The Grenfell Inquiry Phase 1 Report: One critical question it must answer.

UPDATE: I will be responding to the Phase 1 report, but want to do so once I’ve reviewed it fully… It’s lengthly…

On Wednesday the 30th October 2019, the Grenfell Inquiry will publish it’s Phase 1 Report. Almost 2 1/2 years after the fire that killed 72 people and devastated so many lives.

I lived on the 21st Floor of Grenfell from 2011 to 2014 and watched it burn. 7 of my former neighbours died. My thoughts, as we wait for the report to be published, are with those who lost their loved ones; and the firefighters who failed to save them.

I want my response to the report to be considered. After much thought, there is essentially one question against which I will assess it:

Will the Phase 1 Report lead to change?


Professionally I partner organisations in high hazard industries to develop the leadership capability and culture to prevent catastrophic events such as the Grenfell Tower fire. As I watched the building burn, I vowed to do what it takes to ensure we learn and to make those lost lives, in some way, count.

On the 15th June 2017, as the building smouldered, I wrote this…

Phase 1 of the Grenfell Inquiry is focussed on understanding what happened that night. Phase 2 will focus on how and why. To an extent that means the Phase 1 report’s bias will be technical and procedural, but I am looking for signs that the Inquiry intends to explore systemic, cultural and leadership failings.

The fundamental question I will be asking is: Will it lead to change? And specifically:

  • Will it lead to short term change and make people safer?
  • Will the narrative focus on blame or systemic issues and learning?
  • Will the recommendations be implemented?

Will it lead to short term change and make people safer?

Grenfell was not simply a result of the cladding, there were multiple failings and these are not isolated to Grenfell.

There are hundreds of unsafe buildings across the country. The magnitude of the issues raised by Grenfell is still being confronted. Hundreds of buildings have ACM cladding, many more have other forms of flammable cladding. The Barking and Worcester fires have shown how vulnerable many of our buildings are. The materials we have built with and the quality of our work means thousands of people are at risk every day in their homes.

I will be looking to see if the report speaks to the number of failures in the building rather than simply the cladding and breach of compartmentation. Will it address the materials around the windows that allowed the flames to access the cladding? Will it address the failed fire doors? Will it address the failed ventilation system?

I will be looking to see what the report says about regulatory compliance and whether Grenfell was deemed habitable after the refurbishment. Expert witness Dr Lane said during her evidence: ‘I think that if those materials had been known the building shouldn’t have been occupied because then the London Fire Brigade (LFB) would have then also known what was facing them.’

The following is a link to part of Dr Lane’s evidence around compliance of the single stairwell. Failure of this inhibited rescue and escape. What will the Inquiry say about compliance of the building and whether it should have been occupied?

As we know, there are hundreds of buildings with similar failings as Grenfell. So, I will be looking to see what the report says about the compliance to regulations at Grenfell, but also how the recommendations will make others safe in their home.

To lead to to change the report must make strong recommendations to ensure past failings in fire safety are swiftly corrected and people are safe in their homes.

Will the narrative focus on blame or revealing underlying systemic issues and learning?

I understand the desire to blame people and whilst I believe people should be held to account, blame does not lead to learning.

A culture of blame can develop because it is often easier, cheaper, and more emotionally satisfying to hold an individual responsible for an accident than to acknowledge more fundamental problems in an organisation.

These may be more problematic, requiring resources, and more work. A culture of blame prevents the identification of other underlying causes.

Andrew Hopkins, Understanding Human Error, 1990.

I’ll be reading the report to see if the focus is on blaming individuals or understanding underlying systemic issues and enabling learning.

Whilst it might feel as if justice is served by an individual being blamed, action is context-dependant. If we remove somebody, they will simply be replaced by someone else operating in the same context, and the new person is likely to make similar decisions under similar circumstances. For learning and change we need to both understand and then shift the context inside of which actions are taken.

To do this we must explore and understand why decisions made sense and guard against hindsight bias. This will be particularly relevant regarding the firefighters.

I will be looking to see what is said about Dany Cotton’s statement that training for Grenfell would have been like training for a spaceship landing on the shard. In my view this reveals a lack of understanding of the nature of catastrophic risk and a failure to create a learning culture. These kinds of issues should be called out, rather than a focus on blaming individual firefighters.

I will be interested to see if it delves into competency or at least gives an indication of how it will approach this in Phase 2.

To lead to change, the report must not focus on blame. It must explore the underlying systemic issues and seek to guard against hindsight bias and understand why decisions made sense within the context they were taken.

Will the recommendations be implemented?

There is no accountability structure for the recommendations from Public Inquiries to be either implemented or effective. Fundamentally, the government can either accept or reject the recommendations. Once accepted there is no process in place to ensure that the recommendations are implemented.

The Institute for Government’s report on how Inquiries can lead to change is a valuable resource. In the absence of a mechanism for swift and effective implementation of recommendations, I’ll be looking at what the Inquiry will do.

To lead to change, the report must seek to ensure that it’s recommendations will be accepted and effectively implemented in a timely manner.

In memory….

I wrote this on the memorial wall at Latimer church just after the fire. The rain washed it away.

“Out beyond ideas of wrongdoing and rightdoing,
there is a field. I’ll meet you there.
When the soul lies down in that grass,
the world is too full to talk about.
Ideas, language, even the phrase “each other”
doesn’t make any sense.
The breeze at dawn has secrets to tell you.
Don’t go back to sleep.
You must ask for what you really want.
Don’t go back to sleep.
People are going back and forth across the doorsill
where the two worlds touch.
The door is round and open.
Don’t go back to sleep.”


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