The Grenfell Tower fire began shortly before 0100 on Wednesday 14 June 2017, and killed 72 people. It quickly became clear that the fire had spread from apartment to apartment via cladding on the outside of the building. It later became clear that "it wasn't just the cladding". For instance:
- 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.
This all points to a horrendous multiple failings by regulators and and licensing/inspection bodies.
Four separate Inquiries were begun soon after the fires - see Annex below. They will almost inevitably identify human or political error as the immediate cause of the tragedy. But human error is merely 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. I am indebted to Gill Kernick , a professional involved in helping companies avoid devastating accidents in high risk industries, for helping me identify the following issues. (Follow this link to read Gill's interviews, blogs etc.)
Systemic, Cultural and Leadership Issues
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.
In the case of Grenfell Tower, evidence already submitted to the Inquiry shows that there was one ignition source and (at least) seven dangerous latent conditions. So an ordinary kitchen fire:
- escaped through an insufficiently fire resistant window and ignited supposedly fire-proof cladding,
- spread round the top of the building and down the other sides via a supposedly fire-proof architectural feature,
- broke into other apartments through similar windows,
- and forced residents to flee through their front doors which didn't close behind them (as they should) so allowing poisonous smoke into the single staircase.
- Meanwhile, the Fire Brigade failed to realise that the rapid spread of the fire meant that 'stay put' advice was no longer appropriate.
- But they couldn't effectively fight the fires or rescue people because there was no wet riser delivering water to the top of the tower (although there should have been),
- and the Fireman's Lift did not work, because it hadn't been checked when it should have been.
Gill Kernick summarised one of the key underlying issues very well in a BBC interview:
“For the last 10 years I have worked predominantly in high hazard industries looking at how you create safe cultures … and specifically how to prevent major accidents – low probability, high consequence events. The key to change is creating a connection between the most senior levels of the organisation and the front line. Where the most learning and cultural change happens is when [senior executives] spend meaningful time listening to, and engaging with, the front line. In the case of housing, because of the complexity of the world we live in, it is the tacit knowledge of residents that is critical to keeping people safe. They have the experience of living in the building, they know what the issues are, and they probably know how to solve them.”
It will be necessary, therefore, for the Grenfell Inquiry to consider leadership and culture recognising that safe cultures require both equality of life and equality of voice.
- "All life matters and all life matters equally." This seems obvious, but it is a relatively new concept when you remember that it was regarded as quite acceptable to sacrifice huge numbers of navvies' lives when building railways (100 at Box Hill for instance) - and the same attitude clearly persists to this day on construction sites in the Middle East. Did the authorities unknowingly value tower block tenants' lives rather less than those who lived in grander houses in Chelsea?
- And all voices are heard, particularly the voices of those without power and authority. Indications from Grenfell 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.
So it will be interesting to see whether the Inquiry discovers evidence that the Council and/or other organisations dealt with Grenfell's residents in a condescending way, oblivious of the paramount need for all voices to be heard, and particularly the voices of those without power and authority.
Building on the above, experts know very well that one of the most effective ways of avoiding major accidents is to deploy what is often referred to as mindful leadership or chronic unease. Those responsible for public events, large buildings and other installations must imagine and fear the worst thing that could go wrong. And that means eliminating the sort of dangerous conditions that caused the Grenfell tragedy.
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 incentives - 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. In the case of Grenfell Tower, was there too much emphasis on cost-cutting, both in the refurbishment and in public services, including in the relevant regulators and in the Fire and Rescue Authority.
Also, 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? (And see further below concerning failure to implement the recommendations of formal inquiries.) Inside Housing (see also further below) have drawn attention to what appear to have been persistent failures to learn from, or at least to take the actions recommended by those who looked into the causes of, similar fires in previous years. Click here to read a more detailed discussion of failure to learn.
It should be noted that there were two other relevant latent conditions in addition to the seven listed above:- there was only one stairwell, and the apartments were not fitted with sprinklers. The Inquiry will no doubt consider the relevance of these factors but it does not currently appear that the authorities can be seriously criticised on these two grounds.
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 will hopefully build on Cullen and establish up 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.
Cladding - The Failure of Building Regulations
But it looks as though it was a grave mistake to cover Grenfell Tower with highly flammable material. And Inside Housing have published a pretty good summary of the ways in which building regulation had failed in allowing such cladding to be used. There were also disturbing reports in September 2018 that staff had been sacked for complaining about being required to manufacture non-fire safety compliant cavity wall insulation - other than when an announced inspection was made by a certification body or when they needed to send samples off to be tested.
One obvious answer is to increase the number of unannounced inspections, but there are now so many inspection bodies, all competing for work, that none of them want to annoy their 'clients' by inspecting them too effectively.
There is a similar problem in building inspection where many private sector companies have been approved, since 1997, to carry out building regulation inspections on behalf of developers - such inspections having previously been conducted by public officials. The Guardian's Robert Booth, for instance, drew attention in September 2018 to numerous examples of inadequate inspection, one of which forced the expulsion of the residents of a recently completed block of flats in Manchester. Faults included French windows opening onto thin air and inadequate smoke ventilation.
I suspect that Dan Corry identified an interesting issue when he blogged as follows:
'One of the things which struck me was the amount of complexity which surrounded both the cause of the fire spreading so fast and the subsequent attempt to look after survivors in a decent way. There were multiple agencies, regulators, commissioners, providers, subcontractors and suppliers involved and, in the end, finding out where it all went wrong is going to be tricky. For the follow up there seemed to be a vacuum between the local council, the tenant management organisation and the national government with the local charities and community groups wanting to feed into something but finding no one willing to step up. Some of this is incompetence and neglect or worse and heads have rolled. But it also points to another issue - are we making things too complex?'
There were immediate and understandable calls for those responsible for the building to be prosecuted, including on manslaughter charges. But prosecution would not reduce the chances of future similar disasters. It might also seriously impede the Grenfell Tower Public Inquiry, and Dame Judith's Inquiry into building regulations and fire safety,, as those threatened with prosecution will be very reluctant to speak freely or at all. Worse still, prosecutions strengthen the belief that there has been human error, whereas it is unfortunately all too true that an investigation that ends up blaming human error will have been a waste of time, for no real lessons will have been learned.
The truth is that no-one seriously thinks about the risk of prosecution when making construction or regulatory decisions, so prosecution cannot act as an effective deterrent to poor decision making. As Gill Kernick has pointed out (above), the cultural issues and the competing tensions are very complex and can only be addressed via better regulation and enforcement.
The 'prevent or punish?' question is important in many regulatory areas and a longer discussion is here.
Finally, some media and political comment has portrayed Grenfell's residents as deprived, and it is true that the wider North Kensington area ranks as amongst the 10% most deprived areas in the UK, in stark contrast to other areas of Kensington and Chelsea. But it is important to recognise that Grenfell's residents did not, and do not, regard themselves as downtrodden. The tower was a strong mixed community and included many with good incomes and education. Those who have heard the survivors speak in the months following the fire cannot fail to have been impressed by their dignity and the clarity with which they express their feelings and their concerns. Survivor Mohammed Rasoul put it well: "Everyone says, you know, 'oh, it's the most deprived area in London', but we might ... have been deprived materially, but not morally, not emotionally."
Annex - The Inquiries
The following questions clearly arise:
- Were risks were taken in the procurement of the cladding - in particular to save money?
- Had other unnecessary risks been taken in the recent refurbishment of the building?
- Had there been regulatory failings - in drafting (or failing to revise) building regulations, or in materials testing, or in local authority etc. approvals and inspection?
- Should the extent of fire have been so surprising given that there had been opportunities to learn from previous similar fires?
The government established a formal public inquiry into the disaster, chaired by Sir Martin Moore-Bick. It has very wide terms of reference:- To examine the circumstances surrounding the fire at Grenfell Tower on 14 June 2017, including [various issues but not excluding anything] and ... To report its findings to the Prime Minister as soon as possible and to make recommendations.
The government separately established an Independent Review of Building Regulations and Fire Safety chaired by Dame Judith Hackitt, whose terms of reference were much more detailed. She has already published her final report and the government has published a meaty set of proposals in response - see this separate web page.
The Metropolitan Police have separately mounted a major criminal inquiry.
The Equality and Human Rights Commission launched its own inquiry (Following Grenfell) in December 2017, looking at the human rights and equality dimensions of the tragedy, and seeking to determine to determine if the State is fulfilling its duties under human rights and equality law. It will look at possible failings in these seven areas: The state's duty to investigate, Right to life, Inhumane and degrading treatment, Housing, Access to justice, Rights of children, Equality.