On Saturday 5 October 2019, 31 candles were lit at St Helen’s Church, North Kensington, one for each of the victims killed in the Ladbroke Grove Rail crash (1999). In the same church on 14 June, the second anniversary of the Grenfell Tower Fire (2017), 72 candles were lit to honour those that died.
That is not the only connection. In both examples, as in many other contexts, individuals raising concerns have been portrayed in ways that silence their voice – and thereby ensure critical information is not used in making key decisions.
The Ladbroke Grove Train Crash and the Grenfell Tower Fire
Michael Hodder, the train driver, who died in the crash, passed a red signal and collided with another train. The subsequent Inquiry revealed that since 1993, train crews had warned about the "inadequate sighting of certain signals," including SN109, the one missed by Mr Hodder. In the preceding six years, seven train drivers had failed to see the red light and stop. No action had been taken.
Alison Forster, the train operator’s Director of Operations and Safety had raised the issue with Railtrack repeatedly. In August 1998 she had written to Railtrack’s production manager about SN109 asking ‘as a matter of urgency what he intended to do about this high-risk issue’. She never received a full response.[i]
Last week a tragically similar story emerged at the Grenfell Tower Inquiry, as Design and Build Contractor Rydon gave evidence. Both residents and those involved in the refurbishment had raised concerns.
Residents flagged issues about, amongst other things, a broken self-closing door mechanism and the failure to consult them on the selection of cladding and windows. The windows and the cladding were critical to the rapid spread of the fire; the failure of doors to close on the night contributed to rapidly deteriorating conditions inhibiting rescue and escape.
The following extract is from a letter by Grenfell resident Eddie Daffarn. [i] (p83)
Those accountable for the refurbishment also raised concerns.
For example, Artelia, contracted by the Tenant Management Organisation as co-ordinator, quantity surveyor and employer’s agent, said in an internal email: “This is just to flag that this is becoming a farce. Despite all our efforts to ensure a smooth landing I have to say I do not think I have ever worked with a contractor [Rydon] operating with this level of nonchalance.”
Rydon’s Project Manager, Mr Lawrence himself said in an internal email: “At the moment we have a poorly performing site which is mainly (but not totally) caused by poor surveying and cheap incompetent sub-contractors.”
The tacit knowledge of those at the sharp edge
It is easy with hindsight to act astonished that these signals were not heeded. But the failure to listen to and tap the tacit knowledge of those at the front line is common, it is present in most major accidents including Piper Alpha, Chernobyl and the Challenger Space Shuttle disasters.
Whilst many argue the moral case for engaging with residents and front-line workers, it is their tacit knowledge that is so critical to safety. The experience and concerns of those at the sharp edge can help identify deeper issues.
At Grenfell, for example, the complaint regarding a failed door closer presented the opportunity to identify that this was a broader issue. Consulting residents on the cladding and window design presented an opportunity for the fire safety of these to be scrutinised.
Yet, in the face of an already troubled project, rather than tap the knowledge of residents, what emerged was an insight into the narratives used to silence them.
The narratives we use to silence voices
“I think there were several very vocal, dare I say aggressive residents that, in my opinion, regardless of what work was being carried out or not, they still would have had reason for complaint,” Simon Lawrence said during evidence. Labelling the group rebel residents he used the word aggressive three times and vocal nine times.
We heard that Mr. Lawrence had been ‘tipped off’ by the building manager at the TMO that “there were several vocal residents and one of which could be extremely vocal and was quite well known by the TMO.” When pressed he revealed this to be Eddie Daffarn.
We need to guard against engaging any debate about the validity of these characteristics. Hero / villain narratives displace the ability to engage in robust conversations about learning from errors made by the London Fire Brigade. Rebel Resident narratives should not justify a failure to tap the tacit knowledge of residents and front-line staff.
If only this had happened earlier. Here is a 2016 extract from the blog, run by ‘Rebel Residents’ Eddie Daffarn and Francis O’Connor:
Kensington & Chelsea Tenant Management Organisation (KCMTO)
Playing with Fire
20 November 2016
It is a truly terrifying thought but the Grenfell Action Group firmly believe that only a catastrophic event will expose the ineptitude and incompetence of our landlord, the KCTMO, and bring an end to the dangerous living conditions and neglect of health and safety legislation that they inflict upon their tenants and leaseholders…
Unfortunately, the Grenfell Action Group have reached the conclusion that only an incident that results in serious loss of life of KCTMO residents will allow the external scrutiny to occur that will shine a light on the practices that characterise the malign governance of this non-functioning organisation…
It is our conviction that a serious fire in a tower block or similar high density residential property is the most likely reason that those who wield power at the KCTMO will be found out and brought to justice! …
We have blogged many times on the subject of fire safety at Grenfell Tower and we believe that these investigations will form a crucial part of a damning catalogue of evidence showing the poor safety record of the KCTMO should a fire affect any other of their properties and cause the loss of life that we are predicting.
Rather than questioning the validity of the narratives used to silence the residents at Grenfell, or those on the ground as workers or customers in any context, there is a danger of silencing voices. We should interrogate the narratives that do so. Then we might begin harness the important detailed and tacit knowledge of those so critical to creating safety.
[i] Morse, G; ‘The Lessons from Ladbroke Grove’; October 9 – 22, 2019; Rail; Issue 889; Media House; page 82
About the author
JMJ Associate Master Consultant, Gill Kernick, works with senior executives in high hazard industries to develop the culture and leadership to prevent catastrophic events. Author of 'Catastrophe and Systemic Change: Learning from the Grenfell Tower Fire and Other Disasters', she lived on the 21st floor of Grenfell from 2011 to 2014 and seven of her former neighbours died in the fire. Campaigning for learning and change, Gill writes and speaks to bring the thinking of major accident prevention to preventing disasters. She edits a blog, "The Grenfell Enquirer" dedicated to creating new dialogues. In 2020, she was voted as one of the most influential people in Health and Safety in the UK.