An overview of the regulatory issues associated with the Grenfell Tower fire may be found here.
This web page provides access to advice and comments by Gill Kernick, a professional involved in helping companies avoid devastating accidents in high risk industries. Gill had previously lived in Grenfell Tower and, at the time of the fire, lived in a nearby tower block. She was accordingly interviewed shortly after the fire on Radio 4's Today Programme (transcript at Annex below) and made some very sensible points, subsequently expanded in a blog published by Policy@Manchester and summarised as follows:
The Need for a Systems-Based Approach
The reaction to major accidents is often that they could not have been foreseen; that the nature of ‘low probability’ events somehow means we can’t prevent them. But it is now well understood that a major accident is not the result of a single event; it is a systemic outcome resulting from several latent (pre-existing and often hidden) conditions, usually triggered by an active failure (current failure e.g. human error or an ignition source) aligning at a moment in time that leads to horrific consequences.
One of the most effective ways of avoiding major accidents is therefore to deploy what is often referred to as mindful leadership or chronic unease; that is looking to imagine and fear the worst thing that could go wrong. Indeed, when these horrendous events do happen, there has too often been a shocking failure to learn. For example, in the Texas City disaster, almost every aspect of what went wrong had gone wrong before, either at Texas City or elsewhere. There may have been a similar learning disability around Grenfell: how is it that little notice appears to have been taken of cladding fires on high rise buildings in France, the UAE and Australia?
Indeed, most inquiries into previous major incidents have uncovered many instances of policies and procedures that are outdated, inaccurate and contradictory. Holding the view that ‘policies and procedures’ keep us safe, and the problem is the person or operator that didn’t follow them, is far too simplistic and will not lead to understanding deeper systemic issues. It is instead vital to understand the underlying drivers of behaviour including reward and measurement structures (both formal and practised). In Texas City, for instance, incentives were focussed around financial performance with some incentive around personal safety metrics. Attention to process safety or the prevention of major accidents was not encouraged through organisational reward and measurement structures.
It will also be necessary for the Grenfell Inquiries to consider leadership and cultural issues. Indications from residents (both prior to and in the response to the incident) suggest that there may have been a transactional, one-way leadership style that did not welcome or fully understand the views and concerns of residents.
[In a later interview Gill added detail to this leadership/cultural advice: In safe cultures there is a drive to feature both equality of life and equality of voice. All life matters and all life matters equally. And all voices are heard, and particularly the voices of those without power and authority.]
To summarise, it would be a grave mistake to identify human error as the cause of the tragedy. Human error is symptomatic of trouble deeper inside the system. It is of course necessary to try to find where people went wrong, but even more important to find how people’s assessments and actions made sense at the time, given the circumstances that surrounded them.
Will the Inquiries' Recommendations be Implemented?
Unless particular care is taken, even the best recommendations will not ensure learning. Typically, only around half of the recommendations made by a formal Inquiry will be implemented. In many cases the corrective actions will either not be taken or will not have the impact intended. One recent example is that the strengthening work recommended as a result of the collapse of Ronan Point in Newham (1968, killing four people) was never carried out at Ledbury Towers, South London. But the Cullen Report into Piper Alpha did lead to lasting systemic change. All the 106 recommendations made were accepted. Lord Cullen said: “The industry suffered an enormous shock with this inquiry, it was the worst possible, imaginable thing. Each company was looking for itself to see whether this could happen to them, what they could do about it. This all contributed to a will to see that something better for the future could be evolved.” The Inquiry team and the Hackitt Review should therefore build on Cullen and establish a process for the successful implementation of their recommendations and so ensure lasting change. Failure to consider the implementation of recommendations could severely limit their impact.
Gill has continued to maintain a close interest in the Moore-Bick Inquiry with a view to ensuring that they establish a 'no blame space', that sensible lessons are learned, and that their recommendations are actually implemented. She published a thoughtful paper in 2018 focussing on:
- What prevents regulatory and legislative systems from learning?
- Regulation and the nature of catastrophic risk.
- Ensuring equality of voice between those with power and those with less power.
Not Just The Cladding
Then, in January 2019, Gill published a devastating analysis of the evidence already submitted to the Inquiry, showing that:
- There should have been - but there wasn't - a 'wet riser' taking firefighting water to the top of the tower.
- The fireman's lift should have worked - but it didn't.
- The window glass should not have been set in plastic which melted at 50 degrees - much cooler than a cup of tea or coffee.
- 'Containment' failed - and so the fire authority's 'stay put' advice should have been abandoned - soon after the cladding caught fire.
- Apartment front doors should have closed automatically once residents fled - but they didn't.
In short, no-one needed to have died - cladding or no cladding.
Gill now has her own blog The Grenfell Enquirer . I recommend that you subscribe to it.
Annex - Gill Kernick's Interview
‘Today’ Radio 4
16 June 2017
Matthew Price (Interviewer) You were in some of those Residents Associations meetings of the Grenfell Tower. We know that people were expressing their concerns. How do you feel now about the way in which the residents conducted themselves in those meetings? Do you think they did everything they could to get their concerns across?
Gill Kernick ... there was one particular meeting I went to which was just where they were talking about the refurbishments. And the residents were very angry. I was a resident at that point, very angry, and in my experience the TMO was really not listening to their concerns. It was a very aggressive meeting. And one of my big regrets is at the time I thought this is not right. And in subsequent interactions with the TMO, because I now live in Trellick (MP in the nearby tower block) I've thought 'I need to do something, because this is not right'. The relationship between the management and the residents is not right.
MP The TMO is the tenancy management organisation which says it is aware of concerns and that at the moment is focused on the immediate needs of people here and will be looking at the long term implications. Your work, you work, you know about large scale disasters, you work in high hazard industries like oil and gas to try and make sure accidents don't happen. Are there lessons that can be drawn from your work with those oil and gas industries that you think might make sure that an accident like this can't happen again? What needs to be done?
GK Yes, I think first, .... it's been quite difficult looking at this from a professional perspective as I think there is a lot of lessons that could have been learned that weren't. I think there's two that particularly stand out for me. Number one is in major accidents you typically find cultures where people do not feel free to speak up or are not heard and from what we're hearing there is a clear link to that. The residents were not listened to and were not responded to or taken seriously so I think that is one thing from a cultural perspective that's common in a lot of major accidents. I think another thing is we have to get beyond the blame to the systemic and cultural and leadership issues that actually led to decisions being made. So if we just end up going, oh well, it's because of the cladding or it's because of this, and yes we need to hold people culpable for what they've done but there's broader systemic issues that need to be addressed.
MP Meaning that there needs to be greater communication and channels of communication?
GK Greater communications, channels of communication, we need to begin to understand what kind of competing tensions people are facing. You know, why did they choose the cheaper cladding not the more expensive cladding? What do you need to do to create a culture and a system that is founded on true care? How do we take care of our people? Not how do we follow rules or save money.