a fire at grenfell tower in 2010 under fire at tidesley tower
02:39:30 tower again we don't indeed intend to repeat the submissions here today
02:39:35 today in addition to those files policy note number 633 the lfb's internal policy on high-rise firefighting at the time of the grenfell files grenfell tower stated this
02:39:48 files grenfell tower stated this it may be necessary to undertake a partial or fault evacuation in a residential building where a statewide policy is in place but despite this statement in the lfbs
02:39:59 but despite this statement in the lfbs lfb's high-rise policy and their knowledge of the high-rise fires where evacuation took place either as a result of a cladding foil or otherwise
02:40:08 otherwise at the time of the grenfell tower file the lfb had quote not provide personnel with explicit guidance as to when and how it should be withdrawn
02:40:20 withdrawn this is according to the witness statement of the current lfb commissioner mr andrew rowe who was an assistant commissioner as we know in january 2016 and was in that role on the night of the fire
02:40:32 fire commissioner rowe was the fourth incident commander on the night of the fire from 2 44 am to 12 35 pm and he just disapplied the stay put strategy at 2 47 am
02:40:45 strategy at 2 47 am in his first statement to the inquiry he stated quote lfb openly recognized that there are no clear parameters in its policies or training for when and how stapled
02:40:56 training for when and how stapled strategies should be disapplied and what alternatives should be put in place according to the phase one report lfp instant commander watch managed dowden did not evacuate to chronicle tower
02:41:09 did not evacuate to chronicle tower by 1 58 50 am at the latest he should have realized sorry did not evacuate grenfell tower and quote by 1 50 a.m at the latest he should have realized that the fire had begun to enter the interior of the
02:41:21 begun to enter the interior of the building and that compartmentation which underpins the staple device had been breached the report said that watch manager download should have spoken to the lfb's control room and quote should have
02:41:33 control room and quote should have decided to evacuate the building in his oral evidence inquiry watch manager dallas state that he could not recall receiving training and when a partial or full evacuation may be
02:41:44 partial or full evacuation may be necessary
02:41:46 necessary he said that he had no input from any individual on understanding when it may be necessary to have a full evacuation and he only referred to internal high-rise policy he also said that he could not record
02:41:57 he also said that he could not record training on this and only had experience of theory-based scenarios for training on evacuation from high floors firefighter michael poll the firefighter whom our client mr
02:42:08 the firefighter whom our client mr palace tecla who's here today wished to call his module 5 witness commented in his statement to the metropolitan police that he had not received any training about what to do if a building compartment fails
02:42:21 if a building compartment fails this is despite receiving high-rise training and training on compartment firefighting so you'll recall that at 2 am on the 9th fly mr tecla asked for himself and his
02:42:33 fly mr tecla asked for himself and his family to quote be helped out of the flat but was told by a firefighter that quote we that is mr teklane's family were safe in the flat and they would that we
02:42:44 in the flat and they would that we should just cover the front door with a blanket
02:42:48 blanket in his which same to the inquiry mr tecla stated if we had been given proper instructions by the firefighter we would have attempted to leave at that time
02:43:00 time mr tekley in fact left his flat on the 18th floor at around 2 56 a.m nearly an hour later mr tecla has asked us to remind juicer
02:43:12 mr tecla has asked us to remind juicer and the panel members that tragically his five-year-old son isaac paulus did not make it out of the tower
02:43:20 tower mr tekley firmly believes that had the firefighters carry out carried out their duties correctly his son will still be alive today
02:43:36 the evacuation of residents evacuation strategies and the stay put policy are referenced in the lfb's high rise training
02:43:43 training but they focus on the ideal evacuation rather than practical guidance of when and how to undertake an evacuation of residents following the withdrawal of statehood advice from a high-rise building
02:43:56 advice from a high-rise building in particular where there is no pre-existing evacuation plan the training disclosed also referred to the state but policy but did not refer to the possibility of changing advice to evacuation
02:44:08 to evacuation or the possibility of emergency evacuation or mass rescue of occupants a 2000 babcock powerpoint firefighting training presentation on high-rise incidents referred to
02:44:20 incidents referred to self-evacuation it stated quote firefighters entering a building may find themselves traveling against the flow of people evacuating from the building
02:44:29 building the presentation also referred to residential buildings but noted that quote
02:44:35 quote in residential buildings occupants should only evacuate if the fire or smoke is in their property firefighting operations can be hampered by the number and type of people being evacuated
02:44:47 evacuated a 2011 lfb training powerpoint presentation entitled high-rise buildings and dealing with high-rise fire stated in its slides that quote in residential buildings
02:44:58 that quote in residential buildings occupants should normally only evacuate if the fire is in the flat or maisonet and if the fire is located in another part of the building occupants should normally be advised to stay in their home
02:45:09 stay in their home unless they are being affected by heat or
02:45:12 or smoke a july 2016 babcock high-rise procedure course called op007
02:45:20 op007 which was part of the core skills firefighter development training referred to fire spread from one component to another and the possibility of external fire spread the powerpoint slides also refer to evacuation
02:45:31 evacuation but in relation to commercial high-rise buildings
02:45:35 buildings rather than residential and in relation to pre-planned evacuation procedure in his expert report to the inquiry firefighting expert mr steve kirk stated
02:45:47 firefighting expert mr steve kirk stated quote
02:45:48 quote i've seen some training documents that mention the possibility of changing stateful advice and or evacuating presidents but this is not addressing any detail and nothing that i have seen would indicate that the training
02:46:00 would indicate that the training provided actually address when how this should happen one example of this is the blackwell tower excise and the holcroft house commercial hull craft house command decision
02:46:11 hull craft house command decision excellence that is exhibited to the statement of cara kelly is similar in this respect in addition to this in mr grove's statement to the metropolitan police he commented that there was quote
02:46:22 commented that there was quote there was no stand-alone training on mass evacuation but that was the intention going forward that a standalone package would be created and is quote a direct result of the grenfell tower fire
02:46:35 tower fire we have not had sight of any policies to how the lfb executed or assisted evacuations and premises with a get out and stapled policy we've also seen very few references in
02:46:46 we've also seen very few references in their disclosure evacuating other anyone other than fire service personnel for example the july 2011 babcock training presentation that was disclosed the inquiry concerning
02:46:57 disclosed the inquiry concerning firefighter emergency emergency evacuation and tactical withdrawal focused on firefighter evacuations in his expert report mr mcguire stated
02:47:09 in his expert report mr mcguire stated quote the overall impression is that lfb's incident command training did not prepare personnel for the possibility of needing to evacuate a high-rise building with no pre-existing
02:47:20 high-rise building with no pre-existing evacuation plan specifically when this decision should be taken
02:47:24 be taken and how an evacuation should be carried out
02:47:28 out in his report mr mcgurk agreed with your findings chair that the capacity of the stairs was sufficient for mass evacuation and remains substantially free of smoke
02:47:39 and remains substantially free of smoke until 1 50 am he also agreed with your finding chair in relation to the need to attempt mass evacuation in addition in her statement to the metropolitan police firefighter jasmine
02:47:51 metropolitan police firefighter jasmine bates criticized the strategy for emergency search and rescue evacuation on the night of the fire she said firefighters were being told to go to individual flats when there were actually people in every flat maybe we
02:48:02 actually people in every flat maybe we should have been checking and clearing floor by floor
02:48:07 so it's already been mentioned by mr friedman queen's council about the kent fire and rescue service firefighting policy the alternative the lfp was aware of an alternative
02:48:19 lfp was aware of an alternative firefighter strategy for high-rise residential buildings it was developed by dr paul grimwood of kent fire rescue service it developed a strategy known as rice rescue intervention containment
02:48:31 rescue intervention containment evacuation it was bespoke to high-rise buildings developed by dr greenward in 2008 and focused on the philosophy of quote protect the escape route at all times and still protection
02:48:43 and still protection the strategy also addressed the reversal of stay put advice and according to mr mcgurk's report the following four triggers are used by kent fire rescue to assist an incident
02:48:54 kent fire rescue to assist an incident commander to reverse stay put development smoke travel self-evacuation and a compromised escape route and we have considered dr grumman's work
02:49:06 and we have considered dr grumman's work on stairwell protection advice in further detail in our written submissions we don't intend to repeat it here dr grimwood stated that he was invited as part of a small team of representatives from the chief virus
02:49:18 representatives from the chief virus officers association south east regional high high-rise task group to meet with deputy assistant commissioner peter cowell of the lfb the discussion during the meeting centered on the southeast region's
02:49:29 centered on the southeast region's approach to developing procedures to mitigate smoke entering stairwells and the use of rice in his report mr mcgurk assessed kent's standard operating procedure sop and accepted
02:49:41 operating procedure sop and accepted that rights quote would have potentially made a difference at grenfell even taking into account the practical difficulties outlined in the phase one report and would have been preferable to to the
02:49:53 would have been preferable to to the approach followed by lfb on the night for fire
02:49:56 for fire he explained that the four triggers reversed they put were all present to grenfell at an early stage end quote would have given the signal that evacuation need to be considered if the lfb had trained its
02:50:10 considered if the lfb had trained its firefighters in the use of kent's sop quote he says it is certainly possible even likely that more lives could have been saved however no to caution
02:50:22 however no to caution mr mcgurk emphasized the need not to jump to the conclusion that using kent's sop
02:50:28 sop would have prevented fertilities
02:50:32 module 5 of this inquiry will address the adequacy of what's known as the lfb's training on section 72d visits in brief section 7272-d of the fire rescue service act 2004
02:50:45 of the fire rescue service act 2004 place a responsibility on the fire rescue authority to make arrangements for obtaining information needed for the purpose of extinguishing fires and protecting life the information collected by the lfb
02:50:56 the information collected by the lfb during the section 7t7 2d or familiarized with it is recorded on the operational response database ord in our submissions
02:51:08 in our submissions we say that london fire brigade did not adequately train its operational crews to be aware of the risk of cladding systems and combustible sandwich panels when conducting these familiarization visits
02:51:20 these familiarization visits this is despite its considerable knowledge of planning fliers and the guidance set out in lfb internal policies for example policy note number 800 and policy note number 63 at
02:51:31 800 and policy note number 63 at appendix 1.
02:51:34 i'm not going to take you through those today
02:51:38 today in his expert role mr mcgurk argues that the london fire brigade policies adequately met the requirements of section 2d in reference to those policy documents
02:51:49 in reference to those policy documents however policy note 63 did not refer to cladding explicitly but it did include quote the likelihood of impact of any fire spread beyond the compartment of origin and the potential
02:52:00 compartment of origin and the potential for multiple rescues and quote any building design features which may promote rapid or abnormal fire spreads such as sand wood panels or voids
02:52:08 voids however
02:52:10 however mr mcgurk concludes that the london fire brigade had a superficial approach to management systems to ensure these policy notes were complied with on the ground and failed to train educate operation staff to understand the
02:52:21 operation staff to understand the requirements of section 7 2 d in his phase 2 expert report inquiry professor jose torreira states this in regard to grenfell tower
02:52:33 states this in regard to grenfell tower the lfp failed to obtain the necessary information through inspections to enable it to conduct an adequate risk assessment an adequate risk assessment would have identified the potential for june 14
02:52:45 identified the potential for june 14 2017 scenario and would have determined two possible parts of action of rectification or a change in response tactics
02:52:56 it was also established in phase one's inquiry that watched manager dowden and the north kensington crew who were responsible for the visit to grenfell tower did not discover that combustible materials were used on grenfell tower
02:53:08 materials were used on grenfell tower this we say should have been obtained from kensington chelsea tmo they're also not trained on how materials used in exterior facades might behave in a fire and therefore could not
02:53:19 behave in a fire and therefore could not have been expected to assess risk created by the cladding system in terms of the training materials section on section 72d visits which has been disclosed in the inquiry
02:53:30 been disclosed in the inquiry the lfb publication operational news issue 24
02:53:34 issue 24 indicates that training package was available to london fire brigade operational crews neither the article itself nor the associated powerpoint presentation referred to the consideration of building design features or the relevant
02:53:47 building design features or the relevant hazards
02:53:53 in december sorry we now address the quality and advocacy of section 7 2d operational response database entries in general concerns regarding the quality of section 72d visits and
02:54:05 quality of section 72d visits and adequate guidance to crews were known to the london fire brigade particularly following the lacking house inquest in 2013.
02:54:13 2013. in december 2013 barack obama john elworth was tasked with discharging action 18b of the coroner's rule 43 recommendations namely to create an inspection regime
02:54:24 namely to create an inspection regime targeted at high priority buildings burial commander john elwood sent both assistant commissioner david brown and deputy assistant commander tom george his briefing paper which was entitled
02:54:35 his briefing paper which was entitled action 18b lfb consolidated action plan on the 13th of december 2013. the briefing paper noted quote a number of substandard examples were found this
02:54:47 of substandard examples were found this could indicate a poor understanding of the rushdown and lack of competency and recommended quote further training is provided to all personnel with a role in the ord process
02:54:58 in the ord process despite this the lfb's preliminary report of the head of the grenfell tower review team produced in 2019 following the grenfell tower
02:55:07 tower said this operational risk information provides no practical guidance undertaking seven to
02:55:13 seven to seven two d visits and focused on the process for identifying premises which may become subject to such visits it's also stated quote it's been observed that the information provided in the grey's
02:55:24 information provided in the grey's policies and associated training packages in relation to undertaking 72d visits is not completely lined with policy referred to in operational news
02:55:35 policy referred to in operational news 24.
02:55:39 so panel we deal with the issue of communications the lfb we say we're aware of problems surrounding communication equipment and it's using high-rise concrete buildings and this has been addressed in detail in
02:55:51 and this has been addressed in detail in professor chris johnson's report of the inquiry
02:55:55 inquiry he concluded the failures in communications notified whilst caused by various factors caused a risk to life to both firefighters and residents of grantham tower
02:56:04 tower and reduced situational awareness of firefights on the night of the fight he provided the example
02:56:10 example of the loss of life on floor 14 when firefighters were unable to request additional support to assess in the rescue of residents found there we've considered in some detail the
02:56:22 we've considered in some detail the issue of communication in our written submissions and we summarize
02:56:27 summarize those in this way firstly the age and adequacy of the lfb's communications equipment and their failure to update its equipment we know that in her statement we met police firefighter jasmine bates stated
02:56:40 police firefighter jasmine bates stated quote i feel that better communication would have helped the actual equipment was poor and i was aware that equipment literally fell apart secondly the lfb's awareness and communication problems high-rise
02:56:51 communication problems high-rise buildings particularly following the lack of house fire and their failure to provide policies or training on recovery from widespread communications failures thirdly we note the lfp's consideration
02:57:02 thirdly we note the lfp's consideration of methods of mitigating communication problem in high-rise buildings and finally
02:57:07 finally raised the issue of testing for communication black spots during familiarization visits and we know that professor johnson stated that communications tests carried out for grenfell tower fire did not test
02:57:18 out for grenfell tower fire did not test for potential communication problems sufficient he recommended the lfb adopt could validate test procedures to assess radio coverage in high-rise buildings
02:57:29 so that brings us to what conclusions we might draw from all of this and it seems to our clients that the evidence that we have seen that our clients have considered
02:57:40 clients have considered has been introduced thus far in this module
02:57:43 module and what comes before you in the next few days
02:57:46 few days if it reflects the material disclose and referred to previously the tragedy of the grandfather fire should not and cannot be considered in the context of hindsight as mr
02:57:58 of hindsight as mr thomas queen's council so eloquently put it it is not a situation in which it can be said that quote had we known then what we know now lives could have been saved
02:58:11 lives could have been saved the simple fact is that the lfb did know
02:58:15 did know they knew
02:58:17 they knew and lives could have been and should have been saved for a number of reasons firstly
02:58:24 firstly senior staff at the lfb had considerable knowledge of national and international exterior cladding fires and yet they failed to disseminate this information to its firefighters those on
02:58:35 information to its firefighters those on the ground with this knowledge the lfb should have trained firefighters about the dangers of external cladding and armed them with techniques to fight such fires had the crews and the incident
02:58:47 had the crews and the incident commanders on the 95 been trained to fight external cladding fires they would have been better prepared and so
02:58:56 and so lives could have been saved secondly senior staff at the lfb were aware of the hazards of family for flammable cladding despite this knowledge they did not provide sufficient training to
02:59:08 provide sufficient training to firefighters conducting pre-site familiarization visits to recognize the risks of the use of cladding in high-rise buildings had the crews who inspected grandfather received this training they could have
02:59:20 received this training they could have discovered that dangerous cladding was used during its refusal refurbishment as professor torreira stated had the london fire brigade obtained this information firefighting tactics in relation to
02:59:31 firefighting tactics in relation to grenfell tower could have been rectified in the light of this information so
02:59:37 so lives could have been saved thirdly in relation to pre-site familiarization visits the lfe were aware that information available to firefighters during incidents was often
02:59:48 firefighters during incidents was often incomplete due to the lack of information collected by firefighters during pre-site visits despite knowledge of these concerns the lfp only provide minimal training and practical guidance to the firefighters
02:59:59 practical guidance to the firefighters who carried out those visits had the firefighters who conducted the pre-site visit at grenfell received adequate training and guidance they would not have omitted vital
03:00:10 they would not have omitted vital information from their entries in turn this would have aided firefighter on the night of the fight in their efforts to save the residents of grenfell tower sir
03:00:20 sir lives could have been saved fourthly the lfp had knowledge of previous high-rise fires which resulted in the evacuation of residents despite having a stapled policy in place
03:00:32 having a stapled policy in place the lfp's own high-rise policy contemplated that stapled advice may be abandoned in favor of evacuation despite this the lfb failed to provide firefighting crews with guidance as to
03:00:44 firefighting crews with guidance as to when and how this should be carried out had the lfb provide this training to its firefighters and instant commanders then instant command would have known to abandon stapled advice in favor of
03:00:55 abandon stapled advice in favor of evacuation far earlier than the night of the fire this in turn would have prevented further fatalities on the night of the fire
03:01:05 fire sir i repeat lives could have been saved fifth senior staff at the lfb were aware of alternative high-rise firefighting strategies which would have aided
03:01:17 strategies which would have aided insulin commands and their crews to recognize when stapled fights should be abandoned and how to carry out an evacuation as inquiry expert mr mcguire stated his conclusion
03:01:28 conclusion had the lfb trained firefighters to use these strategies more lives could have been saved sixth as inquiry expert professor johnson noted communication problems on
03:01:39 johnson noted communication problems on the night of the fire cause a significant risk to lives of the residents of grenfell tower the inquiry might consider that the communication problems experienced by firefighters on the night of the fire
03:01:51 firefighters on the night of the fire may have been exacerbated by the lfb's neglect to update its equipment and its failure to train its operational staff and how to mitigate communication black spots and failures
03:02:03 communication black spots and failures solar panel members we invite you to explore this and the methods by which the lfb could have mitigated communication feathers and whether as a result
03:02:12 result any lies could have been saved
03:02:16 so we end finally on the issue of training on diversity
03:02:21 diversity and we note amongst the many thousands of documents that have been disclosed to us
03:02:25 us there is only one mention of training on diversity in all the disclosure that we've had as a result we wrote the inquiry on the
03:02:36 as a result we wrote the inquiry on the 10th of june this year and we asked we said this we found only one reference to any form of equality and diversity training in the material disclose
03:02:47 the material disclose this is a para paragraph five of ms rita dexa's witness state which states that she managed and led the equalities team and we asked sir
03:02:57 sir a number of questions ending in this way we said this quote in short we are trying to ascertain whether there was at any point leading up to the fire of grenfell
03:03:08 grenfell any form of equality and diversity training given to the lfb or any such policies in existence and the inquiry responded and i quote
03:03:19 and the inquiry responded and i quote the inquiry is not specifically sought disclosed from the lfb on its equality and diversity training and policies as such matters fall outside the inquiries terms of reference to the extent that you consider such matters to impact the issues set out in
03:03:31 matters to impact the issues set out in inquiry's terms of reference and list of issues
03:03:34 issues we would invite you to include this in your proposed questions for witnesses and in any representations you may wish to make to the enquiry in the course of module 5
03:03:42 module 5 and or 6.
03:03:46 and so
03:03:50 we must say that our clients were incredibly disappointed to say the least with this response you'll be aware that on behalf our cohort of clients
03:04:01 cohort of clients we have at the outset and i remember the first opening submissions that i made at harwan bars we have consistently been submitting that the inquiry needs to consider the issue of the makeup of the residents of
03:04:13 issue of the makeup of the residents of the town and how they were treated before
03:04:17 before during and after the fire uh you don't need reminding so what we said in our opening statement in relation to phase two we identified we said this we whilst we've identified at
03:04:29 said this we whilst we've identified at least 15 key missed opportunities on the part of those involved in the refurbishment of grenfell tower we note there's actually been a missed opportunity of this inquiry and that is to recognize the issues of race and
03:04:40 to recognize the issues of race and social class which we on behalf of our clients argue should be an integral part of this inquiry
03:04:48 so we yet again urge the inquiry to examine whether the treatment of those who occupy the tower was any different because of their background this is especially so especially so when
03:04:59 this is especially so especially so when the head
03:05:00 the head of the lfp itself mr andero has gone on record
03:05:04 record in the guardian newspaper of the 19th of march 21 2021 state this kurt a culture of casual racism and misogyny remains so prevalent within pockets of the organization
03:05:16 pockets of the organization that he feared his mixed heritage daughter might not be treated with dignity and respect for some fire stations
03:05:23 stations the article went on to state quote andy roe paid tribute to the kindness and bravery of his colleagues who risked their lives regularly and have reached in to rescue people regardless of background
03:05:35 regardless of background but he added this in my experience the same people might then come back to the fire station and express themselves casually in racist terms in misogynist terms use crude language around faith and
03:05:47 use crude language around faith and sexuality
03:05:49 sexuality we are awash with really great people who are really kind and will be there for anyone at their point of crisis but we still have elements of our culture that we need to transparently face up to and pick
03:06:01 face up to and pick and we say this members panel we submit that any organization in which there is clear evidence of racism and misogyny as accepted by its chief officer must at
03:06:14 as accepted by its chief officer must at the very least consider whether it is capable of delivering an appropriate service to a population as diverse as that which exists in london and whether it did so specifically to
03:06:26 and whether it did so specifically to those that lived in grenfell tower there is then an even greater necessity for this inquiry to examine this issue for itself particularly when the proportion
03:06:37 particularly when the proportion of black and minority ethic fire fights in the london fire brigade stands at around 15
03:06:42 around 15 while serving a city with a black and minority ethnic population of around 40 the guardian article referred to the lfb's own data which shows that employees from african
03:06:54 which shows that employees from african caribbean asian backgrounds all with english as a second language were less likely to be promoted more likely subject to formal informal discipline and more likely to made to
03:07:05 discipline and more likely to made to retake
03:07:06 retake training modules
03:07:09 to assert that the lfb's equality and diversity training and policies fall outside the inquiries terms of reference in the light of mr rose's admission of the lfbs
03:07:19 the lfbs at the lfp's own data is our client's opinion
03:07:23 opinion and we
03:07:25 and we don't say this lightly a dereliction of the inquiry's duties and obligations which serves only to cause our clients greater injustice on their behalf mr tecla's behalf we ask
03:07:38 on their behalf mr tecla's behalf we ask that this be immediately rectified thank you very much good thank you very much indeed
03:07:46 well the next statement is due to be made on behalf of the mayor of london by ms stud queen's council but she is not going to appear in person she's going to
03:07:58 going to appear in person she's going to make that statement remotely at two o'clock so i think at that point we must rise for the moment and we will resume with uh miss stud's statement
03:08:10 uh miss stud's statement at two o'clock thank you very much