Grenfell; Space Ships and the Shard – the problem with the London Fire Brigade Commissioner’s statement.
On the 30th October 2019, the Grenfell Inquiry Phase 1 Report will be published. It will consider the failings of the London Fire Brigade. These rest, I believe, in a failure to understand catastrophic risk and to create a learning culture – they don’t rest with individual firefighters.
Whilst giving evidence to the Grenfell Tower Inquiry, in September 2018, the London Fire Brigade (LFB) Commissioner Dany Cotton said that, even with the benefit of hindsight, she would do nothing differently on the night of the fire. She said she would not train firefighters for a cladding fire any more than she would train them for “a space shuttle landing on the Shard”.
Dany Cotton’s recent insistence on sticking to her position has prompted me to write this. I’m not wanting to blame her. I’m not wanting to attack her. From what I’ve seen, there is much to admire about her leadership. I believe she genuinely cares for her firefighters. Her stance on mental health and willingness to speak publicly about her own struggles post Grenfell are admirable.
Her argument that the fire service is not the solution to the multiple failings that allowed a building such as Grenfell to be inhabited is absolutely correct. We cannot expect the fire service to become the mitigation against the appalling failures of government, regulators local authorities, architects, designers and the broader construction industry. We cannot expect the fire service with limited and decreasing resources to make up for the failings of others.
However, her statement that she would not train her firefighters for a fire like Grenfell anymore than she would train them for a space ship landing on the shard is problematic and indicates:
- a failure to understand risk and particularly the nature of low probability, high consequence risks
- a failure to create a learning culture
A failure to understand risk, particularly low probability, high consequence risks
High hazard industries such as oil and gas have, through tragic loss of life, learned many lessons about preventing low probability, high consequence or ‘unexpected’ events. Key to this is practicing chronic unease – imagining and mitigating against the worst thing that can happen.
If I asked anybody the worst thing that could happen in a high-rise residential building – somewhere near the top of the list would be ‘the building engulfed in fire and escape routes compromised‘. They would say this even without any knowledge of the failed opportunities to learn through previous cladding fires, compartmentation failures and calls to review the stay put policy.
From the lens of chronic unease, Grenfell was entirely predictable. It could and should have been planned for. Dany Cotton’s position that firefighters should not have been trained for an event like Grenfell is baffling. The fact that previous cladding fires had not entered the building does not mean they should not have been prepared for such an event. The fact that something has not happened – is not a predictor that it will not happen.
The application of a method such as the widely used major accident bowtie would have helped predict, prevent and prepare for how to respond to such an event.
When your firefighting strategy relies on compartmentation and fire fighting, rescue and egress is restricted to a single staircase – to not consider all of these systems failing catastrophically reveals a troubling lack of understanding about the nature of low probability, high consequence risks and a failure to practice chronic unease.
Grenfell was entirely predictable, it should have been planned for and the failure to do so rests with those at the top of the organisation, not with the firefighters on the night. This failure to understand and mitigate low probability, high consequence risk is a key contributor to Grenfell.
The failure is not limited to the fire brigade, the same could be said of local authorities, government, architects, designers, the construction industry and the housing sector. But, from the perspective of the function of the fire brigade – they should have been prepared for an event like Grenfell. That they were not and the continued denial that they should have been indicates the lack of a learning culture.
A failure to create a learning culture
Danny Friedman QC lawyer for some of the bereaved and survivors said in his closing statement at the Grenfell Inquiry that:
- after the Lakanal House Fire (2009; 6 deaths) the London Fire Brigade said they would prepare for fires that behaved inconsistently with the principle of compartmentation and develop contingencies for when it did; they would also review inspection regimes and information gathering to identify risks before they arose. Policies governing these areas were updated in 2015.
- A training package educating about cladding fires was issued between the summer and autumn of 2016.
- The LFB issues a letter to the Royal Borough of Kensington and Chelsea (RBKC) and other councils across London in April 2017 that cladding panels could be in breach of building regulations.
The multiple failed opportunities to implement corrective actions after other fires such as Lakanal, and the lack of practicing chronic unease indicates a culture that refuses to learn. Organisations don’t learn from trainings, they don’t learn from e-mailed powerpoint, they don’t learn from new policies.
We learn in an environment that encourages discourse around errors. We learn when errors, mistakes and policy violations are openly admitted and discussed without fear of repercussion. We learn when we are not afraid of being blamed. We learn when our views are valued no matter what our position, we learn when our voices count.
Learning is a cultural phenomenon.
I have, and always will defend the firefighters on the ground that night. They were put in a position of responding to an event they were not prepared for and acted with enormous courage to save as many lives as they could. Did they make mistakes – yes. And… they have to live with those choices and their consequences . Anything other than compassion and respect is an inappropriate response.
It is very easy to judge actions with the benefit of hindsight. This biased view does little to enable learning and is simply not fair. To understand and learn we should be exploring why their decisions made sense.
Action is context dependant and it is by understanding the context inside of which decisions made sense that we can begin to move beyond blame and learn.
We will not learn from Grenfell by blaming individual firefighters, we will not learn from Grenfell by coming up with a new policy or training package. We will not learn from Grenfell unless we seek to understand why decisions made sense, why previous events were not learned from, why low probability high consequence events are not planned for.
These issues are cultural in nature and accountability for setting the culture rests with senior leadership. They too are operating in a socio-political landscape that does not pull for learning. We need to explore and understand why decisions made sense, why previous lessons were not learned, why low probability, high consequence risks seem to have been ignored. This will provide the opportunity to learn – a blame narrative won’t.
A final word…
During her evidence Grenfell survivor, Hanan Wahabi (who escaped the fire with her children, and watched as her brother Abdul Aziz Wahabi, his wife and 3 children died on the 21st floor) said:
It was very upsetting to hear Dany Cotton say that she would have done nothing different on the night.
This is like saying that there are no lessons to learn. I know that people tried their best, but mistakes were made.
Sir Martin, as we move forward, I implore you to make the case and space for learning and reflection, for ensuring we hear from witnesses what they have learnt.
Saying they would do nothing differently cannot be an acceptable response if we are serious about learning.
72 people passed away and we can’t bring our loved ones back.
The impact it’s had on our families and our community could have been prevented.
We can’t change that now, but we can change the lives of those we’ve lost to count, for their deaths not to have been in vain.
There has to be change. We have to learn from this.
As a result of this inquiry, I want the truth to be found and for change to happen.Hanan Wahabi, Evidence at the Grenfell Tower Inquiry
I really liked your post and agree with your standpoint about not commenting on the report until it comes out tomorrow, unlike the regular media who simply want to beat their competitors for sales. Ironically the DT is being sold by its owners … I have written about Grenfell in my new book ‘Building Passions’, as I believe better engagement between the built environment sector and the public might help mitigate against such disasters. It seems that the health and safety sector also played an important role in the outcomes so perhaps this becomes tripartite with the help of building standards that are fit for the 21st century?
Thanks Nick. Can you send me details of your book? I also believe creating better connection (or equality of voice) is critical.
Bowties summarise the overall picture of controls for a hazard. But they could only have prevented Grenfell if one identified “whole building conflagration” as the major accident event, “combustible external cladding” as the Cause and “mass entrapments / mass casualties” as the Consequence. The Bowtie would then reveal the absence of Preventative controls to stop rapid external fire spread, inadequate or ineffective Mitigative controls to provide for safe evacuation and the inappropriate firefighting response arrangements. It would then have been obvious the risk was not controlled to an acceptable level and new solutions were needed. All the crucial risk information should have been generated during a management of change process. Phase 2 will pinpoint the systemic and organisational failures that allowed this major accident hazard to be created. But all too slowly.