‘The real failure of Grenfell – complexity, ambiguity and competency.’ Prof. Torero Transcript
Prof. Jose Torero is an expert witness for Grenfell Tower Inquiry. This blog links to a video and transcript (all errors mine). It’s a presentation he made at the launch of a project Professionalising Fire Safety Engineering at the Warren Centre in Australia on 24 July 2018.
It is the best articulation of key systemic issues that contributed to Grenfell I have come across. I would highly recommend everyone listen to / read this prior to the Grenfell Inquiry Phase 1 report being laid before parliament on 30th October 2019.
It is also a brilliant demonstration of a learning and accountability mind-set which is a breath of fresh air. It’s for this reason I’m highlighting it inside of Good Practice!
Thanks to Alison Phillips for sharing this video with me. Prof. Torero – huge respect… Gives me a little hope in an often hopeless terrain.
Transcript (any errors / emphasis are mine)
… in the 1970s and the 1980s there was an enormous advance in our understanding of behaviour – of human behaviour; of structural behaviour in fire, that enabled us to create tools for engineers to be able to design in an explicit way. We were coming from a period, a very very long period, of almost a hundred years, of very strict regulations. That not only narrowed the capacity of professionals to be able to deliver innovative structures, innovative buildings but also introduced massive safety factors in many aspects associated to fire safety.
So, we were coming from an environment where we had over-simplified buildings. We had created situations in which were we were imposing extreme levels of protection and we were introducing measures that were not only expensive but highly over-dimensioned. And therefore there was a need to try to refine and better understand and try to improve the way in which we put fire safety as an application into the built environment.
Now, all that knowledge was created by the forefathers of our field and individuals that were experts in areas such as – combustion; fire safety; structural integrity; material degradation and human behaviour (the psychology of people in buildings); sprinkler systems; smoke detection – a very broad range of disciplines and all this knowledge had been put together in a way that had enabled the creation of numerous tools that now engineers could actually use.
So on the basis of that recognition there was a keen interest around the world to try to find better and more explicit ways to establish fire safety in buildings. Now when you think about more explicit and more clear ways of establishing fire safety, that immediately emphasises the process that we are going to introduce. A process by which we are going to liberalise the set of rules that we were operating with. In certain countries like the United States that process was extremely slow, in other countries like Australia, New Zealand and the United Kingdom that process was extremely fast.
It was accompanied by other drivers such as the need to try to reduce energy consumption; in building sustainably, the use of novel materials, optimisation of structures – all these different elements that effectively required a much more rational view of fire safety because we were an impediment for the progress of the rest of the construction industry. Now this recognition that this was a way forward to try to integrate us within a community of engineers came also with the recognition that there was a need to develop competency.
It seems that this is where we failed and this is where now we find ourselves in a position where we actually need to revisit what happened between the original Warren Centre Report and the situation in which we found ourselves today.
Somehow our attempts to introduce competency into the discipline and to create a true profession within fire safety engineering did not have the same level of success as our success in trying to apply engineering tools into rationalising fire safety engineering. And unfortunately the Grenfell Tower is a perfect example that reminds us in a very very painful way of the mistakes that we made.
Now I would like to take a little bit of a step back and explain a little bit what is the feeling today of what is the big lesson that has been learned from the Grenfell Tower Fire.
So as you all know June 14 2017, there there was a very very small kitchen fire in a residential apartment block in London in the area of Grenfell. And that very very small kitchen fire, the type of fire that we could consider there has a probability of 1 – it’s the size of a wastepaper basket. That fire was capable of breaching the compartment igniting several components of a cladding system resulting in a fire that propagated all 23 stories of the building, propagated laterally trapping eventually 72 people that died in the fire.
The fire service found itself in a position where they were completely incapable of understanding the behaviour of the building and therefore the response towards the fire was to remain within the protocols that they had pre established for a fire of that nature and those protocols failed in a very dramatic way.
So the question is how did we get there? You know what is what happened and what is what we are learning from this process and how does that relate to this Warren Centre project. Now if you really think about it as we introduce the concept of performance-based design as we introduce the concept of engineering tools into fire safety engineering we also realized that there was no need anymore for an incredibly rigid regulatory framework.
And as we looked into this regulatory framework, we started moving in a direction where the regulatory framework became more guidelines than actually rules. So the original recipe that we had that had to be followed in a very careful way effectively became a series of guidelines that left in between very significant ambiguity.
Now this is actually appropriate if you actually look at structural engineering codes if you look at many other areas of engineering that deal with the built environment you will realise that embedded in those guidelines there is ambiguity. Now ambiguity is actually not a bad thing is what enables an engineer to be able to make choices, this is what gives you the freedom to innovate and it gives you the opportunity to be able to create leaner solutions.
But as that ambiguity started expanding so becomes the need for competency. The problem is as you start creating ambiguity then you start creating the need for somebody to interpret that ambiguity and interpret it in an appropriate way.
So effectively you become more and more and more reliant on competency. And as you’re becoming more and more reliant on competency then your efforts into trying to structure and well-defined competency become necessary.
Now the fact that we have more flexibility then enables to introduce new products and as we introduce new products we started changing the complexity of the systems. So if we look at an external building envelope from the 1970s what we will find is a completely non-combustible system with very very small windows that actually protect us completely from vertical propagation of a flame. What we see from a building facade of today is a continuous system that doesn’t have those barriers that encapsulates numerous plastics that try to actually deliver all sorts of other functionalities – like reducing vibrations, reducing energy consumption and so forth.
But this whole process that is giving us all these other functionalities; this whole process is giving us a new aesthetic that architects have expanded and multiplied all over the world at the same time increase in a very very significant manner the level of complexity.
So think of what we have generated: we have introduced ambiguity that requires competency and we have significantly enhanced the level of complexity that once again demands competency. So from both sides we’re coming to the point where we are demanding constantly the evolution of our competency to higher and higher and higher standards.
And this is where we failed. We failed to make a proper definition of what a competent fire safety engineer is. The moment that we failed to make the definition of what a competent fire safety engineer is what we create his confusion of competency. The moment that we create a confusion of competency we start asking ourselves a question: who is the competent authority and this becomes a very unfair working environment not only for engineers but also for the fire service.
What ended up happening in Grenfell was that the engineers delivered the building, those engineers did not exercise competency adequately. Their competence was not consistent with the complexity of what they were doing and they delivered a building on fire to the fire service that the fire service could not manage. It was not the fire service failure to address the problem of the building it is our failure to actually deliver the the building that the firefighters could actually work on.
So the expectation that the fire service should have understood building performance, the expectation that the. fire service should have been able to manage the fire is a really unfair expectation.
Nevertheless today were sitting in front of the television watching the testimonies of the firefighters at Grenfell and we are blaming them for what they were not able to handle . We expected them to come and fix the problem for us. We created the mess and they couldn’t fix the problem and now we want to blame them.
So we have to be very very careful because the problem and this came up in Judy’s Hackett’s our review the problem is as a society we do have an expectation on the fire service and that expectation is that they are the competent authority so when you look at Judith unit hackage report she will state that there has to be a new group of people that actually assess building performance that group of people includes individuals that understand building performance that group of people includes people that understand occupational health and safety and that includes the fire service. Why is that we cannot exclude the fire service because the burning bill is their work environment and we cannot exclude them from the process they have to be part of that process
Nevertheless when you read Judith Hackitt report from beginning to end you will find nowhere in that report the competency that is necessary for that fire service to be able to understand building performance at that level of complexity so that they can actually provide adequate advice for building approvals, Y ou know for building development but also adequate advice to their own responders to be able to understand to sufficient level building performance so that they can actually implement a proper strategy to fight an event of that nature.
So as you can see at the core of this problem is our enormous misunderstanding of competence.
We have enhanced the level of complexity and which have completely underestimate the wake or the implications of our actions; the unintended consequences of our actions.
So we have created a system that is way too complex for our current definition of competency. We have created a system that creates too much ambiguity to be consistent with our current definition of competency and we have created an expectation of competency from the fire service that is truly unfair given the training you know education and practices are currently the fire service have. And therefore it is so fundamental to be able to address this problem head-on because that’s at the core of what we’re doing today.
So these problems that we’re seeing, these problems are being evidenced by the Grenfell Tower fire are fundamentally the tip of an iceberg that truly manifests a poor and misunderstood definition of competency.
So I do hope that this brief presentation gives you a little bit of a sense of why this is so fundamental. Being able to deliver a safe environment for occupants of a building is a fundamental social responsibility that we have as governments as engineers as professionals and if we cannot deliver this fundamental level of safety fundamentally because we’re not understanding the limits of our own knowledge we are effectively not operating within a professional framework.
We do hope that this Warren Centre project is going to deliver the structure that will allow us as a profession to create an adequate framework of competency that will enable us to interact with other professions other disciplines in a way such that we are respected as a profession. Because the final comment that I want to make is that when you have a poor definition of competency the only result of that is conflict – it is unavoidable. The moment that we do not define competency correctly is very very easy to avoid responsibilities it’s very easy to point the finger at others and at the end of the day that’s the responsibility for fire safety is ours as a profession and we need to be able to deliver it at a level that is consistent with the complexity , you know the elegance of the buildings that we want to build the enormous functionality that we are demanding and we cannot be the ones who fall behind and eventually end up being responsible you know for failures like the one of Grenfell
Thank you very much. Thank you.