Submission to the Grenfell Tower Inquiry re including the thinking and learning from Major Accidents

Gill Kernick Submission to the Public Inquiry re the Terms of Reference.


My interest in Grenfell is personal. Between 2011 and 2014. I lived on the 21st floor of the tower. 7 of my previous neighbours died. I watched it burn.  I vowed to ensure we learn lessons. Professionally, I partner organisations in high hazard industries to develop the culture and leadership capability to prevent disasters.  I have a particular interest in the prevention of low probability, high consequence events (Major Accidents or Catastrophic events).  

As I watched the fire I kept thinking of the Piper Alpha oil rig explosion that killed 167 people in 1988.  I believe there are important lessons from this and other major accidents in high hazard industries.  Both in terms of uncovering systemic issues and preventing such events. A key systemic cause of Grenfell Fire is, in my opinion, the failure to understand catastrophic (low probability/high consequence) events and how to prevent them.  have met with the Inquiry team during public consultations on numerous occassions and continue to advocate for this approach.

Submission to the Inquiry

Below  is the submission I made to the Grenfell Tower Inquiry during the consultation regarding the Terms of Reference.   I argued for the Inquiry to include:

  • an event based investigation;
  • a systemic investigation, and
  • a process to ensure that recommendations are successfully implemented.

Viewed through a professional lens, I believe there are key lessons to be learned from the thinking of major accidents (Low probability / High consequence events). Traditional views of safety and incident investigations will not provide the learning needed to prevent a tragedy of this nature happening again.

Viewed through a human lens, I believe there is a moral imperative to do so. It is the right thing to do to honour those that died in the Grenfell Tragedy. It is also the right thing to do to honour those that died in the disasters on which the learning is founded. They died, at least to some degree, having knowingly put themselves at risk by working in high hazard industries. In Grenfell, people died in their homes.

Kernick, G: Submission for Consideration by the Grenfell Tower Public Inquiry, p.2

A note on floor numbers:

In the submission I say I lived on the 22nd (previously the 18th) floor.  I in fact, lived on the 21st floor. The floor numbers were changed as part of the refurbishment.   Beforehand your flat number and floor number matched.  If your flat number was 185 (as mine was) you lived on the 18th floor.  The refurbishment added 3 floors and they changed floor numbers – so Flat 185 was now on the 21st floor.

The new numbers were not clearly marked in the stairwell, which contributed to the difficult internal conditions faced by firefighter and residents on the night.

Views and comments welcome…

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