Reality, Compliance and Leadership: Learning from Grenfell
Without a national register of safety risks, promises to learn from Grenfell and prevent such events in the future will always run hollow.
Gill Kernick
Blog based on a video keynote at the Housing Quality Network event on Digitising Governance and Compliance. 18 September, 2019.
I spend a lot of time sitting at the foot of Grenfell Tower. Thinking and reading the outpourings of pain. It keeps me true. We’re lucky no-one died in the recent fires at Crew Care Home and the Barking, Worcester Park and Hackney apartments. We’re lucky that another community does not have to grieve the way that North Kensington continues to grieve.
More than two years on, regulations remain unclear. Last week the latest edition of Approved Document B was withdrawn due to a potential error. Flammable cladding is still allowed on certain buildings and events continue to raise systemic issues with our building safety and construction practices such as the use of timber cladding, non-compliant fire-doors, the lack of working alarms and missing or incorrectly installed fire-breaks. Grenfell was not an isolated incident.
It’s sometimes easy to forget the human impact of these events, to get caught up in making sense of regulations or unravelling the list of safety concerns and poor practice being revealed.
I remember very clearly, as I’m sure you do, the first moment I saw Grenfell burning – it was out of my window. As much as those images haunt me, I believe staying connected to that moment is vital. That it will help instil a sense of urgency. A desire to move beyond waiting and hoping someone else will solve things…
If Grenfell is to lead to change, we need to confront reality; deepen our understanding of compliance and have the courage to provide bold leadership.
Confronting Reality
I was hopeful in the months after Grenfell that it would be the kind of disruptive event that leads to dramatic and lasting change. In the way that events such as Piper Alpha fundamentally changed the Oil and Gas industry. Two years on I am doubtful that this will be the case. The most significant factor that fuels my doubts is the failure to both confront and make transparent the brutal reality of how bad things are.
The O&G industry has had to learn how to safely operate poorly maintained ageing assets. Which I think is analogous to the housing stock in the UK. They have had to learn how to create cultures where senior managers are not being fed sanitised information and ‘greened’ dashboards. But are getting the ‘truth’. This starts with being willing to confront the brutal reality – knowing and embracing how bad things are.
And, in doing, looking distinctly at catastrophic risk – at preventing low probability, high consequence events. These are far more complex and difficult to see.
Practicing Chronic unease… imagining and mitigating against the worst thing that could happen that would lead to multiple deaths is perhaps the biggest to access to this. We need to expand our thinking beyond the prevention of fires engulfing high rises as in Grenfell to consider what else could cause multiple deaths, such as building collapse or toxicity.
From my perspective, a clear and transparent country-wide register of safety risks that considers low probability/ high consequence events distinctly, has to be the starting point. Until we confront the brutal reality at a national level our actions will at best be reactive and are unlikely to deal with underlying systemic issues.
Doing this will take courage and a move from a blame to a learning narrative. But without it, promises to learn from Grenfell and prevent such events in the future will always run hollow.
Compliance
I worry that we buy into a mythology that compliance will keep us safe. A culture of blind compliance can, in fact, increase the risk of accidents. It either pulls for thoughtlessly following rules without considering or understanding potential unintended consequences, or it pulls for people hiding and lying about where they do not follow the rules.
Regulatory compliance does not guarantee safety. In the UK, we know that both the regulations and the regulator have severe failings. But even good regulatory systems and regulators are by nature reactive. Given the increasing pace of change and innovation, they should be viewed as a minimum standard, not a guarantee of safe outcomes.
I frequently get told stories about bad practice. Of flammable cladding still knowingly being installed on high rise buildings when more expensive alternatives are available. Of people saying they don’t care what is safe as long as it complies with regs. Of people being too scared to speak up about bad practice because of potential commercial repercussions. These stories break my heart. We need to bust the myth that regulatory compliance equates to safe outcomes.
An organisation’s internal standards, policies and procedures can go beyond minimum regulatory standards and thus promote good practice. But we need to understand that there is always a difference between work as designed or imagined (which lives in our policies, procedures and standards) and work as done. People’s resilience and wisdom in navigating this gap is what enables organisations to function and for the most part function safely.
When the difference between work as designed and work as done is not openly explored and discussed, your risks increase. You do not know what is actually happening on the ground, you do not know the real risks and hazards you are facing and you’re making decisions based on an imaginary world, not on what is really happening.
The view that our regulations, systems and processes are perfect, and the problem is simply people not following them is flawed and needs to be openly challenged.
We need to create is a culture of mindful compliance. Where regulatory compliance is not seen as a guarantee of safe outcomes. where there is open exploration of the gap between work as imagined and work as done. Where people understand the potential impact and unintended consequences of their actions and are empowered to stop work and raise concerns.
Moving to mindful compliance demands appreciating and tapping the knowledge of those that at the coal face – of residents and communities, of Housing and Local Authorities employees and contractors. We need to engage and listen not from some paternalistic or moral perspective but because their tacit knowledge and experience will enable safe outcomes. Probably more so than that of the many technical experts sitting removed in board rooms and ivory tower talking about our safety.
Leadership
My interest and experience is in creating the leadership capabilities and cultures to keep us safe. Confronting reality and creating a culture of mindful compliance are ultimately challenges of leadership. As much as Grenfell resulted from massive regulatory failings it was also a result of poor leadership. Of failing to create a safe culture.
Learning from Grenfell will require bold leadership. From all of us. We cannot wait for the government, or regulator, or anybody else to implement change. It needs all of us and it will require looking at ourselves in the mirror and understanding how each and every action we take is sending a message and either building a good culture or not.
If you are engaged with confronting reality this is an enormous opportunity to reset your culture. In particular how you respond to bad news is a key mechanism for embedding a culture. Use it wisely. Don’t underestimate the leadership and courage this will take.
And, when you are faced with difficult decisions, remember that first time you saw Grenfell burning and let that help you make wise choices.
I’ll end with the words that Hanan Wahabi spoke to Martin Moore-Bick after giving evidence at the Grenfell Inquiry. Hanan’s brother, Abdulaziz El-Whabi, his wife Faouzia and 3 children Nur Huda, Mehdi and Yasin died on the 21stfloor.
‘72 people died as a result of what happened. None of them had to die. This could have been prevented and should have not happened. Please make sure there is change’.
Hanan Wahabi, Grenfell Public Inquiry, 2019
Link to video of the presentation.
This is the most relevant observation I’ve read to date on confronting what needs to be done post Grenfell. The shift required is Cultural.
Thank you!