Chapter 79: Fire survival guidance: training and management

Chapter 79: Fire survival guidance: training and management

Background

¶79.1 Taking emergency calls from the public, particularly those who are directly affected by a fire or other life-threatening event, and passing essential information quickly and accurately to those who need to receive it requires reserves of character and effective training. Control room staff receive training when they are recruited, but they also need regular training to ensure that their skills are kept up to date and that they benefit from any advances in learning. In the Phase 1 report the chairman was critical of some of the ways in which CROs handled emergency calls. He also identified various deficiencies in the Reference Information Files (RIFs) provided for the assistance of control room staff.^10411041 Phase 1 Report Volume IV paragraphs 29.49-29.50. We have therefore examined the way in which the LFB managed the training of control room staff in the years preceding the Grenfell Tower fire.

¶79.2 Ultimate responsibility for control room training lay with the senior officers, primarily AC George and AC Brown,^10421042 Hayward {Day199/36:21}-{Day199/37:15}; George {Day205/12:3-6}; Brown {Day206/156:13-17}. but none of them exercised very much oversight of it.^10431043 Hayward {Day199/37:16}-{Day199/38:3}; George {Day205/152:5}-{Day205/153:24}. AC Brown delegated to POM Hayward responsibility for monitoring control room training and ensuring that the training needs of control room staff had been properly identified and effectively met.^10441044 Brown {Day206/156:10-17}. POM Hayward in turn delegated that responsibility to the SOM in charge of the Operational Support Team,^10451045 Hayward {LFB00086213/7} page 7, paragraph 38; Hayward {Day199/38:4-8}. who was responsible for identifying the training required, deciding its content and ensuring that it was delivered effectively.^10461046 Hayward {Day199/33:21}-{Day199/34:1}; Hayward {LFB00055191/17} page 17, paragraph 48; Smith {LFB00121219/6} page 6, paragraph 15. The SOM took full responsibility for training and did not need to obtain the approval of POM Hayward for training packages that were developed.^10471047 Hayward {Day199/34:2-7}. The Operational Support Team was responsible for creating, organising and delivering all training documents and training packages for new entrants to the control room and existing staff.^10481048 Hayward {LFB00055191/7} page 7, paragraph 20; {LFB00055191/17} page 17, paragraph 47; Hayward {Day199/38:9- 13}. In the period between 2009 and 2019 the SOMs responsible for training were Lindsay Turner (2009–2012), Victor Bagnelle (2012–2015) and Joanne Smith (2015–2019).^10491049 Hayward {LFB00086213/8} page 8, paragraph 39.

¶79.3 POM Hayward generally adopted a laissez-faire style of management under which he did not expect to receive reports on matters relating to training unless there was a problem.^10501050 Hayward {Day199/32:6-14}; {Day199/51:6-24}. He therefore did not actively monitor training; he expected the SOM to tell him if there was a problem of some kind.^10511051 Hayward {Day199/51:6-24}. Otherwise, he assumed that the Operational Support Team was carrying out its job properly.^10521052 Hayward {Day199/32:15-21}; {Day199/51:6-24}. In practice, POM Hayward's monitoring of training was confined to discussions with the SOM about problems as they arose and the observation of some training.^10531053 Hayward {Day199/32:15-21}; {Day199/34:5-14}. He did not regularly inspect the training records, despite the provisions of PN164, which contemplated that he would do so.^10541054 Hayward {Day199/118:17-19}; PN164 amended on 28 January 2009 {LFB00084054/3} paragraph 2.5; PN164 reviewed as current on 6 May 2015 {LFB00084054/8} paragraphs 2.5-6. He made none of the decisions about the content of control room training, nor did he consult AC Brown, AC Chandler or AC George about it.^10551055 Hayward {Day199/34:19}-{Day199/35:3}. He expected any problem with training to be raised at Brigade Control Management meetings or in his meetings with the SOMs,^10561056 Hayward {Day199/32:19}-{Day199/33:17}; {Day199/50:20-24}. but apparently none ever had been.^10571057 Hayward {Day199/32:19}-{Day199/33:1}; {Day199/51:6-13}. In the absence of any problems he felt confident that the SOMs were managing training properly.^10581058 Hayward {Day199/32:19}-{Day199/33:1}. For their part, neither AC Brown nor AC Chandler nor (to a lesser extent) AC George, exercised any active supervision of his oversight of training or monitored what he was doing to keep abreast of it.

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¶79.4 In our view, such a detached approach to training should never have been allowed. Although POM Hayward was entitled to delegate the delivery of training to senior managers whom he knew and trusted, he had a personal responsibility to satisfy himself that the training programmes were suitable and were being delivered appropriately. He also had a personal responsibility to satisfy himself that the training was effective. As far as we can see, he did none of those things.

¶79.5 Most of the training was delivered to staff on watch. Accordingly, if during training there was a significant incident or a significant increase in the number of calls, staff could be recalled to their positions in the control room.^10591059 Hayward {LFB00055191/18} page 18, paragraph 52. Generally, training took place in a side room of the premises at Merton where the control room was located.^10601060 Hayward {LFB00055191/17} page 17, paragraph 49. When training had been completed, it should have been recorded manually by the Operational Support Team in a spreadsheet. From April 2019 it was recorded electronically in a system called System Training Evaluation and Performance (STEP).^10611061 Hayward {LFB00055191/17} page 17, paragraph 48; Hayward {LFB00055191/25} page 25, paragraph 72; Training Spreadsheet {LFB00055223}.

Fire survival guidance training after the Lakanal House fire

¶79.6 The Lakanal House Board was responsible for the introduction of a programme of fire survival guidance training introduced in response to the Lakanal House fire.^10621062 Hayward {LFB00055191/24} page 24, paragraph 68. The relevant pre-inquest actions were action 8 (involvement of fire safety officers in training), action 11 (ensure that initial training on handling fire survival guidance calls complied with national guidance) and action 12 (provide refresher training on handling fire survival guidance calls).^10631063 Lakanal Assurance Report {LFB00004801/13-14}.

¶79.7 National guidance on fire survival guidance training for CROs was published by the Home Office in 1993 and 1994 respectively in the form of FSC 10-93 and 'Keeping People Safe',^10641064 Lakanal Control Report {HOM00001124/13-16} paragraphs 49-74. to which we have referred. FSC 10-93 provided that recruits with between 8 and 12 weeks of service should be given fire survival guidance training to enable them, when dealing with callers trapped in domestic accommodation, to make a proper assessment of the situation, give appropriate advice where necessary and otherwise assist in minimising the danger to the caller.^10651065 Fire Service Circular {LFB00003617/1} paragraph 6. FSC 10-93 also recommended that continuation training be provided to CROs, which should include the fire survival guidance training set out in Appendix B.^10661066 Fire Service Circular {LFB00003617/2} paragraph 7. Appendix B recommended that fire survival guidance training should be presented by a fire safety officer and a fire control officer jointly and should comprise a lecture lasting one to one- and-a-half hours followed by a practical role-play session.^10671067 Fire Service Circular {LFB00003617/6}.

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¶79.8 One of the key recommendations of 'Keeping People Safe' was that fire survival guidance refresher training should be undertaken at intervals of no more than 12 months.^10681068 Lakanal Control Annexures {LFB00004750/37}. The training emphasised the need for an assessed role-play session in which CROs should actively participate.^10691069 Lakanal Control Annexures {LFB00004750/28}; Hayward {Day200/120:14}-{Day200/121:25}. Its purpose was to test the ability of CROs to establish whether a caller can leave the building, recognise unusual responses, determine the caller's location and provide appropriate guidance by following a sequence of prompts.^10701070 Lakanal Control Annexures {LFB00004750/28}.

¶79.9 After the Lakanal House fire, the LFB created an initial fire survival guidance training package in 2010 for all control room staff which consisted of three training presentations^10711071 Hayward {LFB00121176/3-4} pages 3-4, paragraphs 13 and 14; Lakanal House Assurance Review {LFB00004801/14}. Further training was developed for new entrants {LFB00107484}. entitled Building Types and Concepts,^10721072 Refresher training presentation on building types and concepts (2011) {LFB00086228}. Fire Survival Guidance^10731073 Fire Survival Guidance presentation {LFB00028265}. and Fire Survival Training: Introduction to Fire and Human Behaviour.^10741074 Fire Survival Training: Introduction to Fire and Human Behaviour presentation, dated March 2010 {LFB00119961}. SOM Lindsay Turner was responsible for drafting the new training package, although the senior management team as a whole was involved in decisions about it.^10751075 Smith {LFB00121219/18} page 18, paragraph 47; Smith {Day203/191:10-16}.

¶79.10 In 2010, fire survival guidance training was delivered to all control room staff, except those on long-term absence.^10761076 Hayward {LFB00055191/25} page 25, paragraph 74; Minutes of Lakanal House Board Meeting of 15 September 2010 {LFB00055192/1}. A full day was allocated for it, off the watch. It was delivered by one of the trainers and included opportunities to ask questions.^10771077 Hayward {Day200/79:9}-{Day200/80:16}; {Day200/80:19-23}; Hayward {LFB00055191/24} page 24, paragraph 69. Half of the training was delivered by the Fire Safety team, in accordance with national guidance.^10781078 Minutes of Lakanal House Board Meeting of 15 September 2010 {LFB00055192/2} item 5.6; Hayward {LFB00055191/6-7} pages 6-7, paragraph 20. At a meeting on 15 September 2010, the Lakanal House Board was informed that all control room staff had received refresher fire survival guidance training which had been fully in accordance with FSC 10-93.^10791079 Minutes of Lakanal House Board Meeting of 15 September 2010 {LFB00055192/1} item 5.4.

¶79.11 In February 2010, before the fire survival guidance training package had been provided to staff, POM Hayward asked for role-play to be introduced as part of an assessment at the end of the week to consolidate the training and to give CROs an opportunity to practise giving fire survival guidance in a controlled environment.^10801080 Email from Scott Hayward to Chris Sharp, Lindsay Turner, Joanne Stibbards and Robin Hannan dated 23 February 2010 regarding Fire Survival Planning Meeting 22nd February 2010 {LFB00028258/1}. As a result, the fire survival guidance training in 2010 included active role-play, in which the trainer would act as the caller and a CRO would take the call.^10811081 Hayward {LFB00121176/6} page 6, paragraph 20. The trainer would improvise a situation based on their own experience and act out a fire survival guidance call to which the CRO would be expected to respond.^10821082 Hayward {LFB00121176/6} page 6, paragraph 20; Hayward {Day200/127:22}-{Day200/128:19}. No specific responses were required but the trainer was expected to ensure that the trainee followed the structure set out in the fire survival guidance RIF.^10831083 Hayward {LFB00121176/6} page 6, paragraph 20.

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¶79.12 The initial fire survival guidance training package was outdated, being based on a fatal fire in the West Midlands in 1990 which had prompted the dissemination of FSC 10-93 and the 'Keeping People Safe' training. It was flawed in a number of respects. First, none of the initial training presentations referred to the Lakanal House fire or to the rapid spread of fire that had occurred on that occasion and the dangers involved.^10841084 2010 FSG Training {LFB00028265}; 2011 FSG Training {LFB00086214}; Hayward {Day200/96:12} – {Day200/97:11}; Building Types and Concepts presentation {LFB00086228}; Hayward {Day 200/107:3-20}; Fire and Human Behaviour Training presentation, dated March 2010 {LFB00119961}; Hayward {Day200/111:2}-{Day200/112:7}. SOM Smith could not explain why that was the case^10851085 Smith {Day203/202:7-11}. and the 2011 training did not remedy the omission.^10861086 2011 FSG Training {LFB00086214/1}.

¶79.13 Secondly, none of the training presentations enabled CROs to understand significant features of modern buildings, such as cladding systems, and how they could contribute to a rapid and unusual spread of fire.^10871087 Hayward {Day200/112:9-14}. It was a serious oversight not to have referred to the Lakanal House fire and modern methods of construction to ensure that control staff understood the relevance and importance of the training.

¶79.14 Thirdly, neither the 2010 nor the 2011 presentations complied fully with national guidance. FSC 10-93 warned that, in situations where the caller was prevented from escaping, CROs needed to be aware that reassuring the caller might not be appropriate and in some circumstances might even be dangerous.^10881088 Fire Service Circular {LFB00003617/1} paragraph 2. Yet the 2010 training presentation told CROs to reassure the caller, to remain positive in order to create a bond and to provide reassurance by saying that the firefighters were on their way and would be there very soon.^10891089 2010 FSG Training {LFB00028265/19-28}. SOM Smith was "extremely surprised" that the fire survival guidance training provided to CROs in 2010 included that advice and accepted that it reinforced bad practice.^10901090 Smith {Day203/200:5}-{Day203/201:25}. The advice to create a bond with the caller was removed from the 2011 training package, but that version still encouraged CROs to reassure the caller by telling them that the firefighters were at the scene.^10911091 2010 FSG Training {LFB00028265}; 2011 FSG Training {LFB00086214/21}. POM Hayward accepted that that was contrary to national guidance but could not explain why it had been included.^10921092 Hayward {Day200/102:2-24}; {Day200/108:13}-{Day200/110:1}.

¶79.15 Fourthly, neither the 2010 nor the 2011 training presentations addressed some of the problems that CROs had encountered in connection with the Lakanal House fire, such as difficulty in identifying a safe room or problems in understanding the layout of the flat caused by the caller's moving between rooms or even between flats.^10931093 Hayward {Day200/104:2-16}; FSG Refresher Presentation {LFB00086214/15-16}; 2010 FSG Training {LFB00028265}.

¶79.16 Fifthly, neither the 2010 nor the 2011 presentations referred to FSC 54-04 or the need to ask specifically about the caller's age, gender, ethnicity or mental or physical ability.^10941094 2010 FSG Training {LFB00028265}; 2011 FSG Training presentation {LFB00086214/21}.

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¶79.17 In August 2011, POM Hayward asked SOM Smith to review the fire survival guidance training packages to ensure that they were consistent with FSC 10-93.^10951095 Hayward {Day200/116:24}-{Day200/118:1}. SOM Smith did not review the role-play exercise,^10961096 Smith {Day204/49:20}-{Day204/50:2}. but she did review the 2011 version of the fire survival guidance training presentation and concluded that it was materially incomplete, in particular, because it used neither the definition of a fire survival guidance call found in PN539 nor that found in current national guidance.^10971097 Comments on FSG {LFB00083547/1}. However, her criticisms, which were bluntly expressed, were not acted on. SOM Smith could not explain why, in August 2011, more than two years after the Lakanal House fire, fire survival guidance training for CROs still contained the errors she had identified.^10981098 Smith {Day204/65:11-15}.

¶79.18 A new fire survival guidance training presentation was created in 2012, but most of SOM Smith's comments were not acted on and the contents of the presentation were substantially similar to those of the 2011 version.^10991099 FSG Brigade Control Training presentation (2012) {LFB00086226}; Smith {Day204/42:4}-{Day204/48:12}. SOM Smith could not explain why that was the case.^11001100 Smith {Day204/42:4-19}. She thought she had discussed her criticisms with POM Hayward but there is no record of any such discussions having taken place.^11011101 Smith {Day204/42:4-19}.

¶79.19 The history of this matter only reinforces our view that POM Hayward failed to exercise proper control over the development and delivery of training. The fault does not lie solely with him, however, since more senior officers should have been taking responsibility for ensuring that a matter of such importance was being properly managed.

SM Kelly's audit of control room training

¶79.20 On 3 August 2010, SM Stephen 'Ned' Kelly completed an audit of the Training team's systems for managing the quality of training courses and assessing the performance of trainees, using the fire survival guidance refresher training course as an example.^11021102 Audit of Quality Management Systems Fire Survival Training Course dated 3 August 2010 {LFB00109082}. Having witnessed some practical role-play exercises, he noted that each candidate was exposed to a single fairly simple fire survival guidance call lasting between 90 seconds and two minutes, during which their performance was monitored.^11031103 Audit of Quality Management Systems Fire Survival Training Course dated 3 August 2010 {LFB00109082/6} paragraph 40. He made a number of criticisms, noting in particular that each trainee took part in only one fairly straightforward exercise and that the assessment of their individual performances was very informal, there being no documented note of what was expected of them or any record kept of their performance. He therefore recommended that the role-play element of the training be reviewed and that a robust assessment process be implemented.^11041104 Audit of Quality Management Systems Fire Survival Training Course dated 3 August 2010 {LFB00109082/11}.

¶79.21 POM Hayward told us that the control room had implemented some, though not all, of SM Kelly's suggestions to improve the assessment of trainees' performance.^11051105 Hayward {Day200/131:22}-{Day200/132:22}. Four fire survival guidance role-play exercises were produced in 2011, for which a document was provided to enable CROs' performance to be recorded and assessed.^11061106 Hayward {LFB00055191/26} page 26, paragraph 75; 2011 FSG Role Play scenario 1 {LFB00055226} 2011 FSG Role Play scenario 2 {LFB00055227}; 2011 FSG Role Play scenario 3 {LFB00003788}; 2011 FSG Role Play scenario 4 {LFB00003682}. However, the control room did not implement any of his other recommendations because they considered that the course was already long enough.^11071107 Hayward {Day200/131:22}-{Day200/132:22}.

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Fire survival guidance refresher training

¶79.22 The Lakanal Control report noted that at the time of the Lakanal House fire there had been a lack of structured, regular fire survival guidance training.^11081108 Lakanal Control Report {HOM00001124/52} paragraph 308. The Lakanal House Board decided, therefore, by way of pre-inquest action 12, that a recurring programme of fire survival guidance refresher training should be established for all control personnel in accordance with national guidance.^11091109 Minutes of Lakanal House Board Meeting 15 September 2010 {LFB00055192/2}; Minutes of Lakanal House Board Meeting 15 November 2010 {LFB00055213/1}. At a meeting of the Board on 15 September 2010, Commissioner Dobson noted that one of the areas that needed to be considered was to ensure that refresher training for the control room on handling fire survival guidance calls was maintained and recorded on STEP.^11101110 Minutes of Lakanal House Board Meeting 15 September 2010 {LFB00055192/2}. Despite his comment, however, nothing appears to have been done, either to maintain refresher training or to record it on STEP.

¶79.23 National guidance required that refresher training on fire survival guidance calls should take place at least every 12 months and should include the training described in Appendix B of FSC 10-93. It recommended that training be delivered jointly with a fire safety officer and include active practical role-play.^11111111 Fire Service Circular {LFB00003617/6}; Lakanal Control Annexures {LFB00004750/37}. FSC 10-93 also recommended that refresher training be given systematically on the watch to all CROs, and should be scheduled and monitored.^11121112 Fire Service Circular {LFB00003617/3} paragraph 11. It emphasised that such training should cover little-used procedures and areas of weakness.^11131113 Fire Service Circular {LFB00003617/3} paragraph 11. AC Brown and SOM Smith accepted that fire survival guidance was a little-used procedure and SOM Smith accepted that the LFB's response to the Lakanal House fire had demonstrated that it was an area of weakness.^11141114 Smith {Day204/13:23}-{Day204/14:6}. For those reasons AC Brown accepted that the need for fire survival guidance refresher training should have been made clear to CROs.^11151115 Brown {Day207/59:8-11}.

¶79.24 The programme of fire survival guidance refresher training was approved at the Lakanal House Board. In the second half of 2010, it was decided that there should be a two-year refresher training programme, under which a full day of classroom training would be delivered in the first year and a computer-based training package in the second.^11161116 Hayward {LFB00055191/24} page 24, paragraph 68. Minutes of Lakanal House Board Meeting of 22 June 2010 {LFB00055208}; Minutes of Lakanal House Board Meeting of 15 September 2010 {LFB00055192}; Minutes of Lakanal House Board Meeting of 8 November 2010 {LFB00055213}. It was always intended that the full day of refresher training would include active role-play and would be delivered jointly with the fire safety team.^11171117 Hayward {Day200/143:8-19}; Smith {Day204/19:6-12}. The plan was that in alternate years CROs would complete the computer-based training package on their own,^11181118 Hayward {Day200/147:16}-{Day200/148:3}. the intention being for them to be allocated time to complete it while on the watch.^11191119 Hayward {Day200/157:3-6}. There was no plan to provide role-play exercises in the years when the computer-based training package was delivered; instead, CROs would be asked to complete a questionnaire designed to test their understanding of the principles involved.^11201120 Hayward {Day200/147:16}-{Day200/148:3}. The intention was to deliver the first computer-based training package in 2011.^11211121 Hayward {Day200/154:24}-{Day200/155:2}.

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¶79.25 The two-year programme did not comply with national guidance because it did not provide for annual fire survival guidance training delivered jointly by a fire control officer and a fire safety officer and did not include an annual role-play exercise. Although the Lakanal House Board formally approved it,^11221122 Brown {Day207/64:7-17}. there was no discussion at its meetings about whether the programme complied with national guidance.^11231123 Minutes of Lakanal House Board Meeting of 22 June 2010 {LFB00055208}; Minutes of Lakanal House Board meeting of 15 September 2010 {LFB00055192}; Minutes of Lakanal House Board Meeting of 8 November 2010 {LFB00055213}; Hayward {Day200/148:19-23}. At the meeting of the Lakanal House Board on 8 November 2010 action 12 was marked as "complete" because a system for delivering training had been established.^11241124 Minutes of Lakanal House Board Meeting of 8 November 2010 {LFB00055213/6}; Brown {Day207/64:1}- {Day207/65:8}. The Board did not continue to exercise oversight of the action despite the continuing nature of refresher training.

¶79.26 AC Brown thought that the biennial programme was a reasonable and efficient approach to training.^11251125 Brown {Day207/61:16}-{Day207/63:4}. He regarded delivering a full day of classroom training every year as a significant workload for a team that was already delivering other training.^11261126 Brown {Day207/62:8-21}. SOM Smith, on the other hand, did not think that a two-year training programme was appropriate and expressed her concerns to Scott Hayward and Lindsay Turner.^11271127 Smith {Day204/21:8-25}. POM Hayward said that a two-year programme had been adopted to allow other training to take place.^11281128 Hayward {Day200/149:3-11}. SOM Smith also pointed to the need for CROs to continue working while training was being provided.^11291129 Smith {Day204/23:20-24}.

¶79.27 Although we understand the difficulty of making CROs available for training, we do not think that it was sufficient to justify a two-year programme, given the weaknesses in providing fire survival guidance exposed by the Lakanal House fire and the fact that SM Kelly's audit had revealed the need to strengthen the role-play element of training. The training required would take one day and SOM Smith accepted that it was possible to arrange shift patterns in a way that would allow training when staff were off duty, as had been done with training for the Vision system.^11301130 Smith {Day204/25:4-12}. In the circumstances, we do not think that POM Hayward was right to conclude that a one-day training course each year would exclude other important training.

¶79.28 Finally, in the Lakanal Control report the LFB told the coroner that a two-year refresher training plan, which had an active role-play element to it, had been put in place.^11311131 Lakanal Control Report {HOM00001124/53}. However, by the time of the inquests in January 2013, it is clear that training of the kind that had been described was not in fact being provided. The LFB failed to notify the coroner that, in this respect at least, its intentions had not been realised, and no satisfactory explanation was given for that failure.

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¶79.29 In the event, refresher training on fire survival guidance was not delivered as intended. In 2011 the computer-based training package that it had been intended to deliver to CROs that year was still under development and was therefore unavailable.^11321132 Hayward {Day200/154:24}-{Day200/155:5}. As a result, POM Hayward approved the use by staff of the materials they had used in their initial fire survival guidance training.^11331133 Email from Scott Hayward to Lindsay Turner and Joanne Stibbards dated 31 May 2011 regarding Fire Survival Refresher Package {LFB00058087/1}; Hayward {Day200/180:15-25}.,^11341134 Hayward {Day200/154:24}-{Day200/155:25}; Hayward {LFB00055191/10} page 10, paragraph 21.8. The course was not led by trainers but was designed for CROs to study alone for about an hour to an hour and a half.^11351135 Hayward {Day200/155:6}-{Day200/157:15. It is likely that staff undertook the training on the watch during the four-hour rest period that became available after the shift patterns had changed.^11361136 Hayward {Day200/167:6-16}; FSG Training Record {LFB00041763}. The training plan for 2011 did not include active role-play, but CROs used call scripts and the RIF^11371137 Hayward {Day200/162:17}-{Day200/163:3}; Hayward {LFB00055191/26} page 26, paragraph 75; Hayward {Day200/184:14-17}. to confirm their understanding of procedures.^11381138 Hayward {Day200/162:10-16}. However, the exercise did not involve active role-play and the performances of the CROs were not assessed.^11391139 Hayward {Day200/162:17}-{Day200/163:3}; Hayward {LFB00055191/26} page 26, paragraph 75.

¶79.30 POM Hayward provided us with information about the number of CROs who had undergone fire survival guidance training between 2011 and 2017.^11401140 Hayward {LFB00055191/26} page 26, paragraph 74. He accepted that the figures might not be entirely accurate and AC George and AC Brown both cast doubt on their reliability. However, we think they provide a helpful indication of the numbers who had received fire survival guidance training during that time. The evidence indicates that 94% of the available control room staff received training in 2011,^11411141 Hayward {LFB00055191/26} page 26, paragraph 75. but when compared to later years the figure looks very high. POM Hayward could not explain it and we have some doubt about its accuracy.^11421142 Hayward {Day200/168:16-22}.

¶79.31 In 2012 CROs should have received a full day of fire survival guidance refresher training, including active role-play.^11431143 Hayward {Day200/171:15-17}. However, in that year the provision of training was much reduced. The role-play element of the fire survival guidance refresher training was changed to a passive exercise in which staff were required to listen to pre-recorded simulated fire survival guidance calls and discuss their positive and negative aspects.^11441144 Hayward {LFB00086213/14} page 14, paragraph 73; Email from Chris Sharp to Natalie Bagnelle, Vic Bagnelle, Sam Coaker, Scott Hayward, David Hughes, Steve Perry, Joanne Stibbards and Lindsay Turner dated 27 September 2012 {LFB00060696}. Either SOM Turner or SOM Bagnelle (it is not clear which) approved the change,^11451145 Hayward {LFB00086213/14} page 14, paragraph 73; Hayward {LFB00055191/24} page 24, paragraph 69; Hayward {Day200/190:6-11}. which was made in response to indications from staff that they felt very uncomfortable taking part in that element of the training.^11461146 Hayward {LFB00086213/14} page 14, paragraph 74; Email from Victor Bagnelle to Scott Hayward regarding Control Report {LFB00122840/1}. POM Hayward told us that he had not been consulted about the change and had not been aware that it had happened. He did not think that embarrassment was a sufficient reason for abandoning role-play, which he thought was an effective way of confirming CROs' understanding of the training.^11471147 Hayward {Day200/192:8-15}. This episode only goes to reinforce our criticisms of POM Hayward's management of the control room.

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¶79.32 At about the same time, the length of fire survival guidance refresher training was reduced.^11481148 Hayward {LFB00055191/24} page 24, paragraph 70. Instead of a whole day off the watch, the training took place during a four-hour short shift.^11491149 Hayward {LFB00055191/24} page 24, paragraph 70. The decision to reduce the length of the training was made by SOM Bagnelle without reference to POM Hayward.^11501150 Hayward {Day200/195:24}-{Day200/196:6}. POM Hayward said that the same training had been delivered but that by reducing the number of breaks and the number of staff involved, it could be condensed into a four-hour period.^11511151 Hayward {Day200/196:10-24}. However, that ignores the fact that the content was much reduced because there was only a brief discussion about difficult calls, as opposed to the one and half hour discussion originally included, and the element of active role-play was removed.^11521152 Hayward {LFB00055191/24-25} pages 24-25, paragraph 71. Passive role-play reduced the time it took to complete that part of the training because a group discussion was substituted for individual participation.^11531153 Hayward {Day200/197:4-10}.

¶79.33 In addition, fire safety officers were withdrawn from delivering the training. From 2012 onwards, fire survival guidance training for control room staff was intermittent and did not comply with national guidance. As a result, the refresher training that had been approved by the Lakanal House Board was not implemented.

¶79.34 POM Hayward said that he had become aware of the change to the training only during the Lakanal House inquests,^11541154 Hayward {Day200/195:24}-{Day200/196:6}; Hayward {LFB00055191/24} page 24, paragraphs 69-71. but the evidence suggests that AOM Sharp had told the control room senior management team, including POM Hayward, about the change to the fire survival guidance role-play in September 2012.^11551155 Email from Chris Sharp to Natalie Bagnelle, Vic Bagnelle, Sam Coaker, Scott Hayward, David Hughes, Steve Perry, Joanne Stibbards and Lindsay Turner dated 27 September 2012 {LFB00060696}. POM Hayward did not recall either having received her message or having discussed the proposal with AOM Sharp.^11561156 Hayward {Day200/218:1}-{Day200/219:5}.

¶79.35 When on 5 February 2013 POM Hayward discovered that the duration and content of the fire survival guidance training had been changed, he asked SOM Bagnelle, who was by then the SOM in charge of training, how it had come about.^11571157 Hayward {LFB00055191/24} page 24, paragraph 69; Email from Thomas Davies to Scott Hayward dated 5 February 2013 {LFB00060872/4}; Email from Scott Hayward to Vic Bagnelle dated 7 February 2013 {LFB00039935/1-2}; Bagnelle {LFB00122821/12} page 12, paragraphs 41-43. AOM Sharp and SOM Bagnelle told him that the reason for the change was to prevent staff from being taken off duty^11581158 Hayward {LFB00055191/24-25} pages 24-25, paragraph 71. and because there were not enough staff on duty between 08.00 and 14.00 to allow training to take place before the afternoon.^11591159 Email chain with Scott Hayward, Chris Sharp, Nicola O'Shea and Vic Bagnelle dated 6 February 2013 {LFB00122840/3-4}. POM Hayward said that nobody had told him that staffing difficulties prevented training taking place for a whole day.^11601160 Hayward {Day200/205:19}-{Day200/206:14}. He had been aware generally that there were staff shortages and had understood that there were often no staff available to carry out training,^11611161 Hayward {Day200/205:19}-{Day200/206:14}. but said he had never thought that training might need to be cut back as a result.

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¶79.36 On or about 7 February 2013, during the course of the Lakanal House inquests, POM Hayward spoke to AC Brown about the changes to fire survival guidance training.^11621162 Email from Scott Hayward to Vic Bagnelle dated 7 February 2013 {LFB00039935/1}; Hayward {Day200/208:9}- {Day200/209:19}. AC Brown told him that he was very unhappy about the changes, particularly as the Lakanal Control report had said that the LFB was carrying out a full day's training with active role-play.^11631163 Email from Scott Hayward to Vic Bagnelle dated 7 February 2013 {LFB00039935/1}. Although AC Brown intended to provide the coroner with information about the changes to fire survival guidance training,^11641164 Brown {Day207/82:4}-{Day207/83:3}. it is unclear what, if anything, was done.

¶79.37 AC Brown expected the biennial plan for fire survival guidance training to be reinstated with a full day of training every other year and a half day of computer-based training in alternate years.^11651165 Email from Dave Brown to Scott Hayward dated 9 February 2013 {LFB00060872}; Brown {Day207/78:7-14}. On the instructions of AC Brown, POM Hayward directed SOM Bagnelle to ensure that the active role-play was reinstated in accordance with SM Kelly's recommendation in August 2010.^11661166 Hayward {LFB00055191/24} page 24, paragraph 69; Bagnelle {LFB00122821/12} page 12, paragraphs 41-43; Email from Scott Hayward to Vic Bagnelle dated 7 February 2013 {LFB00122840/2}; Hayward {Day200/209:16-25}; Brown {Day207/78:7-14}. However, POM Hayward did not instruct SOM Bagnelle to change the duration of training from four hours to a full day as AC Brown had expected.^11671167 Hayward {LFB00055191/24} page 24, paragraph 69; Bagnelle {LFB00122821/12} page 12, paragraphs 41-43; Email from Scott Hayward to Vic Bagnelle dated 7 February 2013 {LFB00122840/2}; Hayward {Day200/209:16-25}; Brown {Day207/78:7-14}.

¶79.38 Despite AC Brown's instruction, active role-play was not reinstated.^11681168 Hayward {LFB00055191/26-29} pages 26-29, paragraphs 67.5 and 69; Hayward {Day201/15:20}-{Day202/16:8}. The episode illustrates our broader concerns about the LFB's management systems at the time. POM Hayward should have been made aware of the change to the role-play exercise.^11691169 Hayward {Day200/188:7-25}. Equally, once he had become aware of that change, it should have caused him to question the effectiveness of his supervision and monitoring of training.^11701170 Hayward {Day200/190:22}-{Day200/191:10}. Had he done so, the failure to reinstate an element of active role-play in fire survival guidance training might have been identified and cured in time to make a significant difference to the performance of the control room in response to the Grenfell Tower fire.

¶79.39 In early 2012, AC Brown and AC Turek decided that fire safety officers did not need to deliver fire survival guidance refresher training.^11711171 Brown {LFB00032166/21} page 21, paragraph 65; Brown {LFB00084020/10} page 10, paragraph 20; Brown {Day207/43:21-24}. Email chain between Scott Hayward, Lindsay Turner and Joanne Stibbards dated 22 February 2012 {LFB00058256/1-2}. The decision was inconsistent with both national guidance (FSC 10-93) and pre-inquest action 8.^11721172 This was accepted by AC Brown. Brown {LFB00084020/10} page 10, paragraph 20. AC Brown explained that the decision coincided with a restructuring of the brigade (including the Fire Safety department)^11731173 Brown {Day207/43:21-24}; Brown {Day207/48:25} – {Day207/49:8}; Brown {LFB00032166/21} page 21, paragraph 65. and reflected the view that using fire safety officers to provide training on fire survival guidance was an unnecessary use of resources. There was a dedicated control room training team to provide that training and fire safety officers could be better employed inspecting premises.^11741174 Brown {LFB00032166/21} page 21, paragraph 65.

¶79.40 AC Brown and AC Turek were satisfied that the fire safety officers had had sufficient involvement in the design and content of the new fire survival guidance training and they continued to be involved in the training of new control room staff.^11751175 Brown {LFB00032166/21} page 21, paragraph 65; Brown {LFB00084020/10} page 10, paragraph 20. AC Brown also appears to have thought that as fire safety officers had been involved in a full day of fire survival guidance training in 2010, that was sufficient.^11761176 Brown {Day207/46:13-21}. However, national guidance required the contribution of a fire safety officer to each refresher training session and the longer CROs remained in their roles, the greater the importance of refresher training. At all events, the training team subsequently provided training without any contribution from a fire safety officer.^11771177 Brown {LFB00032166/21} page 21, paragraph 65. AC Brown may have had confidence in the competence of the trainers, as he said he did, but we find it difficult to identify any steps that he had taken to satisfy himself of their ability to teach matters relating to fire safety.^11781178 Brown {LFB00084020/10} page 10, paragraph 20. Although AC Brown said that he had relied on his personal knowledge of the members of the team and information obtained from senior managers, POM Hayward did not remember ever having discussed the withdrawal of fire safety officers with him.^11791179 Brown {Day207/47:25}-{Day207/48:18}; Hayward {Day201/8:15}-{Day201/9:7}.

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¶79.41 Between 2013 and the Grenfell Tower fire, existing control room staff did not receive the full day of fire survival guidance refresher training that had been planned and approved by the Lakanal House Board and promised to the coroner.^11801180 Hayward {LFB00055191/26-29} pages 26-29, paragraphs 77 to 78.4; Hayward {Day201/16:6-8}; Smith {Day204/87:19}-{Day204/88:4}. Some of the CROs were given training relevant to fire survival guidance, such as reviewing the RIF for Operators. They were also given some informal training and were involved in command unit training exercises, but none of that reflected the training that national guidance recommended.^11811181 Hayward {LFB00055191/26-29} pages 26-29, paragraphs 77 to 78.4; Hayward {Day201/16:6-8}; Joanne Smith {LFB00121219/23} page 23, paragraph 60; Smith {Day204/110:23}-{Day204/111:16}.

¶79.42 The command unit training exercises involved units attending the control room at Merton and carrying out exercises to test activities such as two-way communication between the control room and the incident ground.^11821182 Hayward {LFB00055191/28} page 28, paragraph 78.2.2. The exercises had an element of role-play because CROs were required to take calls on the mobilising system and ensure that the information was passed to the command unit.^11831183 Smith {Day204/123:7-20}; Brown {Day207/109:10-24}. However, the training was not designed for control room staff and those who took part did little more than help train the crews of the command units.^11841184 Hayward {LFB00055191/28} page 28, paragraph 78.2.2; Smith {Day204/123:7-25}; {Day204/132:1-9}; Minutes of Operational Review Team Meeting on 11 January 2017 {LFB00040541/2}; Brown {Day207/109:10-24}.

¶79.43 Some computer-based training was available, but not all CROs were able to take advantage of it due to technical problems that had not been resolved by the time of the Grenfell Tower fire.^11851185 Smith {LFB00121219/24} page 24, paragraph 62; Smith {Day204/113:23}-{Day204/116:12}. Moreover, the content of the fire survival guidance presentations used in the computer-based training was out of date, not having changed between 2013 and 2017.^11861186 Hayward {LFB00055191/29} page 29, paragraph 78.3; Hayward {LFB00086213/7} page 7, paragraph 35; Hayward {Day201/80:13}-{Day201/84:8}. As POM Hayward accepted, the system for delivering them deteriorated as the presentations improved.^11871187 Hayward {Day200/110:24-25}. The Operational Support Team did not create an alternative training opportunity for CROs who could not obtain access to computer-based training.^11881188 Smith {Day204/116:17-23}. SOM Smith's preference was to introduce a computer-based training package because of the shortage of staff, particularly due to the introduction of Vision,^11891189 Smith {Day204/117:11-22}. but that made little sense in the face of the long-standing technical problems. Sessions led by trainers without the need for computer resources had been tried previously with only partial success. AC Brown said he had been taken by surprise to discover in 2016 that computer-based training had still not been implemented, but he refused to accept that the failure to implement the recommendation made in 2010 to introduce computer-based training for all control room staff on fire survival guidance reflected a chronic failure of management.^11901190 Brown {Day207/105:15}-{Day207/106:25}.

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¶79.44 Assuming that the statistics produced by POM Hayward are broadly correct, the number of control room staff involved in fire survival guidance training, such as it was, between 2013 and 2017 was strikingly low. In 2013 and 2014, only 28% and 29% respectively of control room staff received any form of training.^11911191 Hayward {LFB00055191/26} page 26, paragraph 74. In 2015, no fire survival guidance training was carried out at all because of the introduction of Vision.^11921192 Hayward {LFB00055191/26} page 26, paragraph 74. In 2016, only 46% of control room staff received fire survival guidance training, and by the time of the Grenfell Tower fire in 2017, no fire survival guidance training at all had been delivered to any existing control room staff member that year.^11931193 Hayward {LFB00055191/26-29} pages 26-29, paragraph 74 and paragraph 78.4; Smith {Day204/91:13-21}.

¶79.45 POM Hayward explained that in 2013 the LFB's priority had been to ensure that its new mobilising system, Vision, was working, as they had initially been given less than 14 months to deliver it.^11941194 Hayward {Day201/16:9-22}. We shall return to Vision, but it is sufficient for present purposes to note that its introduction was a significant undertaking, which diverted attention from chronic problems affecting the management of fire survival guidance calls and related training. The control room also suffered from significant staffing problems and underwent restructuring between 2009 and 2017.^11951195 Hayward {LFB00055191/30} page 30, paragraph 79; Hayward {Day201/17:12-18}. During that period, none of the senior control room managers sought to take stock of training needs or take steps to ensure that all necessary training was given.^11961196 Hayward {LFB00055191/30} page 30, paragraph 79; Hayward {Day201/17:12-18}.

¶79.46 In January 2015, when SOM Smith returned from her secondment to the Chief Fire Officers Association, she assumed responsibility for the Operational Support Team and control room training.^11971197 Smith {LFB00121219/6} page 6, paragraph 15. She asked for a list of CROs who had fire survival guidance training outstanding. She thought she must have received one, but had no specific recollection of it.^11981198 Smith {LFB00121219/22} page 22, paragraph 56; Smith {Day204/79:22}–{Day204/80:15}. We were not shown any such list.

¶79.47 On returning to her position in the control room SOM Smith had a handover discussion with SOM Bagnelle, but it did not touch on the numbers of control room staff who had received fire survival guidance training during her time on secondment (i.e., from September 2012 to January 2015).^11991199 Smith {Day204/79:9-20}. She was not told that the number of staff receiving fire survival guidance training had collapsed in 2013 and 2014,^12001200 Smith {Day204/78:3-18}. nor was she told about the changes that had been made to the training or that active role-play had been changed to passive role-play in 2012.^12011201 Smith {Day204/81:13}-{Day204/82:10}. She was unaware that in 2013 and 2014 fire survival guidance training had been limited to CROs reviewing presentations and being involved in command unit training sessions.^12021202 Smith {Day204/83:1-6}. She was told that fire survival guidance training had been reduced from a full day to four hours,^12031203 Smith {Day204/81:17-20}. but she did not ask why training had not been delivered as originally planned. She assumed that appropriate training had been provided while she had been away.^12041204 Smith {Day204/84:1-15}.

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¶79.48 In 2015, SOM Smith discovered that there were not enough trainers to provide fire survival guidance training in the way that had been intended in 2011.^12051205 Smith {LFB00121219/25} page 25, paragraph 68; Smith {Day204/96:7-21}. Although she asked POM Hayward to make additional resources available to the Operational Support Team and two or three members of staff were seconded from the watch, they were required for training on Vision and were not available for fire survival guidance training.^12061206 Smith {Day204/96:22}-{Day204/98:9}.

¶79.49 From the latter part of 2016, SOM Smith monitored fire survival guidance training because she was trying to revise the computer-based training packages and resolve the problems with access.^12071207 Smith {Day204/91:22}-{Day204/92:7}. It is not clear why she had not been doing that from the time she returned in January 2015. During 2017, she worked with the training team to create a new fire survival guidance refresher training package which was due to be delivered in September 2017,^12081208 Smith {Day204/92:4-7}. but it did not lead to an increase in the number of CROs being trained in fire survival guidance or to any improvement in the content of the training.

¶79.50 Although the LFB could not reasonably have foreseen the considerable difficulties that were encountered in implementing Vision, that does not excuse the failure of the senior officers responsible for the operation of the control room, namely, SOM Smith, POM Hayward and AC Brown, to keep fire survival guidance training under close review and, in particular, to decide how to deliver such training once it became clear that the problems flowing from the introduction of Vision were dominating the control room's attention, time and resources.

¶79.51 Despite the failure to deliver fire survival guidance refresher training, neither POM Hayward nor AC Brown informed the Lakanal House Board, the Lakanal House Working Group or the co-ordination board that training had fallen far short of that which had been approved and promised to the coroner.^12091209 Brown {Day201/21:22}-{Day201/22:4}; Hayward {Day201/73:12-25}. It seems that no one in senior management was aware of the true scale of the failure to provide fire survival guidance training between 2012 and 2017. For example, in January 2013, AC Brown told AC Dexter that 94 out of 104 staff had been given fire survival guidance refresher training.^12101210 Draft LFB Report 'Review of the Lakanal Action Plan' {LFB00085854/14} and {LFB00085854/26}. See comment "d10". That figure, which amounted to 90.4% of staff, was far in excess of the figure of 61% provided by POM Hayward in his witness statement,^12111211 Draft LFB Report 'Review of the Lakanal Action Plan' {LFB00085854/14} and {LFB00085854/26}. See comment "d10"; Hayward {LFB00055191/25} page 25, paragraph 74. but although the basis of his figure of 90.4% could not be identified, AC Brown remained confident that training had been taking place. He thought that any apparent shortfall in numbers was attributable to poor record-keeping.^12121212 Brown {Day207/72:14-22}; Brown {LFB00032166/21} page 21, paragraph 66.

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¶79.52 In his review of the Lakanal pre-inquest actions in June 2013, AC Chandler said that the refresher training programme had been put in place and that no further action was required.^12131213 Email from Chandler to Brown dated 28 June 2013 regarding Lakanal Audit {LFB00060701/1}. The Chandler review was sent to AC Brown and POM Hayward for information,^12141214 Email from Chandler to Brown dated 28 June 2013 regarding Lakanal Audit {LFB00060701/1}. but POM Hayward did not correct him and provide the true picture.^12151215 Email from Chandler to Brown dated 28 June 2013 regarding Lakanal Audit {LFB00060701/1}; Hayward {Day201/29:8-19}.

¶79.53 In 2014, Adrian Bevan, an LFB health and safety manager,^12161216 Hayward {Day201/30:1-10}. asked for information from AC Brown about control room training to enable him to answer a request from the Health and Safety Executive for information on control room practices, procedures and training following the Lakanal House inquests.^12171217 Email from Brown to Bevan copied to Scott Hayward, Philip Evans and Danielle Cotton dated 3 July 2014 regarding HSE info – control training {LFB00037428/1-2}. On 3 July 2014, AC Brown told Mr Bevan that between February 2011 and June 2014 277 individual fire survival guidance training sessions had been delivered by senior control room officers in addition to the regular watch training sessions.^12181218 Email from Brown to Bevan copied to Scott Hayward, Philip Evans and Danielle Cotton dated 3 July 2014 regarding HSE info – control training {LFB00037428/2}. However, although the source of that particular statistic is not clear,^12191219 Hayward {Day201/31:8}-{Day201/32:16}. it is plain that POM Hayward did not tell AC Brown that by July 2014 fire survival guidance refresher training was being given to less than a quarter of control room staff.^12201220 Hayward {Day201/35:11-22}. It is also notable that the Health and Safety Executive was not told that since 2012 fire survival guidance training had not met national guidance in some material respects.^12211221 Email from Brown to Bevan copied to Scott Hayward, Philip Evans and Danielle Cotton dated 3 July 2014 regarding HSE info – control training {LFB00037428/1-2}.

¶79.54 AC Brown accepted that he did not know how many CROs were actually being trained in fire survival guidance at the time, but he said that after his discussions with POM Hayward and the CROs he had been left with the impression that fire survival guidance refresher training was being delivered where practically possible.^12221222 Brown {Day207/92:1-14}; Brown {LFB00084020/13} page 13, paragraph 29. However, at no stage did POM Hayward ever provide AC Brown with a reliable record of fire survival guidance training, which would have enabled it to be effectively monitored, and AC Brown never asked for one.^12231223 Hayward {Day201/55:6-24}. Nevertheless, AC Brown was aware of periods during which fire survival guidance refresher training was not being provided as had been agreed – for example, between 2015 and 2017, when the training of control room staff concentrated on the Vision mobilising system.^12241224 Brown {LFB00084020/13} page 13, paragraph 30; Hayward {Day201/55:22}-{Day201/57:14}; Brown {Day207/94:15- 20}. Although he accepted in the light of the Lakanal House fire and the findings of the Mayor's Office for Policing and Crime^12251225 Email chain between Scott Hayward and Karen Mason dated 17-18 November 2014 regarding Brigade Control Audit {LFB00030108}; Hayward {Day201/42:1-4}; Internal Audit – Progress Report Quarter 3 2014/2015 dated 9 March 2015 {LFB00044640/1}. (to which we refer later) that fire survival guidance training was of critical importance, AC Brown sought to justify its absence on the grounds that all available resources had been taken up by the need to train staff on Vision. He maintained that the quality of the control room's response to fire survival guidance calls had been kept under continuous review.^12261226 Brown {Day207/94:10}-{Day207/95:16}.

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¶79.55 The introduction of Vision clearly made great demands on the resources available for training, but the fact remains that there was a chronic, systemic failure to ensure that effective fire survival guidance refresher training was consistently provided to all control room staff. Such quality assurance as existed had signally failed to identify the fact that, from 2012 onwards, the number of CROs receiving such training was low. There was a consistent failure to comply with national guidance or with the assurances given to the coroner.

¶79.56 In July 2016, at the instigation of AC Brown, AC George carried out a review of the control room, but did not identify fire survival guidance training as an area of concern.^12271227 Review of Brigade Control Report dated July 2016 {LFB00032826}; George {LFB00083884/11} page 11, paragraph 34; George {Day205/55:6}-{Day205/57:6}. It had not been included in his terms of reference,^12281228 Review of Brigade Control Terms of Reference {LFB00032827/1}. which had been informed by discussions with staff between September and November 2015.^12291229 Review of Brigade Control – the issues raised by staff prior to the review commencing {LFB00032831/3}; George {Day205/36:13-20}; George {LFB00032823/4} page 4, paragraphs 12 and 13. In these discussions, CROs had not expressed concern about the lack of fire survival guidance training^12301230 George {Day205/55:6-14}. or about their readiness to handle fire survival guidance calls.^12311231 George {Day205/57:3-6}. AC George himself was not concerned about fire survival guidance training because when he started his review AOM Sharp had given him a schedule of planned training.^12321232 George {Day205/65:4-8}. He was not aware of the changes that had been made to the fire survival guidance refresher training by the Lakanal House Board;^12331233 George {Day205/65:9}-{Day205/67:3}. nor was he aware that in 2015 and 2016 training on Vision had, to say the least, placed severe restrictions on it.^12341234 George {Day205/80:8-19}.

¶79.57 AC George was confident that fire survival guidance training was taking place because he witnessed it in 2016 and early 2017^12351235 George {Day205/151:6-25}. and he was assured by AOM Sharp, POM Hayward and SOM Smith that it was being delivered.^12361236 George {Day205/151:6-25}; George {Day205/153:16-24}. However, the training he witnessed was command unit training, which was not aimed at CROs, and he did not attend the training sessions himself, having simply seen from his office window a number of people and command units gathered outside.^12371237 George {Day205/151:20}-{Day205/153:5}. AC George did not examine the content of the fire survival guidance training packages and he had no direct knowledge of the extent to which they had been delivered in 2016 and 2017.^12381238 George {LFB00032823/8} page 8, paragraph 31; George {LFB00083884/14} page 14, paragraph 49.

¶79.58 In the report of his review that he presented to the Corporate Management Board in February 2017 AC George said that additional familiarisation training on fire survival guidance had been given to all staff.^12391239 CMB report on Review of Brigade of Control for CMB, dated 15 February 2017 {LFB00032824/6}. Insofar as that gave the impression that additional fire survival guidance training had been provided to all CROs since his first report in July 2016,^12401240 Hayward {Day201/75:2}-{Day201/76:3}. it was misleading. AC George accepted that, as head of the Operational Response department and, from March 2017, Director of Operations, he should have been aware of the consistent failure to provide fire survival guidance training to CROs in 2016 and 2017^12411241 George {Day205/165:9-22}. and that that failure was both chronic and systemic.^12421242 George {Day205/165:9-22}. He said that POM Hayward and SOM Smith had regularly told him about the problems being encountered with Vision, which had crowded out other training,^12431243 George {Day205/165:23}-{Day205/166:10}; {Day205/169:23}-{Day205/170:2}. but there is no evidence that he made any effective effort to ensure that regular and structured fire survival guidance training was provided.

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¶79.59 The importance of fire survival guidance refresher training cannot be over-stated. The senior officers responsible for the control room plainly understood the need to give priority to such training, particularly because of the weaknesses in handling emergency calls exposed by the Lakanal House fire in 2009. At that time no structured or regular fire survival guidance refresher training was being conducted by the LFB and at the time of the Grenfell Tower fire in June 2017 that remained the case. The failure to provide CROs with regular fire survival guidance refresher training is undoubtedly a serious indictment of the LFB. Even allowing for the difficulties resulting from the introduction of Vision, there is no justification for such a longstanding failure to address a vital element of the control room's work that was well known to senior management.

¶79.60 Even though the Lakanal House fire demonstrated the real danger to life posed by the failure to provide effective fire survival guidance training, the fact is that none of senior officers responsible for the operation of the control room ever tackled the challenge of providing the necessary training with the seriousness or dedication it deserved.

Monitoring the quality of responses to fire survival guidance calls

¶79.61 The need to monitor and manage the performance of CROs, particularly in relation to handling fire survival guidance calls, was identified in the Lakanal Control Report, which recommended the introduction of a policy identifying the standards that staff were expected to reach and how performance would be assessed and monitored, particularly in relation to calls where fire survival guidance was given.^12441244 Lakanal Control Report {HOM00001124/53}; Lakanal Control Report {HOM00001124/31} paragraphs 161-163. That recommendation was said to have been implemented by senior managers' undertaking a review of all high-rise or fire survival guidance calls and amending the RIFs and training packages to ensure that they reflected FSC10-93 and 'Keeping People Safe'.^12451245 Lakanal Control Report {HOM00001124/53}; Lakanal Control Report {HOM00001124/31} paragraphs 161-163. Although it did not give the impression that a new policy of the kind envisaged by the recommendation had been introduced, the statement was misleading insofar as it gave the impression that the omissions and flaws that we identified earlier had been put right.^12461246 Brown {Day207/28:5-20}. AC Brown explained the failure to introduce a policy of the kind contemplated by the recommendation by the fact that those with responsibility for the control room had revised the existing materials in a way that met the substance of the recommendation.^12471247 Brown {Day207/28:21}-{Day207/29:5}.

¶79.62 In late 2009, after the Lakanal House fire, a quality assurance system known as 'Call Coach' was introduced. At the suggestion of SOM Smith it was supplemented by a review of fire survival guidance calls to check whether the training introduced after the Lakanal House fire had been effective.^12481248 Smith {Day202/49:11-15}.

¶79.63 Call Coach was a structured system of reviewing and learning from the way in which CROs handled calls coming into the control room. In summary, a supervisor would choose at random from a short list of three calls at least one call a month for each call-handler and one call every three months for each team leader.^12491249 Call Coach Management Note {LFB00121231/6}; Smith {Day202/31:10}-{Day202/32:23}. The supervisor would listen to the call and assess the call‑handler using a prescribed standard which included a scoring system.^12501250 Call Coach Management Note {LFB00121231/2-3}; Smith {Day202/34:1-23}. After the assessment, a meeting would be held between the call-handler (or team leader) and the supervisor to discuss and review the assessment.^12511251 Call Coach Management Note {LFB00121231/2-3}. The supervisor assessing the call was then responsible for coaching the call-handler or team leader and monitoring the results obtained from successive assessments.^12521252 Call Coach Management Note {LFB00121231/4}. SOM Smith was responsible for introducing the system,^12531253 Smith {LFB00121219/7} page 7, paragraph 17. which had been operated monthly between 2010 and November 2015.^12541254 Smith {Day202/35:10-14}; {Day202/45:10}-{Day202/47:11}.

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¶79.64 However, fire survival guidance calls were not included in the Call Coach assessments.^12551255 Smith {Day202/38:1-18}; The detail required to assess a fire survival guidance call was not included in the call‑handling excellence standard, Call Coach Management Note {LFB00121231} Appendix B; Smith {Day202/38:11- 18}. The decision to exclude them appears to have flowed from an agreement between DAC Payton, then Deputy Assistant Commissioner for Control and Mobilising, and the trade unions.^12561256 Smith {Day202/39:4-13}; {Day202/59:15-21}. The reason for any such agreement is unclear, but it meant that supervisors did not have an opportunity to assess the quality of the response to fire survival guidance calls except when they supported a CRO handling such a call or during the fire survival guidance review process described below.^12571257 Smith {Day202/38:19-22}. Since assessment was not the purpose of the supervisor's involvement, supporting a CRO during a fire survival guidance call did not amount to an effective form of monitoring and managing performance.

¶79.65 Call Coach provided supervisors with a degree of reassurance about CROs' ability to handle calls, but POM Hayward did not think it was a particularly good system.^12581258 Hayward {Day199/56:22}-{Day199/57:17}; see SOM Smith's comments on the draft training audit report prepared by SM Kelly {LFB00109082/9}; Smith {Day202/41:25}-{Day202/43:13}. However, partly because of the money that had been spent acquiring it and partly because of the time spent bringing it into operation, POM Hayward was not inclined to look into other ways of assessing those skills.^12591259 Hayward {Day199/58:1-10}. SOM Smith was not aware of Operational Support Team's analysis of the CROs' performance and AC Brown did not ask her to consider the outcome of reviews.^12601260 Smith {Day202/37:3-16}; Brown {Day207/27:9-17}.

¶79.66 In November 2015, when Vision was introduced, Call Coach became obsolete and was replaced by a new system called Neptune Intelligence Computer Engineering (Neptune).^12611261 Hayward {LFB00055191/39} page 39, paragraph 96. However, Neptune was not used to review call-handling by CROs and no formal arrangements were made to make up for the loss of Call Coach.^12621262 Hayward {LFB00055191/39} page 39, paragraph 97; Hayward {Day199/59:15-19}. No quality assurance review process was therefore in place to monitor CROs' call-handling in the years leading up to the Grenfell Tower fire.^12631263 Smith {Day202/47:10-12}.

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¶79.67 Following an incident, however, it was standard practice for senior managers on duty to review fire survival guidance calls.^12641264 Smith {Day202/50:15-25}. There was no policy or guidance document available to direct their reviews so they relied on their own experience and training.^12651265 Smith {Day203/9:2-21}. A description of the circumstances in which each call had been made and a summary of its contents were recorded in an electronic database, but the database did not include any comments critical of the call-handler.^12661266 Smith {Day203/10:13-19}; FSG Database {LFB00031757}. Although SOM Smith said that the database was of some value, for example, in identifying causes of concern or examples of good practice, the process did not amount to a systematic appraisal of the performance of CROs.^12671267 Smith {Day203/11:6-14}. There was no evidence of how the review was used or how it contributed to their training or development.^12681268 The FSG Database did not record any lessons to be learnt or systems to be reviewed {LFB00031757}.

¶79.68 In addition to the review carried out by senior managers, SOM Smith reviewed every fire survival guidance call and every call from a high-rise building on the system^12691269 Smith {LFB00121219/8} page 8, paragraph 18; Smith {Day202/50:13}-{Day202/51:12} and {Day202/52:20-23}. to check that the correct advice had been given in accordance with FSC 10-93, and later, PN539.^12701270 Smith {LFB00121219/8} page 8, paragraph 18; Smith {Day202/54:4}-{Day202/55:6}; {Day202/54:7}-{Day202/57:6}. If deficiencies were found, the CRO's line manager would take the necessary action.^12711271 Smith {LFB00121219/8} page 8, paragraph 18; Hayward {Day199/64:16}-{Day199/65:5}; Smith {Day202/49:16-20}. POM Hayward said that he and SOM Adam Crinion had also listened to the calls.^12721272 Hayward {Day199/62:21-25}; SOM Smith also thought that Peter Suarez, Control Commander in the Technical Support Group, also listened to the call {Day202/52:15-19}. However, the findings of SOM Smith's review were not recorded anywhere and we have seen only a few of the reports that were provided to OMs and CROs about the handling of fire survival guidance calls.^12731273 Hayward {Day199/63:22-24} and {Day199/65:10-12}. The only email about feedback after a fire survival guidance call review provided to the Inquiry was: Email from Joanne Stibbards to Keith Diamond dated 22 October 2011 {LFB00121235}. Those that we have seen are all positive and do not identify any mistakes in the way that calls were handled.^12741274 Email from Joanne Stibbards to Keith Diamond dated 22 October 2011 {LFB00121235}.

¶79.69 Although SOM Smith told us that the obligation to review fire survival guidance calls fell to the person on duty at the time a call was received,^12751275 Smith {Day202/62:21-24}. SOM Keith Diamond and SOM Bagnelle assumed that task after she had been seconded to the Chief Fire Officers Association in September 2012.^12761276 Hayward {Day199/64:3-7}.

¶79.70 When SOM Smith returned to the LFB in January 2015, she did not ask SOM Diamond or SOM Bagnelle for a report on the fire survival guidance reviews they had undertaken in her absence,^12771277 Smith {Day202/64:10-24}. but she did resume her review of all fire survival guidance calls, relying on her expertise rather than PN539.^12781278 Smith {LFB00121219/8} page 8, paragraph 19; Smith {Day202/66:7-17}. By that time she found it had become impossible to review all the calls from high-rise buildings because the number of calls typically received by the LFB during high-rise incidents had become too great and her workload had increased with the introduction of Vision.^12791279 Smith {LFB00121219/8} page 8, paragraph 19; Smith {Day202/69:3-14}. She did not delegate the task to anyone else and was confident that the Operational Support Team had not had the capacity to take it on because its workload had also increased as a result of the introduction of Vision.^12801280 Smith {Day202/69:15-18}. Given that Call Coach had become obsolete at the same time, there was no review of CROs' call‑handling after 2015, apart from the limited and uncritical review described above. SOM Smith told us that a structured debriefing process had been in place since 2011 to enable CROs, supervisors and OMs to share and discuss their experiences following an incident.^12811281 Smith {Day202/69:19}-{Day202/70:9}. On any view, however, that was not the kind of independent review of call-handling that she had previously undertaken.

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¶79.71 The absence of any effective arrangements for undertaking a critical review of the quality of responses to fire survival guidance calls compounded the pre-existing problem surrounding the correct description of a fire survival guidance call that the LFB had failed to resolve effectively. After Call Coach became obsolete in 2015, the LFB failed to introduce an alternative system for critically reviewing fire survival guidance calls to make sure that CROs were meeting the standard required by PN539. No good explanation was provided for that failure, which provides another example of the LFB's continuing inability to recognise the importance of fire survival guidance calls in ensuring the safety of people affected by fire and smoke.

Policy No. 790

¶79.72 On 23 February 2012, the LFB issued a new policy, Policy No. 790 (PN790) 'Fire survival guidance calls' to replace PN155.^12821282 Fire Survival Guidance Calls (PN790) {LFB00001257}; It was designed to complete Pre-Inquest action 14, Lakanal Assurance Report {LFB00004801/15}; For the Phase 1 findings in respect of PN790, Phase 1 Report Volume IV paragraphs 29.18 – 29.23, 29.47 and 29.48. It was an operational policy designed for use by firefighters and covered the exchange of fire survival guidance information between the control room and the incident ground.^12831283 Utting {LFB00118918/3} page 3, paragraph 8; Smith {Day203/129:12-14}; {Day203/155:16-23}; Smith {MET00080606/13}. It was not designed for use by the control room itself, even though it had a significant bearing on the handling of fire survival guidance calls.^12841284 Smith {MET00080606/13}. It was developed primarily by SM Patrick Utting, working closely with SOM Smith throughout the drafting, consultation and approvals process.^12851285 Utting {LFB00118918/3} page 3, paragraph 8; Smith {Day203/128:20}-{Day203/129:7}.

¶79.73 Although PN790 recognised that a large number of fire survival guidance calls could be received during a single incident,^12861286 Fire Survival Guidance Calls (PN790) {LFB00001257} paragraphs 4.1, 5.13, 6.2, 7.6 and 9.4, and Appendix 3. it offered no guidance to control room staff on how best to respond to such a situation.^12871287 Brown {Day206/124:3-19}. Neither AC Brown nor any other senior officer asked POM Hayward to assess the effect of the new policy on the control room or to determine what training might be required as a result. AC Brown sought to justify that omission on the basis that the control room was used to handling many different incidents at the same time and that although fire survival guidance calls were different and not received very often, CROs used the same knowledge, skills and experience as they used on a daily basis when handling them.^12881288 Hayward {Day206/124:3-19}. We cannot accept that. The seriousness of fire survival guidance calls and the fact that incidents giving rise to multiple fire survival guidance calls occurred relatively infrequently make it difficult to see how he could reasonably have considered them to be a part of normal business. The various failures in handling fire survival guidance calls identified by the LFB itself following the Lakanal House fire required a more considered approach to making sure that CROs were given as much help as possible in responding to the challenges presented by the need to handle several fire survival guidance calls at the same time. We do not understand why that never occurred to AC Brown or any other senior officer responsible for the control room.

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¶79.74 Following its introduction, supervisors discussed PN790 with CROs to ensure that they were generally familiar with its contents, but no formal or structured training was provided.^12891289 Hayward {LFB00121176/6} page 6, paragraph 21: Hayward {Day199/223:3}-{Day199/224:10}. The training records indicate that only some of the control room supervisors themselves received any training on it.^12901290 Training Spreadsheet {LFB00055223}; AOM Christine Sharp and AOM Gary Court were provided with training "Fire Survival Guidance calls – 790" but there is no other training recorded about PN790 in respect of any other control staff member. There was no training for PN790 recorded on the Control FSG Training Record {LFB00041763}. Although that may reflect poor record-keeping, that fact alone meant that the LFB had no accurate note of who had received training on the new policy and who had not.^12911291 Training Spreadsheet {LFB00055223}; AOM Christine Sharp and AOM Gary Court were provided with training "Fire Survival Guidance calls – 790" but there is no other training recorded in respect of PN790. There was no training for PN790 recorded on the Control FSG Training Record {LFB00041763}; Hayward {Day199/224:25}-{Day199/225:7}.

¶79.75 Paragraph 8.7 of PN790 recognised that in exceptional circumstances an incident commander might consider informing control that the "stay put" advice to callers should be changed and that they should try to leave their property. At the same time, it warned the incident commander that such advice might be contrary to national policy for control staff engaged on fire survival guidance calls and that it would be necessary to communicate with the officer in charge at the control room to get agreement for such a change.^12921292 Fire Survival Guidance Calls (PN790) {LFB00001257/5} paragraph 8.7.

¶79.76 In the context of the Grenfell Tower fire that was an important provision. SOM Smith was the principal author of paragraph 8.7, so after the Lakanal House fire she was aware that "stay put" advice might have to be changed.^12931293 Smith {MET00080606/13}. However, even though she and POM Hayward were aware of that paragraph, they gave no consideration to training CROs on how to explain to a caller that the advice previously given had been changed.^12941294 Hayward {Day199/221:10-14}; Smith {MET00080606/13}. SOM Smith's explanation for that failure was that the LFB did not think that in practice it would be necessary to do that.^12951295 Smith {MET00080606/13}; Smith {Day203/97:7-25}. POM Hayward's evidence echoed that of SOM Smith. He said that the LFB had not expected "stay put" advice ever to be withdrawn, so no training had been given on how best to respond to that situation.^12961296 Hayward {Day199/221:15-23}.

¶79.77 It is impossible to reconcile the attitude displayed by POM Hayward and SOM Smith with the clear terms of paragraph 8.7. In effect, they simply ignored it and by doing so deprived those who worked in the control room, and thereby the LFB as a whole, of the training designed to prepare them for the challenges they would face if "stay put" advice had to be revoked. That was a very serious failure for which no plausible excuse has been offered. Moreover, the procedures that the control room would rely on if multiple fire survival guidance calls were received were never properly tested in a training exercise. After the Lakanal House fire a few training exercises were held to test the handling of fire survival guidance calls, and in particular, the arrangements for passing information to the incident ground, but none of them tested the effectiveness of the control room's own procedures.

¶79.78 The first of those tests was the Heygate Challenge, held on 16 June 2011, which was designed to test the proposed amendments to the high-rise firefighting policy (PN633) and the new fire survival guidance policy (then PN155).^12971297 Email from Andy Roe to numerous LFB participants {LFB00033345/1-4}. Four fire survival guidance calls were used in the exercise.^12981298 Minutes of the Heygate Estate high-rise exercise de-brief meeting {LFB00056628/4}; Feedback: High Rise and FSG Policies Test Exercise 16th June 2011 Southwark {LFB00033384/11}. POM Hayward explained that the exercise had been designed to test communications rather than to assess the capacity of the control room to deal with a significant number of fire survival guidance calls.^12991299 Hayward {Day199/213:24}-{Day199/214:7}. In other words, the focus was not on the training of CROs. No-one representing the control room appears to have had any influence on the number of fire survival guidance calls used. As we have noted in chapter 78, neither POM Hayward nor SOM Smith could explain why the exercise had assumed the existence of only four fire survival guidance calls, given that five had been received at the Lakanal House fire.^13001300 Hayward {Day199/213: 24}-{Day199/214:7}; Smith {Day202/172:1-16}.

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¶79.79 Although the magnitude of the challenge presented by multiple fire survival guidance calls was identified in the exercise, the LFB never organised an exercise specifically to test the number of calls that the control room could effectively handle.^13011301 Feedback: High Rise and FSG Policies Test Exercise 16th June 2011 Southwark {LFB00033384/11}; Minutes of the Heygate Estate high-rise exercise de-brief meeting {LFB00056628/4}; Hayward {Day199/214:15-23}. In view of the difficulties experienced by CROs in handling the five calls generated by the Lakanal House fire, no good reason was given for that failure.

¶79.80 The second exercise, held on 20 December 2012, was Exercise Florian, which simulated a fire on the seventh floor of a 15-floor purpose-built block of maisonettes, generating three fire survival guidance calls involving four persons, three of whom were rescued and one of whom escaped without assistance.^13021302 Exercise Florian Facilitator Briefing {LFB00122827/5}; Bagnelle {LFB00122821/15} page 15, paragraph 55. The aim of the exercise was to find out how well PN790 worked in practice and whether it contained any defects.^13031303 Hayward {Day200/4:16}-{Day200/5:2}; Fire Survival Guidance Calls (PN790) {LFB00001257/1}.

¶79.81 However, the exercise did not focus on all aspects of PN790. For example, it did not practise the revocation of "stay put" advice or consider the consequences that might flow from that.^13041304 Brown {Day206/134:9-18}. Nor did it use the same number of fire survival guidance calls as had been received during the Lakanal House fire, although AC Brown thought that the three calls that formed the basis of Exercise Florian had reflected the three calls received simultaneously at the Lakanal House fire.^13051305 Brown {Day206/135:8-15}. He said that no consideration had been given to including more than five fire survival guidance calls in order to test the arrangements in PN790 because there was an unspecified exercise going on in the background in the control room, which simulated other incidents. AC Brown believed that together they would have put the control room under the same pressures.^13061306 Brown {Day206/135:16}-{Day206/136:9}. Even if that were so, however, the exercise did not address the important function of rigorously testing the arrangements for handling multiple fire survival guidance calls.

¶79.82 Unfortunately, Exercise Florian did not test the control room's ability to handle a growing number of fire survival guidance calls.^13071307 Brown {Day206/134:9-18}; Exercise Florian Facilitator Briefing {LFB00122827/5}. As with the Heygate Challenge, its focus was on the response of operational crews rather than the control room's ability to handle multiple fire survival guidance calls. The CROs' function appears to have been to assist in the exercise and act as observers rather than undergo training.^13081308 This is also recognised by Vic Bagnelle in an email dated 5 November 2013 regarding Exercise Penfold {LFB00050721/1}. Given the failings in handling fire survival guidance calls later identified in the Lakanal Control Report, appropriate training for the CROs should have been included in the exercise. One of the suggestions made following that exercise was that someone should turn the documents created for the exercise into a regular training programme.^13091309 Email from David Lindridge to Dave Brown, Patrick Utting, Martin Corbett, Scott Hayward and Victor Bagnelle dated 9 January 2013 {LFB00118958/1}. POM Hayward said that regular training took the form of training with the command units, which ran from mid-2013 until 2015 and again from mid-2016,^13101310 Hayward {Day200/14:11}-{Day200/15:24}. but again, that training was not designed for the benefit of CROs.^13111311 Hayward {LFB00055191/28} page 28, paragraph 78.2.2. It appears, therefore, that no training was introduced for CROs following Exercise Florian.

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¶79.83 The third exercise was Exercise Penfold, which was held on 14 November 2013.^13121312 Brief for Exercise Penfold {LFB00122841}; Bagnelle {LFB00122821/14} paragraphs 51-53. It simulated a ten-pump high-rise fire with several seats of fire and persons trapped on various floors.^13131313 Email chain between Paul Trew and Scott Hayward and Vic Bagnelle dated 27 June 2013 {LFB00050487/2}. The exercise involved four fire survival guidance calls, to which the CROs were expected to respond using the RIF for guidance.^13141314 Bagnelle {LFB00122821/14} page 14, paragraph 52. An AOM was available to assist the CROs.^13151315 Bagnelle {LFB00122821/14} page 14, paragraph 52. Again, it is unclear why the decision was taken to limit the exercise to four fire survival guidance calls, given that five had been received at Lakanal House, or why the LFB did not seek to test the limits of PN790 by using more than five calls.^13161316 Scott Hayward could not assist, Hayward {Day200/42:9-24}. After the exercise, it was suggested that AOMs and the OM be more directly involved in an exercise of that kind in order to practise their roles within fire survival guidance procedures, such as communicating directly with the fire survival guidance command unit.^13171317 Feedback from N O'Shea following Exercise Penfold {LFB00122826/2}. POM Hayward could not say whether that suggestion had been pursued.^13181318 Hayward {Day200/48:1-4}. Following Exercise Penfold, no further exercise or training on PN790 was organised for CROs. At most, they were asked to assist at and observe command unit training exercises which practised communicating fire survival guidance information from the control room to the incident ground. Such exercises were not designed to benefit them.

Fire survival guidance training for supervisors

¶79.84 Pre-inquest action 17 in the Lakanal Control report recommended that an enhanced fire survival guidance training package be developed for control room supervisors to enable them to provide support to CROs handling fire survival guidance calls to ensure a standard commensurate with national guidance.^13191319 Lakanal Assurance Report {LFB00004801/16}. In June 2011, the Operational Support Team produced a training package for supervisors in response to that recommendation, supported by a slide presentation.^13201320 Hayward {LFB00055191/8} page 8, paragraph 20; Hayward {Day201/94:18-23}; Supervisor FSG Training Presentation {LFB00086222}. The presentation stated that the supervisors' main function was to support CROs taking fire survival guidance calls and to make sure that the information they gathered was passed to the incident commander or the command unit.^13211321 Supervisor FSG Training Presentation {LFB00086222/7}. It suggested ways in which a supervisor could support a CRO taking a fire survival guidance call, including ways of gathering relevant information from the caller.^13221322 Supervisor FSG Training Presentation {LFB00086222}. It also suggested ways in which a supervisor could assist in passing information to the incident ground, for example, by appointing a supervisor to act as the sole contact between the control room and the incident ground.^13231323 Supervisor FSG Training Presentation {LFB00086222/7-10}. The presentation contemplated that multiple fire survival guidance calls might be received but did not include any advice about how a supervisor should collate the relevant information and transmit it to the incident ground.^13241324 Hayward {Day201/99:16-22}; Supervisor FSG Training Presentation {LFB00086222/13}. The presentation included a list of prompts for information that should be collected and passed immediately to the incident ground, but did not refer to the need to remind the CRO to obtain information about any vulnerabilities the caller or others with them might have.^13251325 Supervisor FSG Training Presentation {LFB00086222/9}. POM Hayward said that CROs normally asked for information of that kind but that in any event they expected callers to volunteer it without needing to be asked.^13261326 Hayward {Day201/98:8-16}. The training did not include any reference to the Lakanal House fire, nor did it identify any lessons to be learnt from it.^13271327 Supervisor FSG Training Presentation {LFB00086222/9}; Hayward {Day201/99:23}-{Day201/102:25}. Notwithstanding SOM Smith's evidence to the contrary, the training does not appear to have been revised after November 2012 to reflect the reasoning and conclusions of the Lakanal Control report, despite its relevance to any supervisor who might need to manage the control room during an incident of that kind.^13281328 Smith {Day204/150:18}-{Day204/153:1}.

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¶79.85 In 2014, the Operational Support Team developed another short training exercise for control room supervisors lasting between 30 and 60 minutes.^13291329 Bagnelle {LFB00122821/17} page 17, paragraph 62; Supervisor FSG Training Powerpoint {LFB00122832}. It partly remedied one of the defects in the previous training by reminding supervisors that CROs should ask whether the caller was disabled, used a wheelchair or whether they were ill and used oxygen,^13301330 Supervisor FSG Training Powerpoint {LFB00122832/5}. but it did not tell supervisors to remind CROs that such information should be passed to the incident ground.^13311331 Supervisor FSG Training Powerpoint {LFB00122832/13}.

¶79.86 It is not clear whether the training we have described was provided to all supervisors.^13321332 There is no reference to it in Scott Hayward's witness statements or in the Control FSG Training Record {LFB00041763}; Training Spreadsheet {LFB00055223} does record that a number of supervisors received various forms of fire survival guidance training between 2014 and 2017. It seems clear, however, that they were not trained how to manage the control room during a large incident that gave rise to multiple concurrent fire survival guidance calls.^13331333 Hayward {Day201/103:21}-{Day201/104:6}; Real {MET00080520/6-9}; May {MET00080506/16-17}. Nor were they trained in how to deal with a major incident.^13341334 Hayward {Day201/118:21}-{Day201/119:9}. That was another serious failure for which no satisfactory explanation was given.

Isolation of the control room

¶79.87 There were a number of other causes, mainly of an organisational nature, that contributed to the failure of the LFB to provide the training and guidance needed by control room staff. One clear and consistent theme that emerged from the evidence was the existence of a perception within the control room and the wider LFB that the control room was a separate entity distinct and different from the rest of the brigade.^13351335 Smith {Day202/174:24-25}. That was reflected in the opinion of AC Jonathan Smith when he was instructed by the then Commissioner in July 2019 to undertake a root and branch review of the brigade's control function.^13361336 Jonathan Smith {LFB00121171/9} page 9, paragraph 24. He concluded that the control room needed to be more closely integrated into the brigade, rather than exist as a separate and distinct part of the organisation, as it had become over time. In his view there needed to be a fundamental reappraisal of the position of the control room to ensure that it was given an importance equal to that enjoyed by other sections of the brigade.^13371337 Jonathan Smith {LFB00121171/10} page 10, paragraph 30; AC Smith's 'Control: Overview and Control Improvement Plan' {LFB00084097/11}.

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¶79.88 The reasons for the isolation of the control room are complex, but were essentially historical, geographical and technological.

¶79.89 Originally, there had been a number of area control rooms across London, each located within an operational fire station. At some point they were consolidated and became based centrally at LFB headquarters in Lambeth.^13381338 George {Day205/17:16-19}; AC George recalled the control centres being located at Wembley, Croydon and Lewisham. Throughout both those periods, therefore, control room staff were able to meet their operational colleagues on a daily basis.^13391339 George {Day205/17:19-24}.

¶79.90 In April 2004, the control room moved from Lambeth to Greenwich View Place on the Isle of Dogs and in January 2012 it moved again to a purpose-built London Operations Centre in Merton, which is its current location.^13401340 LFB Lakanal Control Report {HOM00001124/26} paragraph 132. George 'Review of Brigade Control' July 2016 {LFB00032826/4} paragraph 13. When the control room moved to Greenwich View Place, CROs became physically separated from other staff within the organisation.^13411341 George {Day205/18:7-9}.

¶79.91 Technology also played a part in the separation. Over the course of time systems were introduced in other parts of the organisation which could not be used by the control room or were not properly adapted to its needs. The most significant examples are the Staff Attendance Recording System (StARS) and the STEP system.^13421342 George {Day205/75:6-8}; LFEPA Self-assessment 2015 – LGA Peer Challenge {LFB00047742/56}. STEP, which was linked to StARS, was designed to enable a senior officer to review the training undertaken by junior officers and plan for future training needs.^13431343 George {Day205/82:11-18}. Although the rest of the LFB used STEP to record training, the control room was unable to do so because StARS could not accommodate its shift patterns. It was therefore obliged to use a spreadsheet to record information about training which was then added to STEP manually.^13441344 Training Audit Recommendations 15 January 2013 {LFB00106102/2}. In contrast to the live tracking available to operational staff on STEP, the information on the control room's spreadsheet was added at monthly or quarterly intervals.^13451345 Smith {Day202/93:5-8}. It is not clear to us why the adjustment to StARS required to accommodate the control room's shift patterns was not made before it was introduced.

¶79.92 AC George said that when he had started working with the control room in 2016 it was like going back in time ten years. The systems were out of date.^13461346 George {Day205/82:21-23}. He concluded that the control room had not kept pace with the rest of the organisation because managers had not ensured that the LFB's systems operated as effectively for it as they did for fire stations.^13471347 George {Day205/85:7-9}. POM Hayward said that changes to the programming of STEP and StARS had been needed to accommodate the control room's shift patterns, but that things had moved slowly.^13481348 Hayward {Day199/125:5-18}. He said that he had asked for changes to be made, but had been told that other requirements took priority.^13491349 Hayward {Day199/127:22}-{Day199/128:1}.

¶79.93 There was also a marked difference between the control room and the operational departments in the way that training was organised and procured. As set out above, in April 2012, the LFB entered into a contract with Babcock for most of its training requirements,^13501350 LFB Report 'How Training Works' {LFB00055127/5} paragraph 2.7. but that contract did not extend to the training of control room staff. Their training was provided by the Operational Support Team^13511351 LFB Report 'How Training Works' {LFB00055127/5} paragraph 2.7. and, as POM Hayward confirmed, there were no arrangements for assessing the quality of the training it provided.^13521352 Hayward {Day201/123:10-12}. When SM Kelly reviewed the Training team's quality assurance systems in 2010 he found that there was no general plan for ensuring that training was of the appropriate quality, but he identified various systems which enabled the team to assess the quality of the training it had provided. Among them was Call Coach, described above, which he considered to be a very effective tool.^13531353 SM Kelly report {LFB00055220/9} paragraphs 63-64 and 66-68. However, although his audit was based on fire survival guidance training, SM Kelly was apparently not aware that fire survival guidance calls were not monitored using Call Coach or any other system.^13541354 Smith {Day202/38:1-7}. As a result, he appears not to have appreciated that fire survival guidance calls were not subject to any quality review or assurance process.

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¶79.94 In June 2013, AC Chandler reviewed the progress made by the control room in carrying out the Lakanal pre-inquest actions. He concluded that the training syllabus needed to be entirely refreshed and recommended that a fundamental review of training should be undertaken in 2015 or 2016.^13551355 Email from AC Chandler to AC Brown, 28 June 2013 {LFB00060701/2} item 16. However, no such review was undertaken^13561356 Brown {Day207/121:2-3}. because of the overriding focus on implementing Vision.^13571357 Hayward {Day201/129:16-22}. Although AC George covered aspects of training in his review of the control room, it did not amount to the fundamental reappraisal which AC Chandler had called for.^13581358 Review of Brigade Control July 2016 {LFB00032826/11-13} paragraph 49; Brown {Day207/120:25}-{Day207/121:12}.

¶79.95 In the report into his review of the control room AC George had recommended that responsibility for control room training should be transferred to Babcock.^13591359 Review of Brigade Control July 2016 {LFB00032826/11} paragraph 49(b). Although that was considered, AC George and Angela Hale, the LFB's Training Commissioning manager,^13601360 George {LFB00083884/7} page 7, paragraph 29(b). subsequently agreed that the nature of the training required by control staff was so specific that there was limited value in employing Babcock and that it should be retained by the LFB.^13611361 George {LFB00083884/12} page 12, paragraph 40 and George {LFB00083884/6} page 6, paragraph 29(b). It was also decided that the Operational Support Team should continue to deliver that training, apart from certain computer-based training packages.^13621362 George {LFB00083884/13} page 13, paragraphs 41-42. As a result, control room training was not subject to any regular audit by either the LFB's training department or any other organisation.

¶79.96 The Operational Support Team was in practice the only body within the LFB responsible for the development and delivery of control room training and for ensuring that it was of an appropriate standard. However, its members were not recruited as specialist trainers; they were all staff who had previous experience as CROs.^13631363 SM Kelly's Report of Training Audit {LFB00055220/4} paragraph 9. Until 2016 or 2017, when they received a "train the trainers" course from Babcock, its members did not receive any formal training on how to create and deliver training packages.^13641364 Hayward {Day199/28:25}–{Day199/29:9}.

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¶79.97 SOM Smith had not received any training or preparation before assuming responsibility for the training function of the Operational Support Team and had not asked for any.^13651365 Smith {Day202/73:2-18}. In particular, she received no training in quality assurance,^13661366 Smith {Day202/98:17-18} which is a cause for concern, given the absence of any regular or formal process for assessing the quality of training.^13671367 LFB Report 'How Training Works' {LFB00055127/23} paragraphs 7.1; Groves {LFB00102138/44} page 44, paragraph 81.

¶79.98 The control room's isolation was increased by the marginalisation of its senior managers in brigade meetings. POM Hayward attended monthly Departmental Management Board meetings, at which AC David Brown met the DACs to discuss current matters affecting the brigade.^13681368 Hayward {Day199/20:7-12}. POM Hayward said that the meetings had been mainly concerned with operational matters, to the point at which he did not always understand the subject-matter and did not contribute greatly to discussions.^13691369 Hayward {Day199/20:10-17}. That was unfortunate for a number of reasons: first, because POM Hayward clearly felt isolated and ill-equipped to participate, and secondly, because they were one of the points of contact with POM Hayward on which AC Brown relied to be informed about the running of the control room.^13701370 Brown {LFB00032166/5} page 5, paragraph 13. If POM Hayward did not participate effectively in the meetings, there was a risk that AC Brown would not have sufficient information to enable him to exercise effective management oversight of the control room.

The introduction of Vision

¶79.99 The mobilising system enables CROs to carry out their core role of despatching crews to fight fires. As mentioned earlier, in 2015, the LFB changed the mobilising system used by the control room from ProCAD to Vision,^13711371 Hayward {LFB00055191/11} page 11, paragraph 26. a system which had been developed and delivered by a commercial company, Capita. Since the effective despatch of crews is the primary function of the control room, at least in the initial stages of the response, it was vital that staff received adequate training on the new system before it entered service.^13721372 Hayward {LFB00055191/12} page 12, paragraph 29.

¶79.100 Vision had been due to enter service in 2014, but the complexity of the LFB's requirements meant that Capita was unable to deliver the system on time.^13731373 Hayward {LFB00055191/111-12} pages 111-112, paragraph 27. From early 2013 the Operational Support Team started to prepare for its introduction.^13741374 Hayward {LFB00055191/19} page 19, paragraph 56. Initial training on Vision for existing control room staff took place between 24 June 2013 and 14 January 2014 and following further delays, tailored training for CROs continued to be delivered until the system eventually entered service on 17 November 2015.^13751375 Hayward {LFB00055191/20} page 20, paragraphs 59-60; George {Day205/7:4-5}.

¶79.101 The introduction of Vision resulted in a reduction in response times, with the result that appliances reached their destinations about 10 seconds earlier than had been the case when the control room had been using ProCAD.^13761376 George {Day205/19:16-19}. That was no doubt an improvement in performance, but, as AC George told us, the introduction of Vision had been extremely difficult for the control room.^13771377 George {Day205/19:19-22}.

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¶79.102 For a number of years after its introduction, Vision continued to be plagued by significant system failures. More than 500 faults were reported to Capita in the first six months.^13781378 Hayward {LFB00055191/13} page 13, paragraph 35. There were also six occasions during the first year when the system failed altogether for periods of between 40 minutes and three hours, requiring the use of contingency measures.^13791379 Hayward {LFB00055191/13} page 13, paragraph 33. AC George described instances when the mobilising system slowed to the point of stopping completely, causing the CROs to resort to a secondary mobilising system that he described as "basically pen and paper".^13801380 George {Day205/20:4-12}. That was extremely stressful for staff, who had occasionally left the control room in tears.^13811381 George {Day205/20:12}; {Day205/20:2-4}. The scale of the difficulties was such that in the period from 2016 to 2017 the Operational Support Team spent about 60% of its time reporting problems with Vision, revising training packages to reflect changes to the system and training staff on ways to circumvent problems. During the first two years in which Vision was in use, ways were devised to circumvent about 100 problems.^13821382 Hayward {LFB00055191/21} page 21, paragraph 63. Put briefly, between 2013 and 2017, the introduction of Vision generated a very substantial amount of additional work for the control room and the Operational Support Team in particular.

¶79.103 It was accepted by LFB officers that the task of implementing Vision had been all- consuming and had completely swamped the control room.^13831383 Brown {Day207/89:8}; Hayward {Day201/56:12-25}. One of the most significant consequences was its effect on training, which manifested itself in a number of ways.

¶79.104 One immediate consequence of the introduction of Vision was that all the control room's training capacity was directed towards training staff on the new system. When SOM Smith returned from the Chief Fire Officers Association she was asked to create a plan to train all 100 staff in the control room on Vision,^13841384 Smith {Day202/74:12-15}. which was regarded as a priority. That meant arranging 2,000 hours of training on Vision before it went into service.^13851385 Smith {Day 202/74:22-25}. Inevitably, resources were directed to ensuring that the system was effective as soon as possible.^13861386 Smith {Day204/93:19-24}. Between 2015 and 2017, most, and sometimes all, of the Operational Support Team's resources were devoted to that task, because it was essential that the brigade had an effective mobilising system.^13871387 Smith {LFB00121219/23} page 23, paragraph 61. POM Hayward said that the control room had been unable to plan any training until Vision was fully operational and officers could see how it performed.^13881388 Hayward {Day201/63:21-24}. That applied even to areas where annual training was expected, such as fire survival guidance refresher training.^13891389 Hayward {Day201/63:25}-{Day201/64:2}.

¶79.105 In order to cope with the pressure of work expected to result from the introduction of Vision, from 2014 and throughout its implementation the number of AOMs in the Operational Support Team was increased from four to six.^13901390 Hayward {LFB00055191/18} page 18, paragraph 49. The increase was originally expected to be temporary, but throughout 2016 the amount of work produced made any reduction impossible and the increase was made permanent by AC George in 2016.^13911391 Hayward {LFB00055191/18} page 18, paragraph 51.

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¶79.106 The training requirements imposed by Vision did not cease when the system entered service. Minutes of a Brigade Control Management meeting on 8 December 2015 (about three weeks later) refer to a list of problems that Capita had already been asked to resolve and referred to staff having to work around problems with the paging system.^13921392 Brigade Control Management Meeting Minutes 8 December 2015 {LFB00123099/2}. From that point on, the minutes of Brigade Control Management meetings and the Joint Committee for Control Staff record concerns about the performance and stability of Vision.^13931393 JCC Meeting Minutes {LFB00123113/7}.

¶79.107 The problem was not simply one of confidence in the system, because faults needed to be corrected as they were identified. Accordingly, it was necessary to make changes to the system, which in turn made it necessary to train CROs urgently on the revised version. Frequent amendments were very disruptive. On many occasions staff returned from their rest days to find that a change had been made to the system that required them to undergo immediate further training.^13941394 George {Day205/95:12-21}. The burden of training was both substantial and, until at least 2017, constant.^13951395 George {Day205/20:19-23}. The inevitable consequence was that other areas of training, including training on fire survival guidance, were delayed or deferred indefinitely. POM Hayward said that no fire survival guidance training at all had been given in 2015 because of the introduction of Vision.^13961396 Hayward {LFB00055191/26} page 26, paragraph 74 (table). In 2015, the control room had been concentrating entirely on implementing Vision and therefore no other training had been given.^13971397 Hayward {Day201/52:2-5}.

¶79.108 POM Hayward told AC Brown that there were occasions when fire survival guidance refresher training had not been delivered in accordance with the agreed programme, for example, between 2015 and 2017 while the CROs were being trained on Vision.^13981398 Brown {LFB00084020/13} page 13, paragraph 30. The explanation AC Brown gave us for allowing that situation to continue was that Vision was a critical project and that it had been essential to deliver it on time.^13991399 Brown {LFB00084020/13} page 13, paragraph 30. He did not agree, however, that all other training had ceased as a result.^14001400 Brown {Day207/93:7-17}. AC George had also been aware of the general adverse effect that Vision was having on control room training, although he too said that he had not been specifically informed of its effect on fire survival guidance training.^14011401 George {Day205/80:8-14}.

¶79.109 Training on Vision also put a temporary halt to the command unit training on fire survival guidance in which the control room had been involved. POM Hayward said that that training, which had run since mid-2013, had been stopped in 2015 because of the demands of Vision, although it had been resumed to a limited extent in mid-2016.^14021402 Hayward {Day200/15:7-15}. Staff training and development as a whole was adversely affected.^14031403 George {LFB00032823/11} page 11, paragraph 46; George {LFB00083884/14-15} pages 14-15, paragraph 50.

¶79.110 It is not clear what, if anything, was done to mitigate the effect on other areas of training of introducing Vision. AC George said that the sheer volume of work needed to implement Vision made it extremely difficult to devote resources to other training.^14041404 George {Day 205/173:16-20}. It does not appear that consideration was given to evaluating the competing priorities of training on Vision and other forms of training, including training on fire survival guidance, until after Vision had become operational in 2015.^14051405 Hayward {Day201/16:23}–{Day201/17:2}. POM Hayward said that at that point the control room had taken stock of the training needs of staff and had examined how they could run more general training as well as the continuing training on Vision.^14061406 Hayward {Day201/17:12-18}.

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¶79.111 The fundamental review of training proposed by AC Chandler in June 2013 did not take place because of the overriding concentration on getting Vision into service.^14071407 Hayward {Day201/129:16-22}. Although AC George covered aspects of training in his review of the control room, it did not amount to the fundamental reappraisal for which AC Chandler had called.^14081408 Review of Brigade Control, July 2016 {LFB00032826/11-13} paragraph 49; Brown {Day207/120:25}-{Day207/121:12}.

¶79.112 It is clear that the introduction of Vision was a significant challenge for the LFB, particularly for the control room, and required a substantial amount of work to stabilise the system. Its success in reducing the average time taken for an appliance to arrive at an incident together with other operational benefits came at the cost of a reduction in the ability of the control room to provide broader training to CROs, including fire survival guidance refresher training. Given the endless cycle of faults, revisions and need for further training created by Vision, it is unsurprising that the Operational Support Team struggled to deliver fire survival guidance training.

¶79.113 Although it was obviously of the first importance that CROs should be able to mobilise appliances quickly, the LFB should not have allowed training on Vision to squeeze out other forms of training so completely during the four years between 2013 and 2017. For a number of years, but particularly in 2015 and 2016, the introduction of Vision was treated as a reason for ignoring or deferring essential training and even the reappraisal of training proposed by AC Chandler, despite the fact that the "Vision Training Plan" contemplated that training on handling fire survival guidance calls would take precedence and might cause delay to training on Vision.^14091409 {LFB00058876/2}. The failure of senior managers to ensure that training on fundamental skills required by CROs was maintained during that period reflects a failure to establish proper priorities and a weakness of organisation. When AC Brown was told that essential training was not taking place or had been severely curtailed, he should have required POM Hayward to ensure that the Operational Support Team provided essential training to the control room.

¶79.114 His failure to do so was particularly acute in the case of fire survival guidance training. Following the fire at Lakanal House and the LFB's subsequent investigations, the importance of fire survival guidance training ought to have been clear to those responsible for the operation of the control room, including the Operational Support Team. It was a significant failure on the part of the LFB that fire survival guidance training was allowed to lapse during the introduction of Vision.

Training "on the watch"

¶79.115 One longstanding problem affecting the control room was the perception that it was too difficult to arrange for CROs to undertake training while maintaining operational capability in the control room. A number of witnesses said that training on the watch was regularly interrupted by the need to recall staff to the control room to respond to incoming calls.^14101410 Real {MET00080520/14} page 14, paragraph 4; Hayward {LFB00055191/18} page 18, paragraph 52; Hayward {Day199/50:2-6}; Smith {Day202/95:9-13}; George {Day205/111:10-12}; Brown {Day206/160:3-7}.

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¶79.116 That was not a problem peculiar to the LFB or one which arose shortly before the fire at Grenfell Tower. The Fire Service Manual Volume 1: Fire Service Technology, Equipment and Media Communications and Mobilising, published in 1998, noted that training for control personnel had always been hindered by the small numbers of staff available and the need to maintain cover in the control room. Training was usually organised by watches and delivered at the place of work, thereby ensuring that the maximum number of personnel were available. Brigades were therefore advised to consider appointing a Training Officer and organising training days away from the control room.^14111411 Fire Service Manual Volume 1: Fire Service Technology, Equipment and Media Communications and Mobilising {INQ00014945/129}. That document, published nearly 20 years before the Grenfell Tower fire, makes it clear that the difficulties posed by training at work were, or should have been, well known to fire and rescue authorities throughout the country. It is equally clear that it also proposed a solution to the problem.

¶79.117 In the Phase 1 report the chairman described the shift pattern operated by the control room, which was staffed by six watches. From the introduction of the new shift system in 2011 there had been a four-hour overlap between the early and late short shifts, which provided sufficient cover to enable training to take place during that period,^14121412 Review of Brigade Control, July 2016 {LFB00032826/9} paragraph 39; Hayward {LFB00055191/18} page 18, paragraph 52. but in 2014 the shift pattern had been altered, with the result that the short shifts overlapped by only two hours. It had been intended that staff on duty during one of the short shifts would undertake training during the hours with overlapping cover,^14131413 Review of Brigade Control, July 2016 {LFB00032826/11} paragraph 49. but in his review AC George expressed the view that the shift pattern did not allow enough time for supervisors to provide regular effective training to their watches outside the control room.^14141414 Review of Brigade Control, July 2016 {LFB00032826/9} paragraph 39. AC Brown had been heavily involved in consideration of the shift change in 2011 and had asked AC George to see how it could better accommodate training.^14151415 Brown {Day206/66:18-24}; {Day206/157:19-20}. In the report into his review AC George recommended that the control room should revert to the original shift pattern to allow four hours overlap between the short shifts that could be used for training.

¶79.118 Although the problem had been identified by AC George in 2016, the LFB had not tackled the reduction in the overlap between the two short shifts by the time of the Grenfell Tower fire. Indeed, it remained a contentious subject when AC Jonathan Smith produced his own review of the control room in 2019.^14161416 Control - Overview and Control Improvement Plan, dated 22 July 2019 {LFB00084097/4}. He found even then that the use of the short shift was not providing the structured training that was required.^14171417 Control - Overview and Control Improvement Plan, dated 22 July 2019 {LFB00084097/4}.

¶79.119 The importance of an adequate overlap between the two short shifts lay in the level of cover available for responding to the demands of the control room. In essence, the more staff present in the building, the lower the likelihood of the training watch needing to be called to control room duty.^14181418 Tables setting out the minimum numbers of staff required from 2011, Hayward {LFB00055191/5} page 5, paragraphs 15-17. If there were a short increase in the number of calls to the control room, CROs could resume training, but if a significant incident occurred, a new date for their training had to be arranged by the Operational Support Team.^14191419 Smith {Day202/95:9-13}. The concern about the interruption of training is understandable, but to an extent misplaced. The evidence does not suggest that there was a frequent need to redeploy staff from training to the control room. On the contrary, POM Hayward said that it happened only infrequently^14201420 Hayward {Day199/43:19-21}. and he was unable to recall being aware of any problems arising from the fact that staff were unable to complete their training because they had been recalled to the control room.^14211421 Hayward {Day199/49:9}-{Day199/50:1}. There were other problems, however. For example, a shortage of staff in the control room meant that staff from the short shift were often needed to fill gaps in the duty watch.^14221422 George {Day205/111:23-25}. That inevitably reduced their availability for training.

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¶79.120 As mentioned above, the Fire Service Manual recommended that brigades should consider appointing a Training Officer and arranging training days away from the control room.^14231423 Fire Service Manual Volume 1: Fire Service Technology, Equipment and Media Communications and Mobilising {INQ00014945/129}. As a general rule, however, the LFB did not organise training "off-watch" or away from the control room.

¶79.121 It is clear from the evidence of control room staff that there was a commonly held belief that it was simply not possible to organise training "off-watch". SOM Smith considered that the difficulty of making control room staff available for training at work was common to all fire and rescue services because it was not possible for them to go "off the run,"^14241424 Smith {Day204/23:12-24}; Real {MET00080520/14} page 14, paragraph 4. i.e. to be unavailable for duty. POM Hayward said that he had been unable to use overtime to provide training because he could not require staff to work overtime for that purpose and because he had already been making excessive use of overtime to maintain the necessary number of CROs on duty.^14251425 Hayward {Day199/47:1-8}. However, in our view senior managers did not give sufficient consideration to delivering fire survival guidance training off-watch, given that in some other cases training was indeed delivered off-watch. For example, POM Hayward recalled that in August 2006, shortly after he had joined the LFB, staff had been trained on the ProCAD mobilising system off watch following a major revision.^14261426 Hayward {Day199/43:2-5}. He thought that had been the only time staff had received training "off-watch",^14271427 Hayward {Day199/43:6-7}. but in 2010 the initial one-day fire survival guidance training had also been delivered "off‑watch".^14281428 Hayward {Day200/80:19}-{Day200/81:1}. POM Hayward said that although at that time it had been possible to deliver training in that way, the introduction of the new shift patterns in 2011 and staff losses in 2012 had made training "off-watch" "problematic."^14291429 Hayward {Day200/81:2-10}. Despite that, SOM Smith told us that training "off-watch" had been provided in 2015 for the introduction of the new Vision mobilising system.^14301430 Smith {Day202/97:23}-{Day202/98:5}. CROs needed to receive a number of hours of training on Vision, which had been delivered to most of them "off-watch".^14311431 Smith {Day204/24:4}-{Day204/25:3}. It is also the fact that in 2016 and 2017 some CROs worked overtime to support the command unit training exercises.^14321432 Smith {Day204/127:20}-{Day204/128:16}; Hayward {LFB00055191/28} page 28, paragraph 78.2.

¶79.122 Those examples suggest that the belief that training could not be delivered "off-watch" was unjustified and unreasonable. They also suggest that fire survival guidance training was not considered by the LFB to be necessary to enable CROs to perform their role effectively. It is telling that although the introduction of Vision was considered to be of sufficient importance to justify "off-watch" training, the delivery of refresher fire survival guidance training was not. In view of the number of fire survival guidance calls the LFB had received during the Lakanal House fire and the lessons that it had itself identified, as well as the critical nature of the advice provided by CROs taking fire survival guidance calls, the failure to make any obvious effort to provide refresher fire survival guidance training "off-watch" was a serious error of judgment.

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¶79.123 The shortage of staff to which POM Hayward referred had an obvious effect: in order to maintain the minimum number of staff in the control room, training would sometimes have to be cancelled.^14331433 Review of Brigade Control - the issues raised by staff prior to the review commencing {LFB00032831/2} paragraph 3a; George {Day205/52:7}-{Day205/53:6}. A shortage of staff, together with sickness and a need for breaks, was one reason why it had not been possible to train watches away from the control room during the short shift.^14341434 Review of Brigade Control {LFB00032826/11} paragraph 49. However, the shortage of staff, its causes and consequences were well known. Between 2011 and 2012 the LFB was considering a proposal to enter into a contract with a third party for the provision of control room services, which resulted in a temporary halt to recruitment.^14351435 Hayward {Day199/47:4-6}; Hayward {Day199/87:11-13}; Brown {Day206/40:25}-{Day206/41:1}; George {Day205/53:25}-{Day205/54:3}. That remained the position until 2016, when AC George asked for recruitment to resume after he had assumed responsibility for the control room.^14361436 George {Day205/114:5-7}. During his time as a director, AC George also increased the number of CROs and supervisors on each watch.^14371437 George {Day205/114:22-25}.

Planning and recording control room training

¶79.124 Following the Lakanal House fire, the Lakanal Control report identified serious deficiencies in the provision and recording of fire survival guidance training over the long period between 1981 and 2009.^14381438 Lakanal Control Report dated November 2012 {HOM00001124/26} paragraphs 130 and 134 and {HOM00001124/31} paragraph 167. In his report following the audit of the training arrangements SM Kelly observed that, if fire survival guidance and other control room training were to be provided effectively, systems had to be established for planning training and recording its delivery.^14391439 Gap Analysis dated 7 April 2010 {HOM00001125/23}; SM Kelly's draft audit of Brigade Control training dated August 2010 {LFB00055203/7} paragraphs 46-49. Yet, it is clear that, in the years following the Lakanal House fire, senior managers failed to establish such systems, so that the problems persisted up to, and indeed well beyond, 14 June 2017.^14401440 AC Jonathan Smith's briefing note titled 'Control – Overview and Control Improvement Plan' dated 22 July 2019 {LFB00084097/3}.

¶79.125 The need for fire survival guidance training to be structured and planned had been identified in FSC 10-93^14411441 Fire Service Circular {LFB00003617/3} paragraph 11. and in the Fire Service Manual published in 1998.^14421442 Appendix 1 of the Fire Service Manual 1: Fire Service Technology, Equipment and Media, Communications and Mobilising (Published 1998) entitled 'Control Staff – Training, Competence and Promotion' {INQ00014945/129}. Although national guidance was silent on keeping adequate records of training, the LFB's own policy, PN164, issued on 29 September 1994 and amended on 28 January 2009, included detailed requirements on training records. In particular, paragraph 2.5 required a clear record to be kept of the contents of the training, together with details of dates, the trainers and any relevant notes,^14431443 PN164 as issued on 29 September 1994 and amended on 28 January 2009 {LFB00084054/3}. but it was not complied with. Moreover, PN164 did not require training plans to be produced for individual officers or watches or for the control room more generally.^14441444 That was the case for all of its subsequent revisions. PN164 reviewed as current on 6 May 2015, which was the version in force on 14 June 2017 {LFB00084054/11}. Those requirements ought to have been added to PN164 after the Lakanal House fire.

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¶79.126 The LFB had originally intended that records of control room training should be brought into the StARS and STEP systems used by the rest of the brigade.^14451445 Hayward {Day199/77:16}-{Day199/79:11}; Hayward {Day199/121:22-25}; Brown {Day207/4:15-25}; Minutes of the Lakanal House Board Meeting on 22 June 2010 {LFB00055208/3} item 8.8; Minutes of the Lakanal House Board Meeting on 21 July 2010 {LFB00055210/3} item 7.5; Minutes of the Lakanal House Board meeting on 15 September 2010 {LFB00084031/2} item 5.10. In that way they would be automatically entered on STEP without the need for manual intervention^14461446 Hayward {Day199/77:16}-{Day199/79:11}. and control room managers would easily be able to check what training each CRO had received and plan future training.^14471447 George {Day205/82:7-20}. The training records, as they existed at the time, were entered on STEP by 8 November 2010.^14481448 Minutes of the Lakanal House Board Meeting on 8 November 2010 {LFB00055213/1}; Hayward {Day199/123:8-23}.

¶79.127 AC Brown accepted that, although he considered the biennial plan for fire survival guidance training to be robust, it did not amount to an all-encompassing training plan which met SM Kelly's recommendation that an adequate system be introduced for planning training.^14491449 Brown {Day206/163:2-17}. However, neither he nor POM Hayward took any steps at the time to put such a plan in place.

¶79.128 At a Brigade Control Management meeting on 18 July 2012, AC Chandler discovered that there was no single document, such as a training matrix, which recorded what training had been delivered to control room staff and what was needed in the future. He therefore asked the OMs to collate that information for their own watches and present it in the form of spreadsheets. He also asked the Operational Support Team to produce a training matrix.^14501450 Minutes of the Brigade Control Management Meeting held on 18 July 2012 {LFB00113237/7-8} item 5. It is clear, therefore, that SM Kelly's recommendation to introduce an adequate system for planning training had still not been carried out almost two years after he had reported and that training records were still not being entered automatically on the StARS and STEP systems. It is also clear that after he became Head of Mobilising and Control in May 2012, AC Chandler recognised the importance of an effective system of planning training and took some steps to improve the position.^14511451 Brown {LFB00032166/3-4} pages 3-4, paragraph 7. POM Hayward could not explain why a training plan had not been established before July 2012.^14521452 Hayward {Day199/85:23}-{Day199/86:2}.

¶79.129 At the meeting on 18 July 2012 OM Victor Bagnelle referred to the system of record-keeping introduced by the Operational Support Team as a temporary solution while adjustments were being made to the StARS and STEP systems to enable them to accept information relating to the control room.^14531453 Hayward {Day199/78:13}-{Day199/79:2}; Hayward {Day199/123:1-3}. It involved recording information on a spreadsheet which was sent to the information management team once a month to be manually entered on STEP.^14541454 Hayward {Day199/126:6-9}; {Day199/78:23}-{Day199/79:2}; George {Day205/86:22}-{Day205/87:5}. The system was cumbersome and subject to human error, because different staff recorded training in different ways.^14551455 Hayward {Day199/126:12-22}. Moreover, information about watch-based training was not always sent to the Operational Support Team for inclusion in the spreadsheet.^14561456 Hayward {Day199/126:12-22}.

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¶79.130 Training was discussed at the following Brigade Control Management meeting held on 12 September 2012, but no conclusion was reached.^14571457 Minutes of the Brigade Control Management Meeting on 12 September 2012 {LFB00113402/6} item 5. Obviously, therefore, no agreement had been reached on a training plan at that stage.^14581458 Hayward {Day199/96:17-21}. AC Chandler recognised that the LFB would not have a robust defence if anything went wrong in the control room, but although another meeting was due to be held in October 2012 to discuss training,^14591459 Minutes of the Brigade Control Management Meeting on 12 September 2012 {LFB00113402/6} item 5. no training plan was in fact put in place.

¶79.131 In January 2013, GM Lindridge found that the control room was still recording all training on a spreadsheet to be entered on STEP manually.^14601460 GM Lindridge's Review dated 4 January 2013 {LFB00033943/14}. He also found that the technology made it impossible for control room managers to create a training plan on STEP and therefore recommended that a two-year rolling plan should be set out on a spreadsheet by January 2013.^14611461 GM Lindridge's Review dated 4 January 2013 {LFB00033943/14}. It is clear, therefore, that almost two and half years after SM Kelly's report and six months after AC Chandler's request for a training matrix, no training plan had been put in place and that StARS and STEP could still not be used to create training records for the control room.

¶79.132 POM Hayward could not explain why no training plan had been introduced by that point.^14621462 Hayward {Day199/104:15-17}. Nor could he recall whether a training matrix had ever been produced.^14631463 Hayward {Day199/104:18-23}. Apparently one reason why training records still had to be entered manually on StARS was because the programme still did not recognise the control room's short shift patterns.^14641464 Hayward {Day199/125:3-18}; {Day199/126:24}-{Day199/127:15}; {Day199/131:9-18}; Hayward {LFB00055191/23} page 23, paragraph 67; Brown {Day207/6:23}-{Day207/7:14}. He said that there had been competing priorities for attention, in the form of an amendment to StARS to accommodate a change in operational shifts and the introduction of Vision.^14651465 Hayward {Day199/127:16-24}; {Day199/131:5-8}; Hayward {LFB00055191/23} page 23, paragraph 67. He said that, because there had already existed a method of recording control room training, the necessary amendment had been moved down the list of priorities.^14661466 Hayward {Day199/127:16}-{Day199/128:3}.

¶79.133 AC Brown agreed that there had been competing priorities, but he did not accept that operational demands routinely trumped the demands of the control room.^14671467 Brown {Day207/8:6-14}. He accepted that, although he had tried to push matters along, greater pressure could have been exerted to ensure that the control room's training needs were given priority.^14681468 Brown {Day207/7:18-23}; {Day207/8:15-25}. He also suggested that the fact that the control room was based in Merton and was not a presence within the LFB's headquarters probably made it difficult for its managers to make their case to senior officers.^14691469 Brown {Day207/8:15-25}.

¶79.134 On 4 April 2013, when AC Chandler returned from leave, AC Brown asked him to satisfy himself that the pre-inquest actions had been completed. He also asked AC Chandler to talk him through the training plan for the control room.^14701470 Email from AC Brown to AC Chandler on 4 April 2013 {LFB00028942/2}. AC Brown said that he had asked for that to be done because he remained dissatisfied with progress towards a training plan, which by then was overdue.^14711471 Brown {Day206/170:15-24}. He said that AC Chandler had told him that it was in hand.^14721472 Brown {Day206/170:25}-{Day206/171:2}. He also said that he had asked AC Chandler for the training matrix, but had not received it.^14731473 Brown {Day206/171:3-9}.

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¶79.135 On 9 May 2013, POM Hayward sent an email to OM Victor Bagnelle expressing concern that the training database did not provide an accurate picture of the current state of training or the programme for future training.^14741474 Email from POM Hayward to OM Vic Bagnelle on 9 May 2013 {LFB00042081/1}. It is evident, therefore, that the planning of training was still not fully under control at that time. However, on 28 June 2013, AC Chandler reported to AC Brown on progress in completing the pre-inquest actions.^14751475 Email from AC Chandler to AC Brown on 28 June 2013 {LFB00060701/1}. In relation to action 16 he reported that the planning and recording of general control room training had improved.^14761476 Email from AC Chandler to AC Brown on 28 June 2013 {LFB00060701/2}. In light of the continuing problems with planning and recording training, the basis for that statement is unclear.

¶79.136 Very little happened until a year later, when on 22 July 2014, POM Hayward sent an email to SOM Bagnelle, SOM Diamond and SM Ajimal expressing concern at the absence of a robust system of recording control room training.^14771477 Email from POM Hayward to SOM Bagnelle, SOM Diamond and Tejinder Ajimal on 22 July 2014 {LFB00051294}. His concerns were well-founded, and it is disquieting that in July 2014, although work had started, still no robust records existed and the objective of a training programme that was considered, planned and delivered to a measured outcome had not been met.

¶79.137 When SOM Smith took charge of the Operational Support Team and control room training in January 2015, she did not ask whether a training plan had been developed.^14781478 Smith {Day204/160:2-5}. She told us that POM Hayward had asked her to deliver a training plan for Vision.^14791479 Smith {Day204/160:2-10}; {Day204/161:1-4}. Although they had discussed delivering other training after Vision had been implemented, at that time attention was clearly concentrated on Vision.^14801480 Smith {Day204/160:2-10}; {Day204/161:1-4}; {Day204/166:1-6}. Accordingly, there had been a training plan for Vision but not for other training, such as training on handling fire survival guidance calls.^14811481 Smith {Day204/165:13-19}. SOM Smith told us that at that time the training plan had taken the form of large calendars displayed on a wall of the Operational Support Team's office on which entries were made following discussions by email within the team.^14821482 Smith {Day204/162:23}-{Day204/163:4}; {Day204/166:25}-{Day204/167:3}. As she accepted, that did not constitute a detailed formally documented training plan.

¶79.138 In November 2014, the Directorate of Audit, Risk and Assurance in the Mayor's Office for Policing and Crime audited the LFB's arrangements for the management of the control room.^14831483 Email chain between Scott Hayward and Karen Mason dated 17-18 November 2014 regarding Brigade Control Audit {LFB00030108}; Hayward {Day201/42:1-4}; Internal Audit – Progress Report Quarter 3 2014/2015 dated 9 March 2015 {LFB00044640/1}. It was the first time such an audit had been carried out.^14841484 Hayward {Day201/42:1-4}. One of the matters that interested the auditor was how the training team ensured that all staff received fire survival guidance training annually.^14851485 Email from Karen Mason to SOM Bagnelle on 14 November 2014 {LFB00030108/3}.

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¶79.139 The audit identified a number of risks, including:

¶a. intentional or unintentional alteration of the training spreadsheet, affecting the monitoring of training and reporting to senior management;

¶b. inconsistent and inaccurate completion of the spreadsheet, leading to inappropriate decisions;

¶c. ineffective monitoring of fire survival guidance training, leading to reputational damage if serious incidents were dealt with by inadequately trained staff; and

¶d. inadequate training, resulting in inappropriate responses to incidents.^14861486 Summary of MOPAC Audit of Brigade Control dated February 2015 {LFB00044640/25-26}.

¶79.140 It recommended that an independent record of fire survival guidance training be maintained and monitored for all control staff to ensure that all staff were in receipt of training at least annually and that a monthly report be produced by the Operational Support Team setting out the position in relation to training for the current year.^14871487 Summary of MOPAC Audit of Brigade Control dated February 2015 {LFB00044640/25-26}.

¶79.141 Both POM Hayward and AC Brown acknowledged that the risks identified in the audit had existed and that a failure to ensure that staff received adequate fire survival guidance training could result in serious injury or death,^14881488 Hayward {Day201/45:19}-{Day201/47:2}; Brown {Day207/87:6-18}. and we have no reason to think that they were not aware of those matters at the time. Yet, neither of them took effective steps to ensure that the auditor's recommendations were implemented. AC Brown probably used the report as the basis for a discussion with POM Hayward to satisfy himself that everything was working correctly, but did not go further than that.^14891489 Brown {Day207/88:18-25}. It is unlikely that POM Hayward did anything beyond asking SOM Smith to check that the Operational Support Team was maintaining training records, because at that time they were concentrating entirely on training for the introduction of Vision.^14901490 Hayward {Day201/51:17}-{Day201/52:18}. We do not consider that the drain on personnel resources caused by problems with Vision excuses the failure by senior management to give the auditor's findings and recommendations the importance they deserved. That was a significant failure.

¶79.142 When he conducted his review of the control room in 2016 AC George found that training to maintain skills was irregular, not robustly planned and often not recorded on an individual's training record. Staff often failed to record training and were seldom instructed to do so.^14911491 AC George Review of Brigade Control dated July 2016 {LFB00032826/11} paragraph 47. He recommended that each OM ensure that an appropriate, robust, annual training plan was put in place for their own watch, agreed by their SOM and made available to all watch members and managers, and that training be recorded on an individual's training record. He also recommended that senior managers should work with the LFB's information management team to produce a solution similar to the training diaries used by station staff and make effective use of the brigade's systems, including StARS.^14921492 AC George Review of Brigade Control dated July 2016 {LFB00032826/12} paragraphs 49 c-f.

¶79.143 SOM Smith was given the task of implementing AC George's recommendations,^14931493 Appendix 2 to AC George's Review of Brigade Control dated July 2016 {LFB00032826/31}; George {Day205/105:15- 25}. although he accepted that he had been ultimately responsible for ensuring that that was done.^14941494 George {Day205/100:23}-{Day205/101:1}. He said that he had monitored progress through POM Hayward,^14951495 George {Day205/101:2-19}. but despite the force of his findings, StARS and STEP were not fully adapted to accommodate the control room until December 2018, nearly 18 months after the Grenfell Tower fire.^14961496 George {LFB00083884/6} page 6, paragraph 29(b); George {Day205/104:12}-{Day205/105:7}; Hayward {Day199/133:16-18}; Hayward {Day199/143:23-25}. It is also reasonably clear that although some work had been done, robust training plans for individual watches had not been put in place by the time of the fire.^14971497 Email from POM Hayward to AC George on 7 November 2016 {LFB00083865/9}; George {LFB00083884/6} page 6, paragraph 29(b); Smith {Day204/182:12}-{Day204/184:17}; Hayward {Day199/113:13}-{Day199/114:1}; George {Day205/106:7-14}.

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¶79.144 The failure to adapt StARS and STEP to accommodate the control room was the root cause of the difficulties encountered with planning and recording training.^14981498 Brown {Day206/173:6-17}; George {Day205/82:7}-{Day205/84:14}; {Day205/86:6-15}; Hayward {Day199/110:2-24}. AC George expressed surprise that previous managers had not made sure that the systems had been adapted to include the control room.^14991499 George {Day205/83:3-4}. Commissioner Dobson attributed the failure to a decision not to contract out the training of control room staff in 2012. He thought that, if that had been done, as it had for operational firefighters, the problems with training generally, and record-keeping in particular, would have been identified earlier. Regardless of the merits of Mr Dobson's view, however, it is not a good excuse for the failure to plan, record and provide training after 2012.

¶79.145 When he carried out his review of the control room in July 2019, AC Jonathan Smith found that the current provision of training, assurance and professional development required a complete and systematic overhaul. Training was irregular and lacking in structure, there was no system of quality assurance and the recording of training was inconsistent. Those criticisms were linked to wider concerns relating to culture, accountability and leadership.^15001500 AC Smith's briefing note entitled 'Control – Overview and Control Improvement Plan' dated 22 July 2019 {LFB00084097/3-4}.

The management of fire survival guidance training

¶79.146 The failure to deliver regular fire survival guidance training after the Lakanal House fire represents a significant omission on the part of those responsible for the management of the control room. When senior officers were warned in the years after the Lakanal House fire that fire survival guidance training was not taking place, they should have taken effective action to make sure that it was provided. The management of fire survival guidance training was lacking in two other important respects: first, no objective criteria had been established by which to evaluate and monitor training or the quality of emergency call-handling; secondly, fire survival guidance training was not subject to consistent reporting or monitoring.

¶79.147 The LFB monitored only three aspects of the control room's performance,^15011501 Review of Brigade Control, July 2016 {LFB00032826/5} paragraph 22. all of which reflected performance indicators relating to the control room in the London Safety Plan.^15021502 George {Day205/69:14-17}; London Safety Plan 2014 {LFB00032107/70}. They were:

¶a. the average time taken to answer an emergency call;

¶b. the percentage of emergency calls answered within 7 seconds; and

¶c. the average time taken to deal with an emergency call.^15031503 Review of Brigade Control, July 2016 {LFB00032826/5} paragraph 22.

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¶79.148 As far as the control room itself was concerned, it was for the AC and the POM to decide which aspects of performance should be monitored, but no discussion appears to have taken place between them about whether any other aspects of performance should be considered.^15041504 Hayward {Day199/15:22}-{Day199/16:7}; Brown {Day206/47:2-13}. That may have been because AC Brown thought that performance indicators were relevant only to things that can easily be measured.^15051505 Brown {Day206/46:24-25}. He thought that it was difficult to monitor quality because that required the evaluation of a process.^15061506 Brown {Day206/46:21-24}. There was no key performance indicator relating to training, although he took the view that, if the three indicators mentioned above were moving in the wrong direction, that would be a clear sign that training was not effective. For that reason, he thought that the three existing indicators provided some assurance that training was taking place.^15071507 Brown {Day206/45:23}-{Day206/46:15}. That was not the case, of course, because they related only to response times and did not reflect the content or quality of responses to calls, particularly fire survival guidance calls. It is, therefore, unreal to suggest that the key performance indicators could be treated as indicating the overall quality of training. It was a significant failure on the part of senior management not to recognise that there were no effective means of assessing the quality of responses to fire survival guidance calls.

¶79.149 AC George said that the three aspects of the control room's performance to which we have referred reflected the information that LFEPA, as the LFB's supervising authority, required.^15081508 George {Day205/71:9-21}. He thought that LFEPA was interested only in numbers and quantities, which effectively dictated their scope.^15091509 George {Day205/71:11-21}. Although he had reservations about that approach, there is no evidence that he or any other senior officer ever suggested that some other objective standard might be adopted by which to assess the quality of the control room's responses to emergency calls generally or the quality of its responses to fire survival guidance calls in particular.^15101510 George {Day205/71:23}-{Day206/72:3}.

Arrangements for reporting and monitoring control room training

¶79.150 We referred earlier to POM Hayward's laissez-faire style of management. He treated the absence of any reports of difficulties as an indication that the SOMs were managing training effectively, but the fact that fire survival guidance refresher training was not being consistently or effectively provided from 2012 onwards without his apparent knowledge demonstrates the weakness in his approach. There should have been a mechanism by which the SOMs or the Operational Support Team reported to him regularly about training generally and fire survival guidance training in particular. Together with a proper training plan and reliable training records that would have enabled him to monitor the provision of training against established criteria and satisfy himself and more senior managers that the LFB's duty to train control room staff was being properly discharged.^15111511 Summary of MOPAC Audit of Brigade Control dated February 2015 {LFB00044640/25}.

¶79.151 It is significant that when AC Chandler was Head of Control and Mobilising, he recognised the need for improved arrangements for planning and recording control room training and was taking action to put them in place so that they could be easily audited.^15121512 Minutes of Brigade Control Management Meeting on 18 July 2012 {LFB00113237/7-8} item 5; Minutes of Brigade Control Management Meeting on 12 September 2012 {LFB00113402/6} item 5; Email from POM Hayward to OM Vic Bagnelle dated 9 May 2013 {LFB00042081/1}.

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¶Some improvements had been made by June 2013,^15131513 Email from AC Chandler to AC Brown dated 28 June 2013 {LFB00060701/2}. but it is clear that progress came to a halt when he left the LFB in October 2013,^15141514 Email from POM Hayward to SOM Bagnelle, OM Diamond and SM Ajimal on 22 July 2014 {LFB00051294}. because, when AC George carried out his review in July 2016, he discovered that planning and recording training was still a problem.^15151515 AC George's Review of Brigade Control dated July 2016 {LFB00032826/11-12} paragraphs 47-49.c. It is also clear that he did not address the problem effectively before he became Director of Operations in April 2017.^15161516 AC Jonathan Swift's conclusions in respect of the planning and recording of Brigade Control training in July 2019 {LFB00084097/3}.

¶79.152 On any view, as AC Brown rightly accepted, the involvement of the assistant commissioner was important in the management of the control room.^15171517 Brown {Day206/56:19-21}; {Day206/58:2-7}. The consequences of leaving POM Hayward without effective supervision between October 2013 and March 2016 are clear from our description of how matters developed during that period.^15181518 George {LFB00032823/2}; Performance Information Folder: Operations, Prevention and Response for Performance CMB dated 12 February 2014 {LFB00042326/73}.

¶79.153 AC Brown requested the appointment of an assistant commissioner to join the management of the control room as Head of Control and Mobilising in May 2012 precisely because he needed someone senior to manage it more closely than he could himself.^15191519 Brown {Day206/53:5-17}. He said that his position, which at that time was AC Operations, Prevention and Response and Third Officer, effectively combined two important functions, each previously performed by an assistant commissioner, with a significant increase in his responsibilities.^15201520 Brown {Day206/43:25}-{Day206/44:10}; {Day206/53:8-17}; Brown {LFB00032166/3} page 3, paragraph 5. POM Hayward said that as a result, his scheduled meetings with AC Brown would sometimes be cancelled or curtailed and he found it difficult to contact him.^15211521 Hayward {Day199/14:3-9}; {Day199/19:2-5}. AC Brown accepted that, but said that meetings would be rearranged and that even if POM Hayward had not been able to get hold of him when he wanted to, there had been ample opportunity to discuss matters.^15221522 Brown {Day206/44:4-10}; {Day206/52:12-17}. He did accept, however, that when he had become Director of Operations in April 2015 the extent of his responsibilities had adversely affected his capacity to manage the control room generally and POM Hayward in particular.^15231523 Brown {Day206/60:12-20}. In an echo of AC George's observation, AC Brown thought that the geographical separation of the control room had also contributed to difficulties in managing it, because when the control room had been moved to Merton, it had become both more difficult and more time-consuming to visit it.^15241524 Brown {Day206/49:21-25}. The net effect, according to POM Hayward, was that AC Brown did not actively supervise the management of control room training.^15251525 Hayward {Day199/37:16}-{Day199/38:8}. POM Hayward made similar comments about AC Chandler and AC George, although it is evident that AC Chandler did exercise a greater degree of oversight.^15261526 Hayward {Day199/37:19}-{Day199/38:8}; {Day199/95:17-20}; {Day199/100:21-25}; Brown {Day206/56:8-15}.

¶79.154 AC Brown did not think it was his responsibility to examine the control room training records personally to ensure that fire survival guidance refresher training was being delivered properly. He relied on POM Hayward to schedule and monitor it and checked on the position at monthly management meetings. He could not remember having received any complaints about the response of CROs to fire survival guidance calls after the introduction of the regular training that followed the Lakanal House fire and therefore had not had any reason to question whether refresher training was taking place.^15271527 Brown {LFB00032166/21} page 21, paragraph 66.

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¶79.155 We accept that an officer of AC Brown's seniority could not be expected to review details of training records personally, but the failures affecting the provision of training (and fire survival guidance training in particular) were longstanding and were well known to him and other senior officers responsible for the control room. As the various audits carried out between 2010 and 2016 consistently made clear, nothing effective had been done to remedy them. The responsibility for that failure must ultimately lie with AC Brown.

¶79.156 The criticisms of the way in which fire survival guidance calls were handled during the Lakanal House fire provided a powerful reason for senior management to satisfy themselves that fire survival guidance refresher training was taking place.^15281528 Lakanal Control Report dated November 2012 {HOM00001124/49-50}. Moreover, the discovery in February 2013 that the Operational Support Team had both reduced the time allocated for fire survival guidance training and removed the active role-play element^15291529 Brown {Day207/78:2-6}; {Day207/80:2-14}; Hayward {Day200/188:7-23}; {Day200/193:4}-{Day200/194:2}; {Day200/196:4-6}; {Day200/208:2-7}; {Day200/209:10-15}; Hayward {LFB00055191/24-25} pages 24-25, paragraphs 69-70; Emails between POM Hayward and SOM Bagnelle on 7-8 February 2013 {LFB00055221/1-3}. should have sounded a clear warning that fire survival guidance training was not being provided as agreed in the wake of the Lakanal House fire. It should also have alerted him to the fact that positive action and close and regular scrutiny was required. In fact, although both POM Hayward and AC Brown demanded that fire survival guidance training be delivered as promised, neither of them did anything effective to ensure that it was.

¶79.157 The failure to provide the fire survival guidance training agreed by the Lakanal House Board should have prompted AC Brown to question the effectiveness of POM Hayward's oversight of training, particularly given his more general concern about his day-to-day management of the control room.^15301530 Brown {LFB00084020/12-13} pages 12-13, paragraph 28; Brown {Day206/50:19}-{Day206/52:5}. Although AC Brown said that he had raised his concerns with POM Hayward directly and had taken action to address them, POM Hayward said that the only concern that AC Brown had ever raised with him was that he did not communicate with him enough.^15311531 Brown {Day206/50:19}-{Day206/52:5}; Hayward {Day199/18:20}-{Day199/19:17}. Whatever the truth of the matter, the practical result was that AC Brown did not act on his concerns about POM Hayward's management of fire survival guidance training. His failure to do so was serious, given the obvious risks to public safety.

Conclusion

¶79.158 The history of fire survival guidance training is long and complex, but the evidence gives rise to clear and consistent themes that reflect and confirm the broader failings of the LFB identified in this report. The control room was inadequately managed by POM Hayward who, in turn, was ineffectually led by senior managers, most notably AC Brown. The latter, in particular, was ultimately responsible for ensuring that CROs received the fire survival guidance training that they needed and also for ensuring that it reflected national guidance and the LFB's experience at the Lakanal House fire. As is plain from what we have said above, AC Brown failed to do that, leaving CROs ill-prepared to meet the admittedly exceptional challenges of the Grenfell Tower fire.

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