As safety culture expert Gill Kernick watched Grenfell burn, she vowed to do what it takes to ensure we learned from the disaster. This blog explores her concern that recent narratives about the role of the London Fire Brigade’s response will inhibit learning key lessons.
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 it 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, has since announced her intention to depart at the end of the year, four months earlier than planned. Both the criticisms of the LFB in the Phase 1 Report and the resignation of Dany Cotton were met with fierce defences of the firefighters.
Whilst understandable, both narratives inhibit our ability to learn from the disaster.
We have a collective responsibility to move beyond defensive narratives, no matter how well-intentioned, and focus on considered enquiries that will lead to learning and change.
Key Findings of the Phase 1 Report
It is well established in the world of safety management 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. Both under national guidance (GRA 3.2) and LFB Policy (PN633) meant it was supposed to be in place.
- The LFB did not ensure that fire crews were aware of the risks of façade fires yet internal presentations and letters show it did know of these risks, but had not shared the knowledge widely.
- The LFB failed to train crews to gather critical information (such as the functioning of fire lifts and potential communication problems) as required by both national guidance and LFB policy.
In her oral evidence at the Grenfell Inquiry, LFB Commissioner, Dany Cotton said that training for an event such as Grenfell would be akin to ‘developing a training for a space shuttle landing on the shard.’ She added that, even with the benefit of hindsight, there was nothing she would go back and change in firefighters’ response on the night. These insensitive remarks were taken in the report as evidence that the LFB was in danger of not learning from Grenfell. (pp.607; para 607)
It is impossible to review the evidence and not conclude that there were significant failings by the LFB. But some of the developing narratives are inhibiting critical enquiry.
Heroes and Villains
There is an embedded narrative that ‘firefighters are good’ and ‘people who put the cladding on / cut LFB funding / wrote weak regulations etc.’ are bad.
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. We need to move beyond simplistic opposing narratives such as hero and villain, and embrace every opportunity to learn equally.
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. The causes of the fire will be looked at in Phase 2. The failure to comply with the Building Regulations after refurbishment must be rigorously scrutinised in Phase 2. But we should 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. But it is much more useful to look at major failures through the perspective of accountability.
James Reason summarised the problem very nicely 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.
A blame narrative considers who’s at fault, is highly personal and assumes that removing the individual(s) will solve the problems. However, simply replacing someone with another person operating in the same context will likely lead to little change or learning.
An accountability narrative instead considers what structures (e.g. job roles and assurance mechanisms) were in place and how these were fulfilled or not. Many think that the LFB Commissioner Dany Cotton has been unfairly blamed or scapegoated. Based on the evidence, she did fail to deliver on some key accountabilities. Yet this is very distinct from saying she is to blame. Phase II needs to explore why her decisions made sense and explore the context she was operating in (including 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).
The Grenfell disaster as a whole, and the devastating individual stories, 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.
Gill Kernick edits The Grenfell Enquirer