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Category: Learning

Learning from previous events and other industries

Grenfell and the tacit knowledge of those at the sharp end – Ed Daffarn speaks to LBC’s James O’Brien.

LBC’s James O’Brien speaks to Ed Daffarn the author of the blog that predicted a catastrophic event at Grenfell.

An Analysis of the Design, Installation & Materials of the Rainscreen Cladding System at Grenfell Tower:

A technical analysis of what happened at the Grenfell Tower Fire.

This report looks objectively at the design of the cladding system and the way in which it was installed, whilst explaining some of the evidence heard at the Inquiry.

Power and Accountability: The psychological contract & responding to catastrophic event

Power and Accountability. The failure of politicians to be accountable for the psychological contract in the face of catastrophic events such as Grenfell, COVID19 and Hillsborough.

Cummings & our unwritten Psychological Contract: Are we asking the right questions?

This blog explores the Cummings’ crisis through the lens of a failure to attend to and restore an unwritten psychological contract in the aftermath of catastrophic events.

Rather than asking ‘how can we ‘move on’ from the Cummings’ crisis?’ those in power might instead seek to understand what a country in grief needs from them, to understand what it would take to restore the psychological contract and build trust.

COVID-19 Unheeded Warnings #2: Centre for Health and Public Interest 2013 Report

Adaptive capacity is a cornerstone of resiliance. Those that failed to ensure this capacity whilst listing a pandemic as a top civil risk need to be held to account.

A 2013 Report by the CHPI warns that the new NHS structure would impact the ability to fight a pandemic.

From interruption to disruption: Leadership and Covid-19

Rather than viewing #Covid-19 as an interuption and wait for things to return to normal. It offers a unique #leadership opportunity to untether ourselves from the past and step into the Fourth Industrial Age.

Grenfell, Leadership & the Symbolic Dance: Lessons from Mehra; Barwell; Jenrick & others…

Recent decisions about Benita Mehra, Gavin Barwell and Robert Jenrick are perplexing in the symbolic dissonance with the intent for learning and change.

Grenfell narratives displacing our ability to learn

Heroes and Villains – The narratives displacing our ability to learn from Grenfell

This blog looks at the failures of the LFB in preparing for Grenfell and explores the narratives displacing our ability to learn from Grenfell.

The Grenfell Tower Inquiry: Key facts…

In preparation for the publication of the Phase 1 report, I’ve attempted to pull together some key facts about the Inquiry. Please forgive any errors or omissions. I look at:… Read more The Grenfell Tower Inquiry: Key facts…

Grenfell; Space Ships and the Shard – the problem with the London Fire Brigade Commissioner’s statement.

LFB Commissioner Dany Cotton said that preparing for Grenfell would be like a space shuttle landing on the shard. This article explores why this statement is problematic.
It looks at the failures of the LFB to understand and mitigate catastrophic risk and to create a learning culture.

Grenfell: Building reform consultation fails to ensure strong voice from residents.

In another bizarre and ironic twist post-Grenfell, the MHCLG has issued a consultation on the proposed regulatory reform based on the Hackitt review. It calls for a stronger resident voice but fails to ensure this through the consultation process.

Learning from Grenfell: avoiding the next ‘black swan’ tragedy (University of Cambridge, Bennett Institute)

It is time to move on from searching for simplistic cause/effect explanations in the context of such tragedies, begin to learn how to prevent such low probability yet high consequence events.

Grenfell – Creating a bias toward safety: Practical lessons for change from Piper Alpha

Dr Stan Schofield offers ways the approach taken with Piper could be applied to Grenfell. Stan spent 16 years in HSE’s Offshore Safety division in the wake of Piper Alpha.

Grenfell Tower Inquiry: learn lessons & implement changes (University of Manchester Blog)

Uploading a blog Martin Stanley and I wrote in September 2017. I believe this thinking will be important for Phase 2 of the Grenfell Public Inquiry.

Grenfell Tower Inquiry

Submission to the Grenfell Tower Inquiry: including the thinking and learning from Major Accidents

The first submission I made to the Grenfell Tower Inquiry. Arguing for including the thinking of Major Accidents in understanding what happened at Grenfell.