Scott Hayward, London Fire Brigade Principal Operations Manager for Control, testifies about systemic failures in training record systems, implementation of Lakanal House recommendations, and gaps between national guidance and LFB policy on fire survival guidance. His evidence reveals repeated prioritization failures, incomplete gap analyses, and unsent letters warning of defects in national guidance.
00:00:27 would you ask mr hayward to come back in please
00:00:36 [Music]
00:00:40 all right mr hayward i'm ready to keep going i'm indeed sir thank you thank you very much yes 60 minutes when you're ready thank you mr chairman um mr hayward we were in the middle of examining the process of uploading training information onto the step
00:00:51 training information onto the step system i'd like to return to that next please um
00:00:57 please um one nine one lfb0055191 first statement please page twenty three paragraph sixty seven
00:01:02 seven now here you refer to the recommendation made by
00:01:06 made by um station manager kelly a paragraph fifty which we saw and the second bullet point on that page and you say this
00:01:16 implement adequate training planning and recording systems following sm kelly's report in 2010 this was partially achieved with a manual process implemented to update step on a monthly basis for my recollection control were
00:01:28 basis for my recollection control were reliant on ict to make changes to the systems to enable us to access the full functionality this was not considered a priority at the time as stars was being
00:01:39 priority at the time as stars was being updated for the operational shift change among other changes and our requirements were further down the line the fact that we could partially update step manually went some way to addressing the shortfall stars did not
00:01:51 addressing the shortfall stars did not recognize our short shift pattern the station diary that feeds step was not configured for control and was heavily operationally weighted i believe this partial implementation started in 2015.
00:02:02 partial implementation started in 2015. now we've covered quite a bit of this with this morning already mr hayward but first i think um stars um you weren't i think able to identify but it's am i right staff attendance
00:02:13 but it's am i right staff attendance recording system something like that yes what was the full functionality the control wanted to access that you could not achieve so we wanted to be able to allocate
00:02:25 so we wanted to be able to allocate a course to a control officer using this system and then that way they get it they get it to their email they know they've got the course that day it's automatically automatically recorded in the system so we can see that they have
00:02:38 the system so we can see that they have attended or been offered the course and then obviously attended it afterwards because there's a process afterwards where it records that they attended to training
00:02:45 training right and that function um records uh the notification and the attendance and updates automatically from my understanding yes it does and and when you say further down the line
00:02:57 and when you say further down the line in the
00:02:58 in the sentence about halfway down our requirements were further down the line do you mean in time terms or in priority in prior in priorities in priority yes there was a there was an operational change that um needed doing
00:03:11 operational change that um needed doing which took priority over over other work wasn't just control i don't think but there were right other work so can we take it from your evidence you gave before the lunch break but also from what you say here
00:03:23 but also from what you say here that the reason control could not have or did not have full access to step for its continued training program was not because of any technical hurdle particularly or alone
00:03:34 particularly or alone but because of priorities the question of prioritizing when that work would be done uh
00:03:41 uh yes but there are there were technical issues as well of course because the system needed recoding to recognize control shift pattern for example yes and you say there were other
00:03:52 yes and you say there were other priorities why wasn't it considered a priority by you or those to whom you were answerable uh that control access to that
00:04:03 uh that control access to that functionality well i think it was but but the other the other um
00:04:09 um priorities went over the top so so it was a priority we needed it doing but other things needed to do in first before we could have it we could get the update to it and updates weren't
00:04:20 get the update to it and updates weren't regular it had to go to stars who owned the system and they had to plan that in for their changes and and so on and so forth so i don't think it's quite as straightforward as us just going in there and saying can you change
00:04:32 going in there and saying can you change that for tomorrow please it takes a lot to go for a process right from my understanding did anybody ever think to themselves well these control room officers are
00:04:44 well these control room officers are front line responders they're first responders in the event of a certainly in the event of a far survival guidance call they are the absolute priority
00:04:56 yes i'm yes but you know there there were i i don't know what those priorities were so i can't i can't comment on why it was we were prioritized over someone else i just
00:05:07 just that's what i was told doing the best you can
00:05:12 you can can you think of any priority greater than a control room officer giving accurate first survival guidance to a caller who needs it i i don't i
00:05:24 to a caller who needs it i i don't i don't know i can't
00:05:27 in the last sentence in that paragraph there you say i believe this partial implementation started in 2015 why only in 2015 because so we could we could manually upload onto step before
00:05:38 could manually upload onto step before that time but i believe they did a manual change for step to see how to recognize our shift pattern but
00:05:47 but the short shift pattern so we could we could allocate training on the short shift
00:05:53 shift so
00:05:54 so that there was a small change to be able to affect that why did that only happen uh
00:06:00 uh well why was the partial implementation only in 2015 unless you've answered my question because that's that's as soon as that they could that they could do that change why i i don't i don't know
00:06:11 that change why i i don't i don't know um
00:06:12 um do you know when if ever the implementation was finished no i don't it wasn't it wasn't finished when i when i when i'd left right um can we go to lfb triple zero five one two nine four
00:06:24 two nine four please
00:06:26 please this is an email on the 22nd of july 2014
00:06:29 2014 so we're now in the middle of 2014 and here is an email from you to vic bagnal keith diamond that's som diamond i think and to gender ajimoh
00:06:40 i think and to gender ajimoh you see that yes um now tajinder ajimar is who please he was a station manager and he was responsible for resource management right
00:06:51 management right okay now you say in the first paragraph having reviewed our transfer of rmc that's is that resource management it is indeed to merten the clearest concern that has been raised is the recording of
00:07:03 that has been raised is the recording of training
00:07:05 training we still
00:07:06 we still do not have a robust set of records to refer to when training staff or the recording mechanisms to show what training has taken place and uh and then in the next sentence you
00:07:17 and uh and then in the next sentence you say this is not only control but rmc as well
00:07:21 well and in the next paragraph you say we have had goals at this before but it has always fallen by the wayside and then two paragraphs down you say each member
00:07:33 two paragraphs down you say each member of staff should have a training record it would be good to be able to access that record to identify training done yet to be achieved and future training over the year
00:07:44 year also for any of us to access any record to see where staff are and any shortfalls identified it is to be used regularly by staff training and owners should be placed upon the staff to ensure
00:07:55 ensure all events are recorded whilst the focus should be on the newest training it should reflect all training fsgs etc
00:08:04 fsgs etc training records have never been our strong suit and this has highlighted it significantly it has to change and quickly and so i would like to prioritize you go on to say in the next
00:08:16 prioritize you go on to say in the next paragraph it has to change and quickly so i would like to prioritize this and deliver a draft plan by mid-september for an implementation at the beginning of october at the latest and then in the last paragraph
00:08:29 you say i do not think we need to start from scratch as we started to do the work certainly in the control arena but i think we need to satisfy ourselves and the staff that our training in these disciplines are considered planned and
00:08:40 disciplines are considered planned and delivered to a measured outcome i've read to you quite a bit of that much of which i would suggest is self-explanatory mr hayward but first did your concerns and proposals as expressed in this message
00:08:51 proposals as expressed in this message include training of cros on fsg calls it was all training right and why was there still
00:09:01 still as at mid july 2014 no
00:09:04 no quotes robust set of records quotes for training even at this point notwithstanding the national guidance the experience of latino house and all the things that we've discussed
00:09:15 and all the things that we've discussed this morning so so we were we were manually recording um training still as as already explained um that can the ost would record the training because we had
00:09:27 would record the training because we had additional training now we had resource management training as well as um the fire rescue service national coordination center training it was trying to get all these in place to ensure we knew so we knew that staff
00:09:40 ensure we knew so we knew that staff were trained in those particular disciplines so it was it was to it was to highlight to those officers that we needed to make sure that all training was recorded robustly to ensure
00:09:52 training was recorded robustly to ensure that everybody received their resource management all the additional training as well as control and you say as i read to you that you've had goes at this before but it has always fallen by the wayside had it always fallen by the
00:10:03 the wayside had it always fallen by the wayside because there was always some more more important priority no i if the fallen by the way son the fact that we've we've had we have partial fixes
00:10:15 we have partial fixes and in this case with the uh control training it was step so we had the partial fix where we could send the information over and it could be uploaded
00:10:23 uploaded um and now we're again we've got additional training now which was an ongoing training plan to train all staff in in new functionality and at this time as well
00:10:34 functionality and at this time as well it was it was vision training as well so we needed and we weren't recording all that training that time we needed we didn't know where staff were in their training hence the email yes
00:10:46 training hence the email yes and what do you mean when you say training records have never been our strong suit the fact that we've our trai our training our training spreadsheet
00:10:57 training our training spreadsheet is a manual it's a manual spreadsheet and it's subject to to failure at certain points depending on whether it's filled in or not and and we know we haven't got that the checks and balances because all you're you're manually
00:11:09 because all you're you're manually putting it in but you can't cross-reference it because it is only a spreadsheet now looking at the first sentence of of this uh email we need to scroll back up to it if we can please you say
00:11:19 you say by way of an introduction having reviewed our transfer to rmc to merten the clearest concern that has been raised is the recording of training who was it who raised that concern i believe that was the operations managers
00:11:31 believe that was the operations managers because we were releasing control staff um
00:11:36 um to go and train on the resource management and they raised the issue that they didn't know at what point that the staff were because it wasn't a one day and they could do it it was an ongoing training package
00:11:48 ongoing training package um and they just they just wanted to clear a picture on where people were and at what stage they were at i think there was three phases to resource management right why did it take the transfer of rmc to merton for them to realize or
00:12:00 rmc to merton for them to realize or raise with you that there had been a more it was an ongoing problem with recording of training it was that that was specific to rmc not not other training it was just i've raised it as a general training issue oh i see i follow
00:12:13 general training issue oh i see i follow um now um what when you say you wanted something at the beginning of october was it that you wanted implemented i'd like to see a more robust a training
00:12:24 i'd like to see a more robust a training plan
00:12:24 plan in what form a spreadsheet that's all that's all we could that's all we could deliver right but why wasn't there one of those at least never mind about whether you could upload or fix training as it went along
00:12:36 upload or fix training as it went along onto the step system which is a mechanical problem about keeping a record why could you nonetheless not have a continually updated manual paper spreadsheet there was an updated
00:12:47 paper spreadsheet there was an updated paper spreadsheet of training for control the rmc there was one but but uh mr agimol
00:12:54 mr agimol kept it in-house it wasn't shared
00:12:58 why wasn't it shared well because he was doing training for resource management in those early stages they went up into a separate room to do the training so he kept it upstairs and
00:13:09 the training so he kept it upstairs and no one had asked her at that point until we got to here that's rmc though that's not that's not what control room officers crows do is it but they did start doing that yes right
00:13:21 but they did start doing that yes right but i'm i'm really talking about um
00:13:25 um the kinds of topics of training that have been raised by the um the 34 actions yeah at the back of the house fire so at this time there would have been a training plan because of course it was vision training
00:13:37 course it was vision training by this time the vision training had taken place or had been installed it was ongoing training
00:13:42 training so what was it that you wanted implemented by october 2014 that wasn't there before a training plan and why wasn't a training plan before
00:13:54 and why wasn't a training plan before a more robust track there was a training plan but to include resource management uh frsncc
00:14:01 uh frsncc vision training and other control training now if we go then back to uh ac george's review of brigade control in july 2016 at lfb triple zero 32826 please page 11 paragraph 47
00:14:17 32826 please page 11 paragraph 47 we looked at this before i just want to go back again to it he's and i've read it to you this morning i won't re-read it um is it fair to say that the issue that you raised in the july 2014 email that
00:14:30 you raised in the july 2014 email that we've just looked at mr hayward had still not been satisfactorily addressed some two years later hence the conclusion here by ac george
00:14:42 hence the conclusion here by ac george and what paragraph we look at here 47 47 would you like me to read that no no i can i can see it here thank you before
00:14:54 okay so when you look at this in context to the to the
00:14:58 to the actual document that was that was this engagement document or the root and uh root and branch review this developing role was about other training
00:15:08 training so about things like uh leadership courses and non-control specific courses because we couldn't release them to go and do those because of the staffing issue so this was really about
00:15:20 staffing issue so this was really about this was really about in in this instance this was about or you know other training not not necessarily control why do you say that because that was what was raised as a point that come out of that
00:15:31 point that come out of that of the report
00:15:35 well this part of this paragraph paragraph 47 sits
00:15:41 sits in part of the report dealing with development and roles you can see at the top of the screen and and this is all about the control room isn't it
00:15:54 i mean the report itself is called review of brigade control it is
00:15:59 it is but but the but the staff the staff were concerned about because they get as i said before they get from a controller they do a control loss of course a nine week course they go for their probation and then
00:16:10 they go for their probation and then they become a control officer from then on their promotion is just a an assessment process there's no real real development as in a development book which was obviously being addressed
00:16:22 book which was obviously being addressed later on you know later on in the year in the years so at this stage uh we did introduce a an aom package uh to address some of that but this was
00:16:33 uh to address some of that but this was really about other courses as well so not not specifically control type courses but other courses that other staff go on um you know mental health or
00:16:45 um you know mental health or or first aid or or courses like that so it included those courses as well i could see that it might have included those courses but the the point being made in paragraph 47 related to training generally isn't it
00:16:59 related to training generally isn't it it doesn't specifically developing role yes yes and therefore i asked my question again is it fair to say that the issue you raised in your july 2014 email had still not
00:17:10 not satisfactorily been addressed some two years later when ac george came to um issue this report well no because i think training training was delivered
00:17:22 training was delivered uh but but training was specific was focused over this period to things like vision or you know and that was that that was the main focus of of training around that time
00:17:33 around that time certainly when this report was done that was all there was so you can understand that staff were were unhappy that they had they there was neither courses available to him at that point but at that point that was
00:17:44 that point but at that point that was the priority the point being made in paragraph 47 i'd invite you to accept is that uh sometimes uh individuals training was not recorded
00:17:55 uh individuals training was not recorded on their training records properly and there was no robust planning that's the point being made here i i would agree with that yes and given that that was the case in july
00:18:06 and given that that was the case in july 2016
00:18:08 2016 now is it fair to say that the issue that you had raised in your july 2014 email we've just looked at had not been addressed by that time not satisfactorily thank you
00:18:17 thank you and why is that because other that the priorities took over right uh and then if we go over the page we saw this again earlier page 12 paragraph
00:18:29 saw this again earlier page 12 paragraph 49
00:18:30 49 c in the third line where the recommendation is for all training to be recorded on an in individuals itr etcetera we read that before just take a
00:18:41 etcetera we read that before just take a moment to look at it again can we take it from that that by july or even as late as july 2016
00:18:50 2016 controls still hadn't been provided with full access to step such that the training records would be automatically updated i believe that's the case yes and now we're at 2016. why is that
00:19:02 and now we're at 2016. why is that because the system hadn't been configured to allow control i believe i believe in 2015 it could recognize the short shift as a whole but not not in two parts so we had a partial
00:19:13 two parts so we had a partial functionality but not the whole not the whole thing did you ever get as you put it the whole thing before the 14th of june 2017 no what what what did you do and he
00:19:25 no what what what did you do and he worked as pom at this point to make sure that uh you did get the whole thing yeah i raised it with ic george at the time and raised again about outsourcing training to allow a
00:19:36 about outsourcing training to allow a more more robust training system not to mark our own homework as it were and what did he say um we had a meeting with the uh a training manager
00:19:48 training manager they said that they have to wait until the babcock contract comes up again um
00:19:54 um and they couldn't just they couldn't just
00:19:57 just you know introduce us into into babcock at that point well the bad babcock contract wouldn't come up again for many many years i wasn't aware of when that con when the contract was due for review right so
00:20:10 contract was due for review right so what else did you do if anything after that point to make sure that you got full training records being automatically updated into the steps or we could just we could continue to make sure training was recorded
00:20:21 sure training was recorded um if it was had to be recorded manually it was done and um
00:20:26 and um and of course we had that partial access so it could be it will be recorded it would recognize the short the short shifts
00:20:35 shifts but it wouldn't do any of the other stuff it wouldn't tell somebody on a course or anything like that at that point
00:20:40 point and i'm going to move on to ask you some questions about the latino house action points
00:20:45 points by which i mean the sum of the 34 action points that the brigade had identified between the fire in july 2009 and the date of the inquest in january
00:20:57 and the date of the inquest in january 2013. yes yes now um do you remember first that the lacknow house board was a body established by the brigade in october 2009.
00:21:08 2009. yes yes
00:21:10 yes yes and
00:21:10 and is it right that the purpose of the latino house board was to oversee supervise if you like all aspects of the latino investigation done by the brigade
00:21:21 latino investigation done by the brigade and related issues so as to be able better to understand the lfb's response to the fire the latino house fire i believe it was and also to ensure that appropriate action was taken in a timely
00:21:32 appropriate action was taken in a timely manner to deal with those issues i believe it was yeah uh now um we know that the national house board was set up some three and a half years before the the inquest
00:21:41 inquest and we have the 34-point plan was the purpose of that action plan to maintain a record of the actions uh identified and agreed and to give clarity
00:21:51 clarity about who was responsible for what and the time scales in which they should be done i believe that's acacia and is it also right that the individual actions were assigned to a lead officer yes and in respect of control related
00:22:03 and in respect of control related actions that lead officer was ac brown was it not correct now in your statement your first statement if we can go to that please at page six paragraph 20 you say this
00:22:17 i was allocated a number of tasks by the board to implement changes within control
00:22:22 control these developed into actions that were that were then monitored by the board the an actions log is attached to the minutes of each board meeting from 15 september 2010
00:22:33 september 2010 and then you then go on to list the actions that were assigned to you uh
00:22:38 uh in
00:22:39 in paragraph 20 on this page and the following pages and in summary am i right that those were actions 5 7 through to 13 and 16 17 and 18.
00:22:50 and 16 17 and 18. i believe so i i don't remember if the top may have been right i've summarized that from from
00:22:55 from from your statement do you know why those actions were assigned to you in particular uh because they were control specific and what did that assignment mean in terms of your involvement
00:23:08 terms of your involvement um
00:23:11 just to make sure that the actions were completed right did that mean that you took overall responsibility for them
00:23:20 to deliver them yes to deliver them well to ensure that they were completed yes yes did you have to involve did you see yourself as having to be involved in the actual delivery yes you did
00:23:33 the actual delivery yes you did now as i've said there was an inquest into the six fatalities at lachnal house and that started in january 2013 after which you may recall that the coroner made a number of
00:23:44 that the coroner made a number of recommendations in what was then known as a rule 43 report yes and some of those were directed at the london fire brigade weren't they they were and some of those there were there were some recommendations that she didn't make because of the work that she
00:23:57 didn't make because of the work that she had been told the brigade had already done
00:24:00 done is that right yes yes and that included is this right guidance as to the handling of fire survival guidance calls and training for officers dealing with such calls yes yes now i'd
00:24:12 dealing with such calls yes yes now i'd want to ask you some questions about the specific action points identified by the lfb
00:24:17 lfb before the latino housing quest which are referred to in a document produced by the brigade in august 2018 after this inquiry had been gathering
00:24:28 after this inquiry had been gathering evidence for some weeks
00:24:31 weeks in phase one and and the document is called the lack of assurance review can we look at that that is lfb404801
00:24:40 i think you this is a document that was produced
00:24:44 produced uh while you was still at the lfb yes and we could see the date at the foot of the page for to the screen 7th of august 2018.
00:24:51 2018. uh
00:24:52 uh and we if we can use paragraph 20 of your first witness statement as the anchor point to summarize each of the pre-inquest actions let's start then please with point five
00:25:03 please with point five pre-inquest action five and the gap analysis
00:25:06 analysis can we turn to page 12 in this document first
00:25:11 first here we have uh bottom right hand corner action five undertake a gap analysis of national and brigade fire survival guidance policies and guidance in order to produce a report identifying where brigade control
00:25:23 report identifying where brigade control for our survival guidance policy differs from the national guidance and then the report goes on to say a gap analysis of the national control guidance and brigade first survival guidance policies
00:25:35 brigade first survival guidance policies was completed there's a footnote five the gap analysis specifically compared fire service circular 10 1993 training of fire control staff
00:25:46 of fire control staff and the accompanying fire control personal personnel training package keeping people safe 1994 with brigade policy 539 emergency call management september 2007 version and
00:25:59 management september 2007 version and fast survival guidance training materials
00:26:03 materials now what was it that instigated that particular gap analysis
00:26:13 uh during the during the um
00:26:18 setting up the board
00:26:22 board we wanted to identify because it was referenced i think 1093 was referenced somewhere and we didn't actually hold a copy at the time so we wanted to check how training uh was was matching
00:26:35 how training uh was was matching the guidance that was provided by government what was it about the fire the national house fire that led people within the brigade such as you to
00:26:46 people within the brigade such as you to think there might be such a gap which required investigation um the fact how some of the calls were dealt with
00:26:57 how some of the calls were dealt with was was that their advice advice given we just wanted to reassure that the advice that was given um
00:27:04 um was was what the what the training was the national training the national guidance was was telling us right so
00:27:12 so did somebody analyze the calls after the fire yes
00:27:16 fire yes who was that um
00:27:19 um operational support team and jan smith right
00:27:25 and lindsay turner and was there a report that was made to you or
00:27:30 you or anybody to your knowledge no i don't i don't recall why we why the gap losses took place it may have been um
00:27:38 um dac tim cut bill was was lead investigator at the time um
00:27:44 um may have may have raised it because there was obviously other documentation that supported that which was the pamphlets for um where the stay put advice come from yes now um if you go back to your
00:27:57 now um if you go back to your first witness statement please paragraph 20 first bullet point you say there that you conducted the gap analysis with uh som joanne smith dac tim cut
00:28:09 with uh som joanne smith dac tim cut bill and tom davis from the lfb's general council's department that's right is it that's correct right and in your second witness statement if we go to that lfb triple zero eight six two one three page two paragraph ten you
00:28:22 two one three page two paragraph ten you say
00:28:24 say uh some
00:28:26 uh some smith and i carried out the initial gap analysis by comparing national guidance via service secular 1093 and xb fsg training package for national guidance with lfb internal documentation
00:28:37 with lfb internal documentation including policy 539 and the control fsg powerpoint you say and you also say that you consider the reference information file or riff um can you just help me what was each
00:28:49 um can you just help me what was each person's role in conducting the gap analysis so i was i was there because i was the principal operations manager or the principal control at the time joanne smith was on there because of her
00:29:01 joanne smith was on there because of her control background knowledge and lindsay turner was was involved in the incident
00:29:11 the ac cup bill was the operational uh lead for la canal and
00:29:17 and uh mr davis was was counsel so from a legal perspective right and what was the what was the purpose of the gap analysis what did you hope to achieve from it well just to identify
00:29:28 achieve from it well just to identify whether there was any any any gaps in out in our training package with reference to national guidance and why would that be a problem um because if there was a gap we needed
00:29:39 um because if there was a gap we needed to address that gap and improve the and improve the training right so it was does it come to this that the purpose of the gap analysis was to find any gap that existed and then work to fill it yes right
00:29:50 yes right then
00:29:51 then let's look at lfb double zero one zero four one six eight
00:30:00 uh this is an uh and you need to scroll yeah a little look at the second email on the page
00:30:07 the page from dave brown ac brown to you 29th november 2009 and it says scott we spoke briefly last week with regards the latin report and how it was progressing
00:30:21 unfortunately i don't think it's ready to be presented to the board on second december though i would like still like you to attend and give a verbal update lindsay is obviously doing some good work in gathering the informa relevant information and i'm sure this will
00:30:32 information and i'm sure this will continue however i think it more prudent for you to take a greater role in overseeing all the various strands of brigade controls involvement i.e the report gap analysis staff statements etc
00:30:46 report gap analysis staff statements etc up to that point what role had you played in la canal so originally well after the incident um ac brown asked lindsey turner as the
00:30:58 asked lindsey turner as the because she was there on instant to start writing the report um and
00:31:05 um and obviously she wrote the report but there was a um she wrote a version of a report um senator dave brown dave brown wasn't happy with the report and wanted it
00:31:16 happy with the report and wanted it wanted more to it so i think it was because obviously we were not trained necessarily or written reports of that style before um so
00:31:28 um so uh lindsey had tried to to write the report um
00:31:34 um and it needed it needed to be more in depth there may be more to it um so then i got i got on board and started writing a report as well what
00:31:45 started writing a report as well what further depth or greater depth could you bring to it uh as pom greater than lindsey turner's i think it was i think it was the fact that um
00:31:57 it was the fact that um i think lindsay's in this report i don't i don't remember perfectly well it was but it was around four or five pages just about the incident itself there was no no
00:32:08 no no no uh context around the control um uh the shift pattern at the time where control were what they were doing how many calls to take and what other
00:32:19 how many calls to take and what other calls were being taken on that during that incident so it just needed a lot more detail added to it and obviously i could assist in that and do you know why ac brown considered
00:32:31 and do you know why ac brown considered it more prudent is his worth more prudent for you to take a greater role no i don't um why in relation to the gap analysis specifically among other things
00:32:43 i i don't know i can't answer scrolling down to page two if we can the email continues if you look at the first paragraph
00:32:50 paragraph as follows i also understand that the gap analysis needs some further work in terms of detailing how the history needs to be listed chronologically more details of how our policy arose from it
00:33:01 details of how our policy arose from it and the training that is ensued again though i've asked that the lachnal team to work closely with you on this now he says that he understood that the gap analysis needed more work was it was
00:33:12 gap analysis needed more work was it was it you who told him that during the conversation the previous week that he has identified at the start of this email
00:33:19 email no not not that i'm not aware of the i think what it's taught the chronology there was talking about they wanted to go back to 1993 um and how how five
00:33:30 go back to 1993 um and how how five survival goal five survival guidance calls came about and how 1093 fell out from that and and where and where control was at that point oh i see so he wanted
00:33:42 so he wanted is this right from what you've just told me that he didn't just want a gap analysis he wanted to identify when in the history the divergence first occurred why yes so going back to the shirley
00:33:53 shirley uh no um there was an incident in the west midlands in 91 i believe and then
00:33:58 and then 1993 came out on the back of that and control staff drained in 94. and uh
00:34:07 and uh who with the lachnal team that he's referred to in the last sentence of that paragraph
00:34:12 paragraph uh well those that are that was part of the investigation so a number of operational officers right did you work closely with them um at times yes right um now what happens next it appears is
00:34:24 um now what happens next it appears is as follows if you go to lfb3083135
00:34:29 you send an email to som stebards
00:34:37 for which reid smith and uh you say this good morning joanne i need you to review this gap analysis to ensure we are correct in what we are teaching against the guidance having
00:34:49 teaching against the guidance having looked through it i believe we may have overlooked or fudged the comparison to fit london i'm not saying we do it wrong but if the report has any discrepancy then it will not be credible would you please look at the training we
00:35:00 would you please look at the training we do against what the original document proposed to see if there are changes sort of fits or nearly fits is not good enough if the gap is there we must highlight and explain why
00:35:12 now when you say we may have overlooked or fudged the comparison to fit london what was that what did you mean
00:35:22 um i don't recall exactly um
00:35:28 let me did you get the impression that the draft you've been given of the gap analysis thus far uh
00:35:35 uh overlooked quite quite quite quite possibly i i i don't i don't recall exactly and i know we
00:35:44 we and i wanted i asked joanne to look at it because of her background and and and she could see if there was anything that we weren't doing yeah i don't exactly remember what we were what was missing
00:35:55 remember what we were what was missing is it fair to say that you wanted the gap to be identified clearly yes absolutely out of fudge without a mission yes you could address it properly yes right now then um let's then go to the action
00:36:07 now then um let's then go to the action plan
00:36:08 plan uh we see in september 2010 we move forward 10 months lfb 3-0 is 55192 i'll show you the first page of this
00:36:19 i'll show you the first page of this document
00:36:23 this is the minutes of the 15th of september 2010 lachlan house board meeting we looked at before
00:36:32 and if you go to page seven please in this
00:36:35 this we can see that it has some minutes and if you go on page seven to item five undertake gap analysis of control national and london fsg policies
00:36:47 national and london fsg policies you see yeah and the lead officer there is
00:36:52 is acsd and could you just explain who that is
00:36:56 is that's how you see service delivery so that'll be dave brown dave brown and then
00:37:00 then under update 0 7 4
00:37:04 4 10
00:37:05 10 completed that's the 7th of april 2010 isn't it yep so it looks as if the lachnal house board was being told in mid-september that the gap analysis had been completed
00:37:16 that the gap analysis had been completed some months before on the 7th of april that year yes yes
00:37:21 yes 2010.
00:37:22 2010. um was it completed before the first initial fsd fsg training that took place in 2010 do you remember
00:37:33 that took place in 2010 do you remember i don't but i would have i would say yes why would you say yes because if we don't if we'd have identified because we needed to identify the training
00:37:43 training the gaps if there were any and put into the into the into the training package well you might or might not have done it okay i mean that wouldn't have been the case had the training taken place in february okay um
00:37:55 february okay um but is it right that the gap analysis didn't consider first service circular 54-04 uh we looked at 5404
00:38:07 54-04 uh we looked at 5404 which is a emergency call management document there is elements there of fire survival guidance but it's about scripted using scripts and london didn't use scripts at that
00:38:19 and london didn't use scripts at that point
00:38:20 point um not unt and pro cad couldn't couldn't use script i don't believe and it wasn't until vision come in that there was sesh which is the emergency call handling structure events
00:38:32 emergency call handling structure events you call handling sorry what did you call it
00:38:35 call it structured emergency call handling cech scca yes yeah um
00:38:44 um did you have any discussion with s.a.m smith about whether to include 5404 in the gap analysis i believe it was discussed with um with
00:38:55 with um
00:38:56 um ac cup bill and at dac cupberland mr davis
00:39:03 and and it was felt it wasn't it wasn't required
00:39:06 required now given that 5404
00:39:09 5404 was extant national guidance at the time uh why was the brigade content to leave that gap in place i'm not sure there was anything in 50 viral four which would
00:39:21 anything in 50 viral four which would have which would have done anything to enhance the training from 1093
00:39:27 but a decision was made nonetheless it appears that i believe so i don't recall that far back but yes it wasn't it wasn't in the gap analysis so that gap would not be closed
00:39:38 well it wasn't considered it wasn't considered at the time to be to be in a gap in our training well it was a gap wasn't it surely because there was national guidance it
00:39:50 because there was national guidance it was still in existence your training didn't cater for it or cover it so there was a gap no okay well i mean yeah i mean you know when we when we
00:40:02 i mean you know when we when we undertook the gap analysis we considered there to be no gap with 5404 hence why it wasn't included can we go to nfb double zero one zero seven nine seven eight please
00:40:19 now um we if we go to the second page in this email chain the topic is policy 539 and noting the date this is early 2010
00:40:32 and noting the date this is early 2010 um
00:40:33 um before i should just tell you before 539 was amended in september of 2010 so at that stage we're still working on the
00:40:42 the 2007 version that's just a bit of background the chain itself is about pn539 and it's between jill light bound who was policy and
00:40:53 jill light bound who was policy and procedures review officer dc dexter and ac brown and if you go to the top of page two or rather the bottom of page one
00:41:08 uh you can see that there's an email from dave brown to you of the 28th of february 2010. you could just about see it you can't see it's to you no i can't buy coffee
00:41:19 see it's to you no i can't buy coffee and you're right we need to go to the top of page two it's to you scott please note so you're being forwarded the email chain below it and if you go um to
00:41:31 and if you go um to the next email down
00:41:45 you can see that there's an email from july bound to rita dexter no i haven't got that no um if you go to bottom of page two
00:41:57 and then turn to page three
00:42:02 you'll see that she is discussing uh the policy policy 539 owned by sdn mobilizing with mobilizing of the responsible work team
00:42:14 responsible work team um and you can see who she is now if you then go up to uh
00:42:21 to uh the um
00:42:22 the um top the bottom of page one on top of page two
00:42:26 page two you send this email chain on to som turner and som stevards on the 4th of march now we need to get bottom of page
00:42:38 we need to get bottom of page 1 top of page 2.
00:42:42 you see that yes uh and uh
00:42:47 uh and uh you
00:42:48 you uh
00:42:49 uh say
00:42:50 say to them on the 4th of march i think on the face of it jill is right in the fact that policy 539 is a mixture of work that documents a history of what control didn't do and
00:43:01 history of what control didn't do and then in the third paragraph you say this we have discussed changing the name of the ecm policy document as it has caused confusion during local investigations in relation to 5404 emergency call
00:43:12 relation to 5404 emergency call management and what local investigations have taken place in relation to 5404 do you remember i i do not remember you know who carried them out
00:43:23 who carried them out i i do not i do remember this time though this is about
00:43:28 about splitting
00:43:29 splitting some elements of 539 out into separate policies but the likes of automatic fire alarms um it it
00:43:38 it it would be better placed in the mobilizing policy which is a separate policy so it was about it was about making 539 specifically about emergency call management as opposed to a
00:43:50 management as opposed to a to a number of other elements just bought into it to to for for call hand for control right do you remember whether there was a decision or even a discussion at that time about
00:44:03 or even a discussion at that time about uh excluding 5404 from
00:44:07 from either the gap analysis itself or the revisions to 539. i don't remember it being excluded or you know a discussion about that i i just i just remember
00:44:18 remember that it was about it was about scripted calls and you know it was about asking asking a caller whether the car had diesel or petrine or the like which
00:44:31 diesel or petrine or the like which obviously extend your call handling time which we didn't have in in london at the time and it was it was considered it it wasn't required but
00:44:41 but that's all i remember about it i don't remember any firm decisions being made um
00:44:47 um we then go to january 2013 and the lindridge review we know that group manager lindrich completed a review of the latino action
00:44:58 completed a review of the latino action plan
00:44:59 plan uh in the last part of 2012 and in january 2013. and are you familiar with that review i remember it i remember mr linder is doing it yes now if we look at that document this is lfb3085854
00:45:19 um here is
00:45:21 here is uh the
00:45:22 uh the review
00:45:23 review fourth of january 2013 and if we go to page five in this document we can see that
00:45:31 that uh there is some text and some discussion between dc dexter and ac brown
00:45:37 brown uh in the comments on the right hand side of obviously this is a draft as it that date and you can see the comments if you look at the comment in related to the first
00:45:48 at the comment in related to the first paragraph under under the section action five national control guidance versus lfb control policy gap analysis um you can see um that the text says the gap analysis
00:46:00 um that the text says the gap analysis did not include fsc 5404 as part of the national guidance for consideration fsc 5404 introduced a three-staged call handling approach and included
00:46:11 handling approach and included additional fsg questions for assessing the caller the gap analysis also identifies areas for improvement for the national guidance these recommendations have not been addressed or reflected in local policy
00:46:22 local policy and the question that is asked is why not that's dc dexter why was it not included and ac brown replies in the red text first in the first comment bubble
00:46:35 first in the first comment bubble fsc 5404 deals with emergency call management only part of it actually deals with fsg and that is around age gender and mental straight physical disability based on that control
00:46:48 disability based on that control concentrated purely on fsc 1093 and the training package for completeness though i instructed richard chandler to remedy this in november scott is dealing in
00:46:59 this in november scott is dealing in richard's absence uh
00:47:02 uh were you were you dealing with that in richard chandler's absence i i don't recall i i just know that the the the 5404 that the three-stage approach
00:47:14 the 5404 that the three-stage approach or or scripted we didn't use
00:47:21 do do you remember at all being asked by uh
00:47:26 uh dave brown or perhaps richard chandler before he he went on leave to fill the gap between the existing guidance and fsc 5404
00:47:38 fsc 5404 uh
00:47:39 uh no i don't believe i'm i'm not sure there there was a gap really but whilst it wasn't considered or it was considered but it wasn't it wasn't part of the analysis because it didn't
00:47:50 of the analysis because it didn't it didn't impact on the training package which is what we were measuring against
00:47:56 against from what i remember
00:48:00 uh indeed but the view appears to have been taken by there's more senior to you in the brigade that nonetheless the gap should be closed for completeness is that is that fair yeah i mean i haven't seen
00:48:12 that fair yeah i mean i haven't seen this document and hence why it's uh so i my answer is i don't know if if dave asked me to to look at it i would have looked at it but that may
00:48:23 i would have looked at it but that may not necessarily change the outcome of the training package right at all events i think you you do accept or can accept that in the end uh
00:48:33 uh despite what's written here fsc 504 5404 was not included in the gap analysis uh it was considered but but not
00:48:44 uh it was considered but but not included in the overall analysis was the reason given in the lingerie's review the real reason why fsc 5404 was omitted from the gap analysis could i see could i see what he's put please
00:48:58 see could i see what he's put please uh well it's on the page in front of you uh
00:49:02 uh it's in the comment column yes so oh
00:49:19 yeah i think it's more around this this three stage chord hand the core handling that we didn't use in london now
00:49:27 now yes you've said that a number of times the question is really why did the lfb think that it was acceptable not to use the national guidance what was different about london
00:49:39 was different about london i i don't i don't know that this that's the what that was just the way we looked at it we didn't dismiss it but it didn't it didn't enhance
00:49:50 but it didn't it didn't enhance or or improve the analysis
00:49:59 what was have you taken within the brigade that 5404 was no longer fit for purpose or applicable to any fire and rescue service or was this just a london i i can't i can't answer i don't know
00:50:10 i i can't i can't answer i don't know what the brigade felt over overall right can we then look at the gap analysis this is at lfb404750
00:50:26 there's the first page um and this is an annex to the november 2012 uh lack of control report
00:50:35 report uh and if we go please to um page
00:50:38 um page eight
00:50:41 we can see the gap analysis itself and uh in the left-hand column there is entitled national guidance 1093 appendix b fire survival guidance
00:50:52 appendix b fire survival guidance training
00:50:54 training and
00:50:55 and from looking at the detail of that column is it right to say that that includes both what is written in the first server circular 1093 and also the fire control personnel training package
00:51:06 fire control personnel training package keeping people safe 1994.
00:51:10 he doesn't say so but no i don't i don't know you don't know right uh
00:51:16 right uh well let's um you don't know let's just see if we can do this a slightly different way if you look at item one top left it says
00:51:29 it says do you see it says one introduction yes
00:51:33 yes incident have occurred where fire control operators have been faced with a caller who is trapped by fire and domestic accommodation and in a distressed condition now you could see that language if i
00:51:44 now you could see that language if i uh it's probably too small but you think that could be kept on the screen and can we have at the same time please lfb double zero one one eight nine four eight
00:51:55 eight i'll show you the first page of that document let me and i'd like then to go to page five in that document there there's the first page is that familiar to you that yes it is that's the first page of the training note in
00:52:07 the first page of the training note in the home office document keeping people safe published in 1994. yes if we go to page five
00:52:13 page five and look at the left hand column in the first paragraph you can compare the language again it says incidents have occurred so there's no typo incidents have occurred where fire control operators have been
00:52:26 where fire control operators have been faced with a caller who is trapped by fire in domestic accommodation and in a distressed condition so
00:52:35 would you accept that taking the comparison on the screen that the 1994 document keeping people safe was at least in part the source document for the gap analysis
00:52:46 for the gap analysis yes yes
00:52:48 yes yes and now if we can take the right hand document off the screen for the moment and continue with the gap analysis please
00:52:56 please page eight the second column from the left
00:53:01 if we just yeah thank you if you look at the second column from the left or rather the central column that's entitled lfb policy guidance and training notes one policy 539 emergency call management
00:53:13 one policy 539 emergency call management appendix 1 2 control training powerpoint fsg 3 control trainee handout fsg um does that column set up the detail from all of those sources yes
00:53:26 from all of those sources yes and in relation to policy 539 let's just see if we can get that on the screen is that lfb00118944
00:53:36 sorry you could answer the question by reference to the document not a recollection of the number there it is you see it yes is is that that's policy 539 that you're talking about here right
00:53:47 539 that you're talking about here right and uh
00:53:49 and uh that's the version issued in 14th november 2007. um if we take that off the screen and get back to the powerpoint uh
00:53:59 uh item two
00:54:01 item two control training powerpoint fsg if you go to lfb double lfb triple zero six one nine four three
00:54:16 and that's the first page of it and scroll down one or two slides in was that the powerpoint referred to
00:54:26 aim objectives uh fire situations is the next next slide do you remember yeah can you scroll down a few more please yes proactive questions we'll get through this together help me
00:54:38 we'll get through this together help me to help you etc yeah it looks it looks familiar right and then uh if we go to lfb triple zero eight three four seven six
00:54:49 three four seven six was this item three the control the control trainee handout and just wait for it to come up there and perhaps scroll down through it those are the contents
00:55:00 those are the contents so section one introduction to survival guidance training package etc could you scroll down a little bit on that just go to the next page there's an introduction aim and objectives and then page three
00:55:14 aim and objectives and then page three there's uh survival guidance techniques yes so that's that's that document i just wanted to make sure that we've identified the documents that the gap analysis refers to thank you and then let's go back to the gap analysis please and look at the
00:55:25 gap analysis please and look at the third column from the left so back please to lfb404750 page 8. uh and look at the third column from the
00:55:36 uh and look at the third column from the left there gap analysis comparison of national guidance against lfp policy guidance and training and then there are some findings sent out in those columns below that on each of the successive
00:55:48 below that on each of the successive pages were those your findings the yeah between me um
00:55:54 um joanne smith uh d.a.c cutbill and david tom davis tom davis yeah now um the final column is recommendations there uh and did the latino house board
00:56:07 there uh and did the latino house board see and approve those recommendations um i believe they did this was submitted to the board and accepted right we have some minutes
00:56:19 we have some minutes of those meetings in april and may 2010 where the gap analysis was discussed but it's not clear from those minutes that it was that these recommendations were actually specifically approved but your recollections is that they were yeah
00:56:30 recollections is that they were yeah they were submitted and accepted yet submitted and accepted thank you now if we then go to page nine in this document you can see there's a row that deals with call handling techniques
00:56:44 uh paragraph two underneath fsc 1093 appendix b do you see it says call handling technique yes you do and um the text of the gap analysis common says this
00:56:55 common says this uh and the third column both 1093 national guidance and local training handout acknowledge two techniques to use to use to extract information from
00:57:06 to use to extract information from callers
00:57:07 callers both pieces of literature only supply a brief description of the technique and failed to give examples lfb control training handout differs slightly from 1093 national guidance which focuses on
00:57:20 1093 national guidance which focuses on the likelihood of using the proactive technique to obtain incident details whereas 1093 national guidance recommends adopting a fully proactive technique to take control of the situation
00:57:31 situation and it goes on the training powerpoint slide 5 offers examples of proactive questions for lfb control officers to use during these situations however
00:57:42 situations however on review these can be developed further to enhance better understanding
00:57:48 now
00:57:52 was it considered therefore during this analysis that the training in relation to call handling techniques was not fulfilling what was required fully to prepare control room
00:58:03 required fully to prepare control room officers
00:58:04 officers um
00:58:05 um no i i think the idea of the analysis was to was to see where
00:58:11 see where you know there was an extent document and i wanted to know whether that exit document um
00:58:18 um or we were following that extract document
00:58:21 document and in some go although we were in most cases there were some enhancements required to make it better and we can see the correlating recommendations column if we go back to page nine
00:58:33 page nine in relation to this issue it says this the recommendation is that consideration be given to updating national guidance in fsc 1093 and fsc 5404 to include further information on
00:58:46 5404 to include further information on the various techniques that may be required to be used by fire control operators to extract information from callers regarding their situation information relating to those techniques and how they are currently utilized in fire fire control rooms should be sought
00:58:59 fire fire control rooms should be sought and consideration should be given to ascertain the benefits of fire control operators varying these techniques whilst talking to the caller instead of just adopting one approach as 1093 guidance implies
00:59:11 guidance implies rewrite proactive question example slide on training powerpoint is required and it goes on although both national guidance 1093 and training powerpoint
00:59:22 guidance 1093 and training powerpoint cover the assessment of the caller no additional training is provided on how to change
00:59:28 to change how to change to questioning techniques or different styles of questioning for the fire control operator to use if a caller is having problems communicating why did the gap analysis make
00:59:39 why did the gap analysis make suggestions in relation to the national guidance documents
00:59:44 because it was an old and older document
00:59:48 it was the idea that the national guidance documents themselves should be updated and improved yes how could the lfb do that single-handedly or was the idea that the lfb would lead a national initiative
00:59:59 lfb would lead a national initiative well the the a part of the one of the outcomes was to provide a letter um to
01:00:05 um to um
01:00:07 um i believe it was dclg it could have been c four
01:00:10 c four um asking to um
01:00:12 um that we consider then improvements or updating of of the extent documents and that london will be happy to assist in in helping with that well we'll see what happens to that yep suggestion later in
01:00:23 happens to that yep suggestion later in your evidence but but i think you and i agree on one thing i think is it was the purpose of the gap analysis uh not only to examine the lfe's own procedures but to critique the national guidance
01:00:34 to critique the national guidance documents as documents yes
01:00:38 now uh let's look at the the the gap analysis and what it doesn't do
01:00:46 and the first topic is if it and i'm going to suggest to you that it doesn't include a warning about the dangers of offering reassurance to callers
01:00:57 offering reassurance to callers as a general proposition do you accept that the gap analysis doesn't do that um
01:01:04 um it doesn't offer the warning up no let's look at the detail if we go to page 11 in this document please
01:01:13 please in the third column entitled gap analysis comparison of national guidance against lfb policy guidance and training it says
01:01:20 it says that the gap between national guidance and the lfb policy on that was as follows national guidance 1093 acknowledges the possibility that an emotional bond may be formed between
01:01:31 emotional bond may be formed between control operator and caller as the call progresses however emphasize or emphasis i think that should say is given to the fact that this relationship may be adverse and lead to the caller providing
01:01:42 adverse and lead to the caller providing answers that they believe will be the desired response and caution should be used when offering reassurance in case this leads to a full sense of security lfb training package tends to encourage a strong
01:01:54 package tends to encourage a strong attachment between caller and fire control operator and reiterates the use of reassuring phrases which may be construed as offering a full sense of security
01:02:05 security you see that yes now if we go to the first column on page 11 uh looking across to the left uh it says attempt should be made to reassure the caller without promoting a
01:02:17 reassure the caller without promoting a false sense of security that's the national guidance just pausing there do you agree that the training package in place before the latino house fire did encourage the control room operator to to create a
01:02:28 control room operator to to create a strong attachment with the caller i do that was the problem uh and if you look at the second column of the gap analysis then um it it doesn't would you agree with me that it doesn't
01:02:40 would you agree with me that it doesn't specify whether or not the policy pn539 addresses the need for caution when offering reassurance to callers to avoid promoting a full sense of security
01:02:52 sorry can you just clarify what what point am i looking at the our notes now the second second column the second column on page 11. yes there's no there's no um
01:03:03 yes there's no there's no um uh spec there's no point made there about whether or not the policy policy 539 which is the first of the three things being looked at addresses the need for caution when
01:03:14 addresses the need for caution when offering reassurance to callers so as to avoid creating a full sense of security agreed it doesn't yeah nor in the third column is there any mention of a gap in that respect in the policy
01:03:27 that respect in the policy no yes only a gap between the guidance and the training yes yes
01:03:33 yes yes um
01:03:35 um would you agree with me and we can go to the
01:03:37 the the um
01:03:39 the um november 2007 version of pn539 if you like but would you agree with me that that the fsg guidance in the 2007 version of policy 539 doesn't include a
01:03:50 version of policy 539 doesn't include a warning akin to what you see in the national guidance no i agree yes and do you agree that that should have been identified in the gap analysis it was identified as such in the fact
01:04:02 it was identified as such in the fact that whilst the warning wasn't there um you know the idea was to promote people away from the bonding and more to assess so it was identified but not not explicitly the way you've explained it
01:04:15 explicitly the way you've explained it there yes and then we look at the recommendation in the last column of the gap analysis there
01:04:22 in the fourth line do you see it says place
01:04:24 place place the lfb training guidance on call psychology more into context with 1093 national guidance to ensure although the fire control operator adopts aspects of
01:04:36 control operator adopts aspects of reassurance such as exchanging names other suggested phrases used during training do not allow the emotional link to be formed and advice is give given is proactive and supportive without
01:04:47 proactive and supportive without without providing false reassurance my question is what this was the intention that the policy policy 539 should be amended specifically
01:04:58 specifically to say that cross should not form an emotional link with callers and should be careful not to provide false assurances
01:05:09 um i i think i think policy 539 should indicate that that reassurances is accepted and and will happen during a call like that but um
01:05:20 call like that but um so i think there is a place for it i just think that our our policies weigh too heavily on that and not on not on assess it's really the point about the gap that the gap was identified between the national guidance
01:05:32 identified between the national guidance and the training on this point but not between national guidance and the policy which the training was training off that's my that's what i'm putting to you then no it wasn't now if we look at um
01:05:45 now if we look at um fire service circular 1093 again look back at it lfb four zero three six one seven
01:05:52 one seven um and look at page one paragraph two
01:05:58 in the last sentence
01:06:05 uh uh
01:06:07 uh the author says this additionally in circumstances such as these uh a fire control operator may need to take into account that the normal procedure of calming the caller may not
01:06:19 procedure of calming the caller may not be appropriate and may even be dangerous in some circumstances i'm sorry i'm not on that page at the moment i don't think you are have you not got the letter up from the chiefing to the chief executive
01:06:31 from the chiefing to the chief executive county councils what what paragraph is that every paragraph second paragraph okay yes sorry thank you thank you i'll read it to you again the last sentence says additionally in circumstances such as these a fire
01:06:43 circumstances such as these a fire control operator may need to take into account that the normal procedure of calming the caller may not be appropriate and may even be dangerous in some circumstances and would you agree that that was a clear warning about the
01:06:56 that that was a clear warning about the dangers of offering false reassurance set out in in 1993 in this secular that was not included in the 2007 version of policy 539 yes
01:07:07 yes yes and nor in the gap analysis yes but it was yes yeah as it stands there yes and and can you explain why your gap analysis did not identify that gap
01:07:21 analysis did not identify that gap i think we did identify the gap but i identified it in a different way where you know we wouldn't we want to move the control officer away from the bonding and more into reassess
01:07:34 so although it wasn't explicit as you've explained it there it was identified and hence why it the training changed to look at reassess as an ongoing as an ongoing thing rather
01:07:46 as an ongoing as an ongoing thing rather than rather than talking to them and keeping them where they are now the next topic i want to look at with you
01:07:52 with you in the gap analysis is the question of the need for continual reassessment by the call handler um can we please go to the control reporter next year's lfb 404750
01:08:07 reporter next year's lfb 404750 page 14.
01:08:10 this is the gap analysis
01:08:14 uh again uh at page 14 fourth column
01:08:20 and this is against the uh national guidance in the first column uh appendix b to the circular smoke you see that yes and
01:08:31 and the
01:08:34 recommendations column says in the third paragraph it's not numbered but it's after the second indent national guidance 1093 highlights the possible effects of smoke on callers but
01:08:45 possible effects of smoke on callers but fails to offer the fire control operator any practical suggestions to deal with these possible changes any updates to 1093 national guidance needs to provide a suggestion that fire control
01:08:58 provide a suggestion that fire control operators should continually reassess the situation not only to remain aware of changing conditions within the premises but also the state of mind of the caller and then if you look ahead to page 17
01:09:10 and then if you look ahead to page 17 there's a further recommendation along the same lines all again in the fourth column
01:09:16 column national guidance 1093 and lfb training materials recognize the importance of initial assessment as the first stage of an fsg call however both documents do not convincingly explain the benefits of
01:09:27 convincingly explain the benefits of continual assessment or possible reassessment further into the call to ensure the situation or individual circumstances has not or is not changing
01:09:38 circumstances has not or is not changing now that's not such a much so much a gap is it as a criticism of the national standards
01:09:43 standards i i just think as times gone by situations have changed and i just think it's a it was a suggestion uh again which is part of the update in that document and that was the offer you know
01:09:55 document and that was the offer you know to to update the document i just think it's a learning learning from from what wheeler and what we wanted to share so in fact you're looking at two things first of all the gap between nfp
01:10:06 gap between nfp policy and training on the one hand and the national guidance on the other and secondly the um
01:10:13 um the defects as they have now come to be seen in the national guidance itself yes now looking at this recommendation you can see that it doesn't specifically address the 2007 version of policy 539
01:10:25 address the 2007 version of policy 539 emergency call handing specifically but would you agree that that version again did not ask the control room operator to continually assess or reassess the situation i agree with that
01:10:37 situation i agree with that um
01:10:37 um do you know why that recommendation focused on amending the national guidance 1093 and the nfp training material but again not the policy itself not the lfb policy itself
01:10:50 i i don't i don't recall did you actually intend that policy number 539 be amended in light of this record yes you did do you know why that wasn't spelled out in this document no
01:11:02 in this document no can i then turn to a further topic which is lack of consolidation um can you look at page eight in the gap analysis please back at page eight and look at the third column
01:11:18 uh where this is in relation to the first topic we looked at before um no issues identified however the information is found on a number of lfb
01:11:29 information is found on a number of lfb documents and needs to be consolidated and if we look at the lingeridge review in january 2013 so some uh three years later this is lfb3033943
01:11:42 page one there's the review page six is where i want to go action 10.
01:11:52 there it is top of the screen revision of pn539 emergency call handling this is three years later
01:12:00 group manager lindridge comments on that policy and he says
01:12:06 he says in the second paragraph one recommendation of the control gap analysis action five stated the information is found in a number of lfb documents and needs to be consolidated but the structure of brigade policy notes appear to be unchanged from
01:12:17 notes appear to be unchanged from pre-2009
01:12:19 pre-2009 and he's quoting there directly from the gap analysis page 8 we've just seen mr hayward isn't he yes but he then goes on to say no change in the last four years
01:12:30 in the last four years and if we go on to page 12 um
01:12:34 um under action reference 10 and this is in the the schedule to this document
01:12:41 document he says there expected outcome uh
01:12:46 uh ensure policy 539 complies with national guidance
01:12:51 guidance and then under the review process findings
01:12:54 findings he says in the second paragraph pn539 does not contain the complete detail on the lfb's fsg arrangements and needs to be read in conjunction with the training documents and can the control reference information files riffs
01:13:06 information files riffs while it could be argued that pn539 does not contain all of the information in the national guidance it should be noted that the format of the national guidance the detail is in the form of a training package does not lend itself to a
01:13:18 package does not lend itself to a methodical approach
01:13:22 now do you know why it was that the recommendation made in the gap analysis on page eight that there should be consolidation had not been actioned by the time group manager lindrich conducted his review in january
01:13:34 lindrich conducted his review in january 2013 almost uh almost three years later i'll be honest i'm not quite sure what consolidation was required if he's suggesting that the
01:13:45 suggesting that the the 1093 should be should have been mimicked in pn539 then that that that wasn't that wasn't the idea i don't think um
01:13:55 um the idea the idea that that the policy note
01:13:59 note and the fsg element is an annex or appendix to to policy 539 which is about emergency call handling but the reference documents are the reference information
01:14:10 documents are the reference information files and training documentation did anybody do a check or audit to make sure that the recommendations in the gap analysis were carried fully into effect
01:14:21 analysis were carried fully into effect uh yes we would have done as control yes you would have done as control well was there one um i don't recall but i would suggest there was yes you would suggest there
01:14:33 there was yes you would suggest there was but what's the basis for that suggestion
01:14:39 i mean we're talking about we're talking about a i'm not quite sure what what mr linders was trying to was was saying or not saying here he's saying that consider it he's i i
01:14:50 he's saying that consider it he's i i don't know what he's suggesting so i can't really answer the question right and what he's suggesting i i would suggest to you is that
01:15:00 the principles of emergency call handling don't fully reflect
01:15:05 reflect the national guidance but partly because 539 doesn't contain all the information in the national guidance which can be found elsewhere yes it's all scattered around different documents and it needs
01:15:16 around different documents and it needs to be pulled together well it's scattered around the documents which control staff will use if an incident was to occur the five five three nines of policy reference document which is
01:15:27 of policy reference document which is for
01:15:28 for for use by everybody but for an actual incident they would go to the reference information file to be able to follow that through so i don't think i don't think the information is scattered i just think
01:15:40 information is scattered i just think it's put in an appropriate place for a control officer if the incident occurred could pick up there and then not refer to a
01:15:49 to a a policy document which should be quite wildly to get to an appendix where where that fsg information would be well let's just break it down then looking at what's on the screen do you
01:16:00 looking at what's on the screen do you agree with the first sentence of what group manager lindrich says there namely the policy 539 doesn't contain the complete detail on fsg call handling and you need to read it together with the training documents and the riffs
01:16:12 training documents and the riffs yes yes
01:16:14 yes yes and
01:16:16 and do you agree with him that the format of the national guidance itself doesn't lend itself to a methodical approach i'm i'm not sure he means by the format and the national guidance
01:16:28 i mean it's been reformatted since 1993 because it's an old thought it's an old format
01:16:35 format yes and do you agree with him uh that uh whatever the format was it's a letter and an appendix didn't let itself lend itself
01:16:46 didn't let itself lend itself uh to a methodical approach the national the policy document uh the national guide national guard yes i agree thank you mr chairman is now a convenient moment for a break yes i think it probably is um well we have a break in
01:16:59 probably is um well we have a break in the middle of the afternoon mr hayward and i think this is a good time to have it so we'll stop now and we'll resume it 25 to 4 please and again please don't talk to anyone about your evidence
01:17:10 talk to anyone about your evidence good thank you very much [Music]
01:17:20 thank you 25-40
01:37:17 yes would you ask the table to come back in
01:37:30 all right mr taylor indeed thank you sir good thank you very much yes yes thank you mr chairman mr hayward uh i now want to turn to pre-inquest action number 10 which was review of policy number 539
01:37:42 which was review of policy number 539 itself
01:37:43 itself uh can
01:37:45 uh can we please have a look at the lingeridge review on the screen where it actually has this here which is the review itself action reference 10. that's lfb3033943
01:38:03 and the entry on the action sorry page 12 i'm sorry sorry page 12 and the action reference
01:38:10 is number 10 and the expected outcome sorry entry on action log revision of policy 539 emergency call handling we looked at that before the expected outcome was to ensure that
01:38:22 the expected outcome was to ensure that it comply with national guidance now if we go back to your first witness statement please paragraph 20 first witness statement page seven paragraph twenty third bullet up from
01:38:33 paragraph twenty third bullet up from the bottom of the page you say
01:38:49 and we want page seven
01:38:52 seven thank you
01:38:54 thank you uh
01:38:55 uh you say
01:38:57 you say action 10
01:38:59 action 10 the fsg element of policy note 539 emergency call management was revised by lindsay turner and the ost so you say that there now can we go to your second witness statement and i'm sorry to jump around there will be a
01:39:11 sorry to jump around there will be a question coming if you go to paragraph 24 of your second statement of page five in answer to question one c you can see that there you can see the
01:39:22 you can see that there you can see the question
01:39:23 question the question is as to actions 9 and 10 please explain whether you took any role in reviewing and or auditing the work of lindsay turner when she revised the operator and supervisor reference information files and the fsg element of
01:39:36 information files and the fsg element of pn539 please also explain which individuals in the ost were involved and you um say in response to that in paragraph 24
01:39:47 in paragraph 24 i did not take an active role in reviewing and or auditing the work of som lindsay turner when she revised the operator and supervisor rif's and the fsg element of pn539
01:39:59 fsg element of pn539 i was not employed as a control officer and had not completed a control officer's course nevertheless i had a high level understanding of som turner's review i ensured that i had an overview and understanding of the control
01:40:10 and understanding of the control functions
01:40:11 functions when you say that you had a high level understanding of som turner's review can you just explain what you mean yes she would have she would have gone through the policy
01:40:22 the policy of what changed she'd make the policy and did you review the changes the extensive changes that she made yep you did and what did you bring to the exercise
01:40:32 exercise i i don't recall right i mean you didn't have any expertise or experience of call handling no not no yourself so how could you um add any value to the exercise she had
01:40:44 um add any value to the exercise she had already carried out well a comparison to the gap analysis obviously there was me it would have been the three of us so um joanne would have been there as well so it was a critique of the of the policy to see if
01:40:57 critique of the of the policy to see if it
01:40:57 it it complied i see so you your role was to make was really a documentary exercise to make sure it fitted and and joanne smith you say joanne smith helped you with it yes i see and so she could
01:41:08 you with it yes i see and so she could bring the experience in indeed yes i see now let's look at her statement this is lfb double zero one two one two one nine page fourteen this is the statement of some smith
01:41:21 this is the statement of some smith um to the inquiry uh paragraph thirty four
01:41:26 four uh and you can see the question she's answering
01:41:29 answering question nine because the inquiry understands that you may have been involved in the review of policy 539 and notes that you updated the latino house board on the progress of the review of the board meetings on 19th july 2010 and 15 september 2010
01:41:43 19th july 2010 and 15 september 2010 please confirm whether this is correct and set out your involvement in the revision of policy 539 and she
01:41:49 and she says
01:41:51 says in the third line we reviewed pn539 in light of the gap analysis conducted after the latino house incident i recall that i would have looked through the policy with scott hayward identifying
01:42:02 policy with scott hayward identifying relevant and non-relevant items and considered where amendments should be made based on our findings in the gap analysis
01:42:10 analysis um
01:42:11 um i think you agree with that do you uh
01:42:15 uh yeah we would have looked we'd have looked it after the gap analysis to see what was missing yes uh
01:42:23 now you say in your first statement if we get back to that please at page nine
01:42:33 if you look at page 9 paragraph 21.3
01:42:38 you say that you presented the policy to the lateral house ball on the 22nd of june
01:42:43 june 2010
01:42:45 2010 i'm summarizing the first point there did the did the board do you remember review the amendments or just accept the presentation that you gave them i i believe at the board they just
01:42:56 i i believe at the board they just accepted the the presentation that was given they they had access to the five three nines they may have they may have looked at it later but i i can't i can't confirm whether
01:43:07 but i i can't i can't confirm whether they did that or not right you say they just accepted the presentation that was given my question is did you actually give him a presentation i i don't i don't know and that that's you know it was it was brought to the it was bought
01:43:18 was it was brought to the it was bought it was presented 539 it was updated they have access to that policy because it's a brigade policy right let's just look at at the board minute just to
01:43:31 at the board minute just to square this away it's at nfb triple zero five five two zero eight we can just look at that and uh you can see the first page of that document
01:43:42 that document we looked at it earlier you can see that you were present if we go within that document please to page three
01:43:48 three paragraph 8.5 you can see that it says policy 539 is being reviewed to include recent changes to call handling such as persons shut in lift policy and afa policy changes have
01:44:01 lift policy and afa policy changes have also been also been made to appendix a fast survival guidance to better reflect fsc 10
01:44:07 fsc 10 93.
01:44:09 93. it doesn't record a presentation being made to the meeting is it right can we take it from this that what was said is no more than what is recorded there no i would i would i mean a presentation
01:44:22 no i would i would i mean a presentation would normally be a verbal a verbal update as opposed to a a powerpoint or a or a whiteboard you know the meetings were you know
01:44:33 you know it weren't for that so yes you can as it's read there right i mean you say in your first statement of paragraph 21.4
01:44:42 21.4 we don't need to go to it necessarily unless you want to that uh som smith presented on the review of pn539 at the meeting on the 19th of july the following month
01:44:54 following month 2010. do you remember whether the board actually looked at the amendments or just accepted the presentation i don't i don't recall you don't remember do you remember whether amendments were approved at that meeting
01:45:05 approved at that meeting that's the 19th of july 2010. i'm not sure whether they're approved they'd have probably been accepted but again they wouldn't have sat there it was quite a a
01:45:14 quite a a meaty document although the amendments would have been made predominantly to appendix one so in time they would have would have reviewed it and brought back any feedback had there been any but i don't recall and what about assistant
01:45:26 recall and what about assistant commissioner brown did he have any role in the in the process of amending policy 539 or presenting that not that i'm aware of can we then turn to pre and quest action 13. and the top the subject of that is the
01:45:39 and the top the subject of that is the letter
01:45:40 letter or proposed letter to the dclg relating to the gaps found in national guidance themselves um can we start then with the lingeridge review again back to that
01:45:52 review again back to that lfb3033943 page 13.
01:45:57 this is action 13 and uh it says uh
01:46:03 uh expected outcome clarification of national guidance with a consistent approach followed by all frses
01:46:10 frses review process findings and this is obviously january 2013 this action will not be complete until the control report is accepted to ensure all issues are included
01:46:21 ensure all issues are included um
01:46:23 were the clarifications that's referred to there um were those the clarifications identified in the gap analysis that we looked at earlier for example pages 9 10
01:46:35 looked at earlier for example pages 9 10 11 12
01:46:36 11 12 13 14. yes i believe they were um and did did you write the first draft of the letter um that was going to be sent yeah myself
01:46:47 um that was going to be sent yeah myself and joanne smith did you did let's look at that lfb404728
01:47:00 there is the letter addressed to sir ken knight who's the cfra dated the third of february 2012.
01:47:09 that's the first that's the document of which you were the author with joanne smith i think yes do you know what steps were taken after 3rd of february 2012 to progress
01:47:21 3rd of february 2012 to progress this letter to a state where it could be sent
01:47:24 sent uh
01:47:25 uh no um
01:47:27 no um this was submitted to the board for uh signature
01:47:30 signature um by the commissioner the deputy commissioner at the time rita dexter
01:47:36 dexter she suggested that that has held until the control report is published uh and then after that i had no knowledge the letter was was there i had no idea what happened after and i was
01:47:48 no idea what happened after and i was later told by ac brown that it wasn't sent right that is i don't know what the reason is you don't right let's let let me just see if i can explore that a little bit further with you and if you can't help me then okay
01:47:59 you and if you can't help me then okay you can't help me um
01:48:04 you let's start with paragraph 21 4 of your first statement page 9 where you refer to the letter being delayed pending the submission of the what you call the control report the november 2012 control report yes
01:48:16 2012 control report yes my first question is do you know when the decision was made to delay sending that
01:48:21 that no well once it was it was submitted um i mean i believe i gave it to dac tim cuthbill
01:48:28 cuthbill and then it went to the the board and through legal it then sat with the deputy commissioner um for the commissioner's signature and that was the last time i i got
01:48:40 and that was the last time i i got involved in in the letter and why why was it delayed for the submission of the control report i don't know there was no explanation given at the time i just wanted to wait until the control report was published right
01:48:52 report was published right and uh you go on in paragraph 21.9 at page 10 next page of your statement to say this in november 2011
01:49:08 um this is the third line in november 2011 i requested permission from the board for the letter to the dclg to be sent and then the then deputy commissioner rita dexter asked if asked that it be
01:49:21 rita dexter asked if asked that it be deferred to the next board meeting then on 12 december 2011 the commissioner confirmed the letter should be sent and that i was to provide the letter to the commissioner for signing which i recall doing i do not know whether this letter
01:49:32 doing i do not know whether this letter was eventually sent or why that might have been
01:49:37 if we go to the minutes for the latino house board meeting on the 19th of november 2012
01:49:45 which is lfb 3084046
01:49:50 we can see from those minutes first of all that you were not there let's wait for them to come up
01:50:02 this is the latino board meeting 19th november 2012. you're not there you send apologies yup if you go to the foot of page 1 you can see action plan
01:50:13 see action plan 6 6.1 action 13 draft letter to clg on fsg this letter will no longer be sent do you remember being told that at the time no i was i was told by ac brown
01:50:24 time no i was i was told by ac brown that it wasn't sent not that it was no longer to be well the same same same difference right so i was informed you were informed did you ask why it wasn't being yeah and there was no no answer
01:50:35 being yeah and there was no no answer given you said there was no answer given who did you ask ac brown and what does he say he said there was no reason given right
01:50:44 right did you make any representations the next time you attended the lachlan house board uh
01:50:51 uh no what is that because the decision being made by the commissioner or the deputy commissioner at the level was not to be sent so
01:51:00 so uh let's go to it uh lfb304033 [Music]
01:51:06 [Music] this is a meeting that you did attend 14th december 2012 and we could see that you're there you're the penultimate entry on the list of attendees and if we go to page two please
01:51:17 and if we go to page two please paragraph 6.1 action 13
01:51:23 uh draft letter to clg on fsg this letter will not be sent and will be reviewed after the inquest has concluded see that yes very foot of the screen yeah was there any discussion at that
01:51:35 yeah was there any discussion at that meeting
01:51:36 meeting of
01:51:36 of that topic no
01:51:39 no all i recall was the last last information i i got it was the fact that the letter would would be sent after the control report and obviously now this i wasn't aware of this
01:51:52 now this i wasn't aware of this right
01:51:53 right so i don't recall it happening
01:51:56 did you say anything do you think and after all you spent a lot of time and trouble writing the drugs indeed but but no that's a decision was made by the commissioner and that that was that was
01:52:07 commissioner and that that was that was it did you regard it as not your place to ask her yes i think so yeah right do you know if it was ever reviewed after the inquest concluded
01:52:17 no not not that i'm aware of i was never told that it was sent and it saw that that was it right so no were you concerned to your knowledge anybody else concerned that this letter
01:52:29 anybody else concerned that this letter uh which had identified defects or or gaps in the national guidance shown up by organic gap analysis um was now not going to be sent
01:52:40 um was now not going to be sent it was a it was a concern but that the view the view was that um we shared our training and we shared our training with with frs's that wanted to to use it
01:52:52 to use it so
01:52:54 so um yes there was concern but but we felt that the train the training packages that will that were in all improved reflected what needed to be done
01:53:12 then if we go back to the lindridge review lfb 3033943 please page four
01:53:21 this is in fact action five not thirteen but nonetheless we've seen it before but come back to it now on page five
01:53:32 come back to it now on page five you can see uh
01:53:37 key findings action 5 national control guidance versus lfb control policy gap analysis and and we read before the fact that the
01:53:48 and and we read before the fact that the gap analysis did not include fsc 5404 we looked at that together earlier mr mr hayward
01:53:54 hayward can you help us with with which recommendations for improvement in the national guidance have not been reflected in the local policy as the second paragraph there says
01:54:13 i can't without any more detail i'm afraid do you remember whether you took any action to remedy the issue that had been identified if it was raised there i would have i would have thought so but i i really can't recall
01:54:25 let's turn next to pre-inquest action 14 which is the exchange of information between control and the incident ground and that's essentially policy number 790 isn't it
01:54:38 essentially policy number 790 isn't it yes um can we go next to some smith's witness statement please at lfb00121219
01:54:46 paragraph 69 on page 26.
01:54:56 and she is answering the question at the top of the page in relation to action 14 creation of policy 790 the question 15 the inquiry understands that you were involved in the development of
01:55:08 you were involved in the development of policy 790 with patrick utting please confirm whether this is correct and set out the nature of your involvement and she says this at paragraph 69 i had some involvement in the development of pn 790 with patrick
01:55:20 the development of pn 790 with patrick utting after the latino house fire i reviewed pn 790 from a control perspective to ensure that the words and descriptions were accurate i also recommended that a change of advice given to residents in high-rise
01:55:31 given to residents in high-rise buildings could occur and needed to be included in the policy this work was carried out in 2011 before i was seconded to the cfoa pn 790 was not at that time a shared
01:55:42 pn 790 was not at that time a shared policy between operational firefighters and control did you ask some smith to carry out that work on pn 790
01:55:57 uh i do not recall but probably if it weren't you who was it it would have been um
01:56:06 um ac brown
01:56:10 do you know why you asked her to do that work or i see brown asks well it was because it was because policy 790 was about communicating with the control room so we needed an input to
01:56:23 we needed an input to um
01:56:25 um to talk about procedures the current procedures that control control use for past information and of course at that time
01:56:32 time whilst we pass information to the fire ground we didn't necessarily get information back unless asked so the idea of this policy was to establish that two-way communication so it makes sense that a control officer would need
01:56:44 sense that a control officer would need to be involved in the creation of the policy did you give some smith any direction as to the intended purpose of policy number seven no i no i didn't did you give her any direction as to
01:56:55 did you give her any direction as to what control needed to achieve from it no because at the time it was it was established as a an operational document uh originally um so
01:57:05 um so and we were going in there from a control perspective i suppose that that that as it was being developed that probably changed a little bit too to show that there will be more control involvement
01:57:16 control involvement right what was your involvement to interrupt you mr miller can i just ask this this reference to a shared policy suggests that there was a fairly widespread um distinction between operational
01:57:28 um distinction between operational policies and control policies as if the two were completely unrelated parts
01:57:34 parts is that how it was or predominantly so yeah there was operational policies which dealt with operational firefighting and there was control room policies which which dealt specifically with
01:57:46 specifically with control room issues and there you know so
01:57:50 so when we got on board with this policy this was probably one of the first shared documents that we that we had you'd think it might have been a candidate for uh being drafted by
01:58:01 uh being drafted by a team from one of each well it apache gutting was an operational officer yeah and obviously uh jam was a control officer so that's how that's how the policy was was being was being put together so
01:58:13 was being put together so all right thank you very much okay yes did what was your involvement in the development of pm 790. um
01:58:22 um just feedback from from joanne about how the policy was developing did you have any role in supervising the actual drafting no that was done by patrick cutting and
01:58:35 patrick cutting and joanne
01:58:36 joanne and now as as you have seen and as the chairman has just asked you about she says that this was a shared policy between operational firefighters and control
01:58:45 control um
01:58:46 um let's uh she says it was not a shirt sorry it was not at that time a short policy
01:58:52 policy uh between operational firefighters and control um can we please go to lfb four zeroes one two five seven this is the version of pn 790 issued on
01:59:05 this is the version of pn 790 issued on the 23rd of february 2012. and you can see that that is the case reviewed as current then on the 17th of april 2014. owned by the head of incident command
01:59:17 owned by the head of incident command policy and operations review team you can see that yes uh
01:59:22 uh what was your understanding of who the policy was being developed for um for operational staff predominantly but it was a obviously for them to be able to do that it needs a control input so it was a
01:59:34 it needs a control input so it was a share it was a shared document but the actual document was written for operational staff to be able to communicate back to the control room right right so directed at operational
01:59:45 right right so directed at operational staff rather than directed at or shared with control room personnel directed out i mean what it was shared with control was obviously we needed to we needed to understand it to be able to
01:59:56 we needed to understand it to be able to do the communication was there any discussion at the time that it was being developed that it should it should be a shared policy as between operations and control not the oracle
02:00:08 not the oracle given the role that the control room plays in an fsg call did you yourself consider that it should be a shared policy
02:00:18 i yes but i i don't recall did you ever make any representations to that effect no this this policy as i said this policy was was written
02:00:29 was written um not in not in control so joanne would go to
02:00:34 go to headquarters and and do the work over there so it didn't actually come to us until the document was was almost completed
02:00:42 completed right so she was in effect seconded it's not quite the right word but she she was parachuted into operations yes yes did she ever raise with you uh
02:00:56 did she ever raise with you uh that
02:00:57 that that approach making it essentially but predominantly your word an operational policy might create a problem
02:01:06 um i i don't recall i mean we were very very uh we wanted it to happen you know
02:01:17 you know can we go to lfb three zeros three three two six six please
02:01:29 now this is an email chain in february 2011 and if we look at the bottom of the chain we go to the last email in the chain you can see that here is um pat utting
02:01:41 um pat utting sending
02:01:42 sending all assistant commissioners and uh joanne stevards smith and indeed others uh the attached draft policy regarding
02:01:53 uh the attached draft policy regarding far survival guidance calls you can see that from the addresses and the first paragraph
02:01:59 paragraph you see that and and then he says uh
02:02:03 uh could you refer to it to your appropriate teams as required and then once um observations by saturday 26th of february to 2011
02:02:14 february to 2011 and if you go um up the chain to page one
02:02:19 one look at the bottom email on page one you can see uh that dave brown forwards this on to you yep and jose dibards and lindsey turner asking the
02:02:31 dibards and lindsey turner asking the question you are presumably already happy with this as you have inputted into it question
02:02:38 had you in fact provided any input into it as ac brand seems to have thought yes we as controllers not not me specifically but we as the senior managers would have done and were you by
02:02:49 managers would have done and were you by that stage happy with it uh yeah i believe we were if we then move into april 2011 uh lfb triple zero 333
02:03:04 and go to the bottom email on that in that document this is an email of the 13th of april 2011 from michelle is it kunika
02:03:15 2011 from michelle is it kunika to uh pat utting uh subject draft 155 fire survival guidance call now in fact it's right isn't it the draft 155 was the working title yes it was for pm 790. yes
02:03:30 title yes it was for pm 790. yes and
02:03:31 and uh michelle kunika says uh
02:03:35 uh well justice she was an operational policy coordinator at the time wasn't she she was and she says or she asks she says please find attached draft operational procedure for fire survival guidance call please provide any
02:03:46 guidance call please provide any comments or feedback you care to offer on this draft to my cell phone or before wednesday 4th of may please also assess the impact of this new procedure on your department and advise what if any activities straight further work will be
02:03:58 activities straight further work will be needed will need to be undertaken before this procedure is implemented for example does this new procedure require change such as current training provision service delivery resources or future strategic planning
02:04:12 did ac brown ever ask you to carry out the task of assessing the impact the impact of this new procedure on control
02:04:21 control and for example what training provision might be required as had been requested i don't recall him at asking me that
02:04:30 did you carry out that task we would have carried out see what the impact would be yes
02:04:42 and if we go to the top of that chain you can see there's an email
02:04:47 email from dave brown on the 14th of april 2014 to danny cotton and others tim tim chidi dominic ellis ian hughes
02:05:00 asking for comments did anything arise out of that not not that i recall right
02:05:08 right and i then want to ask you about something that happened a little bit later in 2011 uh namely the haygate challenge in june 2011. do you remember something called the haygate
02:05:19 remember something called the haygate challenge in the summer of 2011. no
02:05:25 you have no recollection of it let's see how far we go with the contemporaneous documents then in light of that but let's start with lfb30
02:05:39 this is an email run
02:05:42 at the bottom of page one of which we can see an email from andy rowe andrew rowe 8th of may 2011 to
02:05:50 to a group starting with pat utting but including a number of other people including in the last line of the address he's there joanne stibbards and
02:06:02 address he's there joanne stibbards and finally you you see that and the subject was a high-rise policy test exercise june 16th 2011. and in the second paragraph just above the bottom of your screen it says as you are aware the aim of the
02:06:14 says as you are aware the aim of the exercise
02:06:16 exercise is to test the proposed amendments to the current high-rise policy and the new fire survival guidance policy as a result we've briefed all the crews playing part on the proposed changes and have supplied the draft documents to
02:06:27 have supplied the draft documents to them to study before the exercise say that they can implement any new procedures and if we scroll further down to page two of the email if you go on um you can see that you and som smith middle of the
02:06:39 see that you and som smith middle of the screen there at bottom of your screen yep middle of the page are to be controlled observers stroke facilitators yes
02:06:46 yes see that and then if you go to the top of page three andrew rose says this the exercise is a wet drill situated in a derelict
02:06:57 is a wet drill situated in a derelict high-rise block in south oak controller running a background exercise for their staff said this will be run as a live incident on procad with a dedicated airwave channel a live control room including an officer of the watch
02:07:08 room including an officer of the watch and control operators dedicated to the exercise mdt will be live as will css we know mdt is mobile data terminals and css is the is is the command systems
02:07:20 and css is the is is the command systems isn't it
02:07:21 isn't it um
02:07:22 um did you have any involvement yourself in the planning of that exercise uh yeah only only in the fat to set up the control and to ensure that so um
02:07:34 control and to ensure that so um yes it was next it was an exercise and they they allocated specific pumping appliances to that incident so the prep for control was to make sure those those appliances were
02:07:46 make sure those those appliances were released for uh off procad and we but we can mobilize them from procad so there was some system changes to be needed to be done and also we had obviously allocated people to take pioneer
02:07:58 allocated people to take pioneer exercise and i believe we put a couple of control officers down there to observe
02:08:03 observe right training as well so you have control officers on the ground i believe i believe so yeah and just to go and wait to witness it um right when he says a live control room was that merton
02:08:14 room was that merton um
02:08:16 um uh did he say in 2011 yes so now it would have been it would have been uh either dogs right
02:08:23 right but nonetheless it was it was a control room yeah a light a proper control room rather than a blaze get up yes now um
02:08:32 now um when it says controller running a background exercise for their staff what does that mean in this context
02:08:39 uh well we're just obviously doing looking at pn 790 looking at our other policies and running a an fsg exercise in the background did you give any training to your staff in advance of this exercise as uh say that they would
02:08:51 this exercise as uh say that they would be familiar with pn 790 and know what to do during the exercise so that you could assess them uh i don't recall but if if if we were testing pn 790 then they'd
02:09:02 if we were testing pn 790 then they'd have had a copy of pn 790 with them a copy of the policy yeah right but uh was there a was there any time given to them to read the policy and become familiar with it i i don't recall but i was i would suggest yes
02:09:15 recall but i was i would suggest yes right
02:09:16 right and was there any training done on pn790 in order for them to be able to operate it properly and give the exercise value i can't recall
02:09:27 i can't recall can we then look at lfb triple zero five six six two eight
02:09:41 this is the meeting minutes of the 16th of june by way of the debrief hey gate estate high-rise exercise debrief meeting minutes uh
02:09:51 uh uh
02:09:54 now did you and s.o.m smith attend that debriefing do you think yes probably if we did
02:10:03 and if we go to page four you can see under subject two item two third bullet point down it says unknown this is under i should
02:10:15 it says unknown this is under i should tell you a subject to as the top of the screen says draft fire survival guidance calls policy draft 155 that's as it became 790. and then
02:10:26 and then two is information gathering and the third bullet point down unknown the whole fsg recording was hard enough to manage with four flats it would be almost impossible should you have 60 flats involved can this information not
02:10:39 flats involved can this information not be sent
02:10:40 be sent to the mdt now looking at that is it right that the exercise only involved four fsg calls um
02:10:49 um i'm not sure i'm not sure um well let's just see if we can nail that down further can we look at the um at page 11 of this document
02:11:04 and that may be a misreference let me let me show you something slightly different
02:11:09 different lfb triple zero three three three eight four
02:11:15 lfb
02:11:18 zero zero zero three three three eight four
02:11:22 four page eleven
02:11:26 uh now this is the feedback report and item seven is recording of information and the first bullet point says the
02:11:38 and the first bullet point says the constituency it says yes consensus and specific feedback from the ces was that even with only four fsg calls to cu staff riding as the as only two could not deal with the workload associated
02:11:49 not deal with the workload associated with the fsg policy and their normal duties
02:11:53 duties so does that help you with your recollection that haygate only involved four fsg calls yes did you or som smith have any input into deciding that number
02:12:04 deciding that number what the four fsg there should be four as opposed to three no six no
02:12:09 no can you help us with why only four fsg calls were selected for this this exercise when at lachnal there were five
02:12:21 i don't i don't recall exactly um but you know between we never expected to do anything more than between two and two and five uh fsg
02:12:32 than between two and two and five uh fsg calls i mean that that's multiple fsg uh so i suppose they're just i think they were it was more about testing the communications as opposed to the amount of fsg calls that were coming in but
02:12:44 of fsg calls that were coming in but would the amount of fsg calls coming in not be a critical thing to test yes i must work out what your limits but this was the first the first exercise i just think which was to test the policy itself
02:12:54 itself and then get the feedback which is what they've done here was there a later exercise proposed where you would increase the number of fsg calls not that i recall why was that
02:13:07 i don't know i mean there were i mean we did
02:13:10 did um or stations did organize um exercises um and asked for control input which sometimes we could support and sometimes we couldn't but i couldn't tie
02:13:22 sometimes we couldn't but i couldn't tie down whether they were all fsg or whether we did any more fsg's than that now going back to the the uh debrief meeting
02:13:31 meeting you could see from that that the concept of a large number of fsg calls possibly 60 flats was being discussed at that meeting is that is that right there was a big there was a big issue about command units only being staffed
02:13:43 about command units only being staffed by two operational staff and the amount of information that they have to collate and display uh would mean that doing this type of recording would severely deplete their
02:13:55 recording would severely deplete their ability to do much else so it was raised on the evening of the debrief um and that was for something that they took away i don't know what action happened after that
02:14:06 after that and they were looking at increasing the command unit right but that's a smart thought i know right but my question is a slightly different one or getting at something slightly different which is that
02:14:17 slightly different which is that the concept of 60 flats or fsg calls coming from 60 flats which we've seen referred to in the debrief uh was that discussed as a a realistic
02:14:29 was that discussed as a a realistic possibility no not another time because that never experienced an incident of 60 flats before nonetheless was that not something that was being considered as something that
02:14:40 was being considered as something that controls should plan for not not at the time no was it also your experience of the exercise that it was hard to manage with four fsg calls and verging on the impossible if you had
02:14:52 and verging on the impossible if you had more flats involved it's it's it's difficult because if you've got four simultaneous fights of other calls you're potentially taking up eight members of staff
02:15:03 members of staff so so yes it is it is difficult which is why
02:15:06 why which is why we worked within within that remember between two and five as a multiple we didn't we haven't experienced anything more than that at that point does that tell us that your limits of your fsg training and the
02:15:18 limits of your fsg training and the numbers of fsg calls for training purposes was uh predicated on the number of call handlers and supervisors available to deal with them
02:15:33 in its purest form then yes i suppose it would be
02:15:36 would be do you
02:15:37 do you sorry sorry i'll just uh just to add to that simultaneous calls so if they're all coming in at the same time then yes that would be an issue but experience previous experience has shown that that
02:15:48 previous experience has shown that that sometimes fsg calls we have one in it has stopped another one to come in in which case it's more manageable yes it's about concurrence rather than sheer numbers i accept that i see that
02:15:59 sheer numbers i accept that i see that entirely but uh did you give any feedback yourself to that meeting um control rooms perspective
02:16:08 i don't i don't recall i don't know if i put anything in the notes
02:16:15 uh i want just to examine this question of large numbers of fsg's a little bit more closely with you we've seen that policy number 790 was published in february 2012 when it was published did you
02:16:26 when it was published did you familiarize yourself with its content i read through it yeah yes and if we look at the version in force on the night of the grenfell tower of fire
02:16:35 fire that's the version reviewed as as at 17th of april 2014. it is lfb401257
02:16:50 if you look at that
02:16:54 there's the date on it can i take it that you were also familiar with this revision
02:16:58 revision from the time that it was revised in april 2014. i don't recall but yes right um if we look at page two paragraph 1.1 it says this the the purpose of this policy is
02:17:10 this the the purpose of this policy is to explain what a fast survival guidance fsg call is and to describe how critical information should be exchanged between brigade control and the incident ground it provides guidance on how this
02:17:21 it provides guidance on how this information is to be recorded for use by incident commanders i see would you agree that in part the policy dictated the actions that control staff should take in the event of receiving a
02:17:32 should take in the event of receiving a fast survival guidance call
02:17:38 with regards to exchange information between the fire ground and yes
02:17:44 and it it was was it to work in conjunction with pn 539 emergency call handling
02:17:54 yeah well i mean it did i i think this is about
02:17:57 is about the communication exchange and a 539 appendix one is about fire survival guidance calls so
02:18:07 so it would work hand in hand to pass that information to the fire ground yes yes yes and if we go to page 3 and look together at paragraph 5.13
02:18:19 at the foot of the screen it says if underlined control has sufficient resources
02:18:25 resources then m2fh floa in ops one could be used to free up the main scheme filing radio if there are a large number of fsg calls
02:18:36 did you ever ask well
02:18:38 well did you know first of all what large number of fsg calls meant or was contemplated there we we based it on on la canal so it was based on five
02:18:49 based on five five being you know a multiple incident right
02:18:55 and then if you go to page five at paragraph eight point seven
02:19:02 it says in exceptional circumstances an ic may consider informing control that their advice to fsg callers should be altered eeg to attempt to leave their property the ic should remember that
02:19:13 property the ic should remember that this advice may be contrary to national policy for control staff on fsgs and liaison with the officer in charge at control will be required for agreement to change the prescriptive
02:19:24 agreement to change the prescriptive advice
02:19:26 advice did you
02:19:27 did you when you reviewed this
02:19:30 this draft or perhaps at an earlier stage consider
02:19:33 consider that that also might need to work the other way around the control staff could provide information to help inform any decision by the incident commander as to whether and to what extent the state put
02:19:44 whether and to what extent the state put policy or advice should be revoked no
02:19:49 no why is that because we take out or you know we control take their direction from the fire ground so um re resourcing uh
02:20:00 um re resourcing uh or anything is is dictated by the ic the control room was not a controller commander control function it was a service delivery function yes but did it
02:20:11 service delivery function yes but did it not nonetheless occur to you that there might be things within the control room that the incident grant incident commander couldn't see or know and that that which might impact on whether stay put should be revoked and
02:20:23 whether stay put should be revoked and that therefore the control room should be ready to provide uh information to the incident commander that would bear on that potential decision if there if there is information if there is information
02:20:34 information if there is information pertinent to the instant ground then we would try and pass that information but not
02:20:38 not i don't recall in this situation having that having been told that or doing that no and does it follow from that that you at least gave no thought to whether
02:20:49 least gave no thought to whether control room operators and their supervisors needed to be given any guidance
02:20:54 guidance whether in policy 790 or anywhere else about what information they should be gathering and passing on to the incident commander so as to assist them
02:21:05 commander so as to assist them with the decision as to whether to revoke stay put or not well i mean the information that the control paths to pass the fire ground is about fire survivor guidance calls
02:21:17 survivor guidance calls that that's what that's what they they do
02:21:19 do regarding regarding um anything more like fire spread for example is you know that they're not the experts
02:21:28 experts to provide that sort of information that's what operational firefighters do and hence we take our direction from from them
02:21:35 from them but
02:21:37 but i think you would accept this much that
02:21:40 that it might be the case that because of what is being fed into the information into the control room through far survival guidance calls or ordinary callers perhaps callers from outside
02:21:51 callers perhaps callers from outside um
02:21:52 um it might be something that the incident commander themselves could not see and therefore that might be relevant for them tonight potentially you know and grenfell aside
02:22:04 grenfell aside you know that that information would get passed down to the fire ground if there's information that's pertinent but but of course you need people to be listening on the other end and the like so
02:22:15 so yes i agree yes
02:22:18 yes did you ever consider how a cra would go about giving advice to a caller in in in the situation where the incident commander had changed the stay put advice
02:22:30 put advice no it was not it was not considered in training or discussed openly that that's something that we would do um given what is said in eight seven here on the screen although there may be
02:22:41 here on the screen although there may be exceptional circumstances uh why was it that no training was ever given to ciara's about what advice to give where in those exceptional circumstances an
02:22:52 in those exceptional circumstances an incident commander told control uh that statement should be revoked and everybody should leave because as a brigade that was something that we didn't expect ever to happen
02:23:04 that we didn't expect ever to happen so there was no training at any level i don't think about about how that would how that would play out you say as a brigade that was something we didn't expect ever to happen um but on
02:23:15 expect ever to happen um but on the face of the policy they were circumstances which might arise although perhaps exceptionally
02:23:25 again i go back to the point that the commander control is is on the fire ground and not in control and we would wait you know to see if the fight if the fire ground come
02:23:37 if the fight if the fire ground come back and says there's a change to change then we would respond to that not necessarily other way around and i'm not sure the control staff would be they're certainly not trained or qualified to make that sort of
02:23:48 make that sort of decision that then at that point no but
02:23:53 no but my question to you is why would why do you say
02:23:56 you say that it was a as a brigade it was something you didn't expect ever to happen when the this policy itself expressly contemplates that it might albeit exceptionally
02:24:08 exceptionally but because up to that point it hadn't happened
02:24:11 happened then i mean i i don't i can't answer i can't answer the question i i understand what's bit what's what you're saying but but i can't i can't you know the expectation was that would
02:24:22 you know the expectation was that would never happen and it hadn't happened today and therefore we don't we went no further with it at that point now in respect of training on pn790 for control staff can we look at
02:24:33 pn790 for control staff can we look at your third statement please that's at lfb double zero one two one one seven six and if we go to page six in that you say at paragraph 21 you say this
02:24:47 and this is under or in the answer to the question which presentation either referred to in your witness statement or otherwise delivered the training on policy 790 to control room staff that's
02:24:58 room staff that's that's the question and the answer at 21 is to the best of my recollection there was not a formal presentation which delivered the training on policy notes 790 pn 790 instead i believe on-watch
02:25:12 790 pn 790 instead i believe on-watch training
02:25:13 training involved an aom discussing the policy note with those who are attending the familiarization training which could be one-to-one sessions at desks or group sessions in an area of the control room
02:25:25 sessions in an area of the control room so is it right looking at that that training was really more of an informal discussion no it would have been it would have been training
02:25:33 training or familiarization and that they were minimizing the sales of a policy so it wouldn't have been a you know a two-hour session necessarily it would have been you know talking through the policy
02:25:42 policy and making sure that staff understood it that's how i recollect it being done
02:25:48 you refer to something called the familiarization training we just go back to the bottom of page six where you see that phrase afraid the two words straddle the pages
02:26:00 afraid the two words straddle the pages discussing the policy note with those who are attending the familiarization training what was the familiarization training right familiarize ourselves with the document with p990
02:26:11 with the document with p990 why was there no formal training on policy number 790 arranged for control staff given the policy's application to cros in fsg calls i i do not i do not recall
02:26:24 i i do not i do not recall why didn't you yourself personally ensure that they were given formal training
02:26:31 i don't i don't recall was the was the training that you do describe here the one-to-one sessions at desks or group sessions in an area of the control room uh ever recorded anywhere on the
02:26:42 uh ever recorded anywhere on the training database or in your spread your manual spreadsheets that you kept i believe i believe there is some um some training recorded in in the spreadsheet right we haven't seen it
02:26:54 spreadsheet right we haven't seen it anywhere in any of the fsg training records okay where might you have seen it do you think i thought i might have seen it on the spreadsheet but i i may be wrong right
02:27:05 did does that take us to this conclusion that there was no you can't as he sitter today point to any system whereby the brigade could make sure that all control staff had been given
02:27:16 that all control staff had been given even the
02:27:17 even the training you describe on watch in respect of policy 790. i i can't i can't if it's not recorded i can't guarantee i can't guarantee it was done but i believe it was done because
02:27:30 done but i believe it was done because it was a new policy coming into control yes thank you um mr chairman we're going to move to a different sub-topic but it's a slightly lengthy subtopic topic well it would be sensible to stop at
02:27:42 well it would be sensible to stop at that point i think it would thank you very much yes um well mr hayward i think we've reached a convenient point to stop for the afternoon exactly so we'll break there but i'm afraid i'm gonna have to ask you to come back to uh answer some more
02:27:54 to come back to uh answer some more questions tomorrow but i think you were expecting that um so we'll do that at 10 o'clock in tomorrow morning please and again please don't talk to anyone about your evidence of course or anything related to it while you're away from the
02:28:06 related to it while you're away from the room okay all right thank you very much thank you
02:28:18 thank you mr miller at 10 o'clock tomorrow thank you mr chairman
02:28:38 you