Questioning the unintended consequences of our default narratives and engaging in compassionate and informed enquiry is essential for learning. We all have a role to play in this.Gill Kernick
I’m posting a more detailed version of a blog published by the Bennett Institute for Public Policy at Cambridge University.
Link to the Cambridge Bennett Institute blog
A more detailed version…
14th December 2019 marked 30 months since the Grenfell Tower fire killed 54 adults and 18 children.
The Grenfell Inquiry Phase 1 Report, published on the 30th October 2019, was critical of the London Fire Brigade (LFB), concluding that the LFB was an ‘institution in danger of not learning the lessons from the Grenfell Tower fire’. (p.607, para 28:55)
The Commissioner of the LFB, Dany Cotton, recently announced her intention to depart at the end of the year, four months earlier than her planned retirement. This followed a meeting of the group impacted by the fire with the London Mayor, Sadiq Khan.
Both the criticisms of the LFB in the Phase 1 Report and the resignation of Dany Cotton were met with outrage and fierce defence of the firefighters. Whilst understandable, these narratives inhibit our ability to learn.
After presenting some key finding of the Phase 1 Report, the article considers three specific narratives:
- Heroes & villains;
- Cause & response and
- Blame & accountability.
It concludes that we have a collective responsibility to move beyond well-intended defensive narratives and focus on considered, compassionate enquiries that will lead to learning and change.
Key Findings of the Phase 1 Report
It is well established that practicing chronic unease (that is imagining and preparing for the ‘worst thing that can happen’) is the key to preventing and mitigating catastrophic (low probability, high consequence) events.
Bearing this in mind, some of the failings highlighted in the Phase 1 Report include:
- The LFB did not ensure that a contingency evacuation plan was in place at Grenfell in the event that compartmentation was breached, and the stay put policy became untenable. This was required both under national guidance (GRA 3.2) and LFB Policy (PN633).
- The LFB did not ensure that fire crews were aware of the risks of façade fires. The LFB did know of these risks:
- In 2016, it developed an internal presentation ‘Tall Building Facades’ concluding that whilst external envelopes should not contribute to fire spread, new materials were being used on facades which could affect the way fires develop and spread. This was not widely shared and, at most, one of the firefighters on the ground at Grenfell had seen it.
- Following a 2016 fire at Shepherd’s Bush Court; in May 2017 the LFB wrote to the Chief Executives of all London Boroughs warning that the façade at Shepherds Bush had not met building regulations in terms of limiting the speed of fire spread. It encouraged Local Authorities to include considering the extent to which external panels complied with building regulations in their risk assessment process.
- The LFB failed to train crews to gather critical information as required by both national guidance and LFB policy. They should have collected information specific to Grenfell relating to the likelihood and impact of fire spread beyond compartmentation and need for evacuation; the functioning of fire lifts and potential communication problems.
- The LFB did not learn all the necessary lessons from the Lakanal House fire, specifically around Fire Survival Guidance (FSG) Calls. For example, the LFB assumed that firefighters would always arrive quickly and rescue people when this might not be the case. (Chapter 8: pp 73)
It should be noted that most of these failings were thought to be common throughout the LFB, rather than isolated to Grenfell.
In her oral evidence, at the Grenfell Inquiry, the LFB Commissioner, Dany Cotton, said that preparing a training for an event such as Grenfell would be akin to ‘developing a training for a space shuttle landing on the shard.’ She also said that, even with the benefit of hindsight, there was nothing she would go back and change in terms of the firefighters’ response on the night. These remarks were called out, in the Phase 1 Report, both as insensitive and as evidence that the LFB was in danger of not learning from Grenfell. (pp.607; para 28.55)
It is impossible to review the evidence and not conclude that there were significant failings and that the LFB had failed to learn from previous incidents. The following are some key societal narratives that are inhibiting critical enquiry and learning.
Heroes and Villains
There is a instinctive narrative that ‘firefighters are good’ and ‘people who put the cladding on / cut LFB funding / wrote weak regulations etc.’ are bad. This narrative, whilst understandable, inhibits learning.
It is true that,
- the building should never have been covered in cladding that promoted the spread of fire,
- the firefighters should never have been put in a position of having to fight such a fire
- the firefighters’ bravery and courage on the night is beyond question
Yet, none of the above detracts from the fact that there are lessons for the LFB to learn. The Phase 1 Report suggests these failings are endemic and suggests a culture that does not learn.
We need to move beyond simplistic opposing narratives such as good and bad, or hero and villain, and embrace every opportunity to learn equally. We need to challenge any narrative that justifies or promotes any party not fully embracing learning and implementing lessons from Grenfell.
In the case of the firefighters this is emotionally complex. The public’s instinctive response to defend is founded in a deep respect for those that risk their lives to defend ours. But, this may have the unintended consequence of entrenching and reinforcing a culture within the LFB that does not learn or prepare for such catastrophic events.
Cause and Response
Closely linked to the hero/villain narrative is the need to distinguish between cause and response. The argument that the LFB should be immune from scrutiny because they did not put the cladding on the building is flawed. The LFB’s response to the event should be looked at irrespective of its cause.
The LFB knew of the dangers of façade fires and knew there was a risk that building façades did not meet regulations. They should have been better prepared, and the failure to do suggests the lack of a learning culture.
A consequence of the sequence of the Grenfell Inquiry Phases is that scrutiny of the LFB’s response has been highlighted in Phase 1 (what happened on the night of the fire) whereas the causes will be looked at in Phase 2.
Moore-Bick significantly found that the external envelope of the building did not comply with the Building Regulations (B4(1)) requirement of resisting the spread of fire. He said ‘it is clear that the walls did not resist the spread of fire. On the contrary, they promoted it, as can be seen in the video recordings of the rapidly developing fire which engulfed the building in just over 2.5 hours.’ (pg. 583, para 26.4). He also concluded that prior to the refurbishment the exterior walls fully complied with this requirement.
We must ensure that those culpable for causing the fire are rigorously scrutinised in Phase 2.
But, let’s not unintentionally buy into the narrative that because the LFB did not cause the event, they should not be held to account for failings in their response to it.
Blame and Accountability
As a society we are fixated with blame. If something happens, our first response is to look at who to blame. Unfortunately, this inhibits our ability to learn. It is much more useful to look at major failures through the perspective of accountability. James Reason summarised the problem in his book Human Error.
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.James Reason; 1990, Human Error
A blame narrative considers who’s at fault, is highly personal and assumes that removing the individual(s) – like some cancer – will solve the problems. People sometimes think ‘justice is served’ by removing the ‘person to blame’. However, action is context dependent and simply replacing someone and having them operate in the same context will likely lead to little change or learning.
An accountability narrative considers what structures (e.g. job roles and assurance mechanisms) were in place and how these were fulfilled or not. They may reveal failings by individuals in fulfilling their roles, organisational failures to assure that accountabilities were fulfilled, or missing structures. Even if an individual is found accountable, it is not a personal attack. It indicates a failure to fulfil on their role.
Many think that the LFB Commissioner Dany Cotton has been unfairly blamed or scapegoated. Let’s consider her position through the lens of accountability.
She had been in the position since early 2017, and prior to that was the Director of Safety and Assurance. She is retiring on full pension and being paid in full through to her initial planned retirement date in April.
The obligations of the Commissioner include: (Grenfell Tower Phase 1 Report, Volume 1: page 53, para 7.2, 7.3, 7.4)
- The promotion of fire safety and making provision for the extinguishing of fires and protection of life and property
- To fulfil this obligation the Commissioner is nrequired:
- to secure the provision of the personnel, services and equipment necessary efficiently to meet all normal requirements
- to secure the provision of training for personnel
- to make arrangement for dealing with calls for help and for summoning personnel
- to make arrangements for obtaining information needed for extinguishing fires and protecting life and property.
From this perspective, based on the evidence, the LFB Commissioner Dany Cotton did fail to deliver on some key accountabilities.
This is very distinct from saying she is to blame or personally attacking her. We need to understand in Phase II why her decisions made sense and explore the context she was operating in (including for e.g. cuts to fire crews). We need to understand what accountability mechanism were in place to ensure she fulfilled her accountabilities. (e.g. performance reviews, implementation plans for learning from Lakanal). To simply say, she has left and that equates to us learning would be to fail to honour either her, the firefighters’ who risked their lives or the 72 people who died.
We need to move beyond a blame narrative and with both compassion and a willingness to confront some difficult conversations, explore the failings of Grenfell through the lens of accountability.
Then perhaps we will be able to learn.
A Final Word
The human costs of the failure to learn are seen in the devastating account of Flat 142. Kamru Miah, his wife Rabeya Begum and their adult children, Mohammed Hamid, Mohammed Hanif and Husna Begum. The family called 999 four times, over the course of two hours, but no firefighter was ever sent to attempt to reach them.
The Grenfell disaster as a whole, and individual stories such as that of Flat 142, evoke high emotion and to some extent represent a microcosm of the divisions and narratives we face as a country. 72 people died; thousands of other buildings across the country are unsafe. There have been six major fires since June 2019.
Questioning the unintended consequences of our default narratives and engaging in compassionate and informed enquiry is essential for learning. We all have a role to play in this.
Grenfell Tower Inquiry: Phase 1 Report; REPORT of the PUBLIC INQUIRY into the FIRE at GRENFELL TOWER on 14 JUNE 2017; Chairman: The Rt Hon Sir Martin Moore-Bick October 2019
Reason, James; 1991; Human Error, Cambridge University Press.