Published on 1 April 2019
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Learning from Grenfell – avoiding the next ‘black swan’ tragedy

As we approach the second anniversary of the Grenfell Tower fire, and the end of Phase 1 of the Grenfell Tower Inquiry, many explanations have focused only on the cladding on the exterior of the building. But the evidence to the Inquiry has revealed many contributory factors. It is time to move on from searching for simplistic cause/effect explanations in the context of such tragedies, and instead begin to learn how to prevent a much wider range of such low probability yet high consequence events by thinking about the system as a whole.

Persistent failure to learn appropriate lessons from all sorts of previous tragedies – or to forget such learning soon after formal inquiries have been completed – seems to have been a problem for several decades. For instance Dr Kevin Pollock’s report for the Cabinet Office and the IfG’s 2017 report on public inquiries. The IfG found that of the 68 public inquiries that had taken place since 1990, only six had been fully followed-up by select committees to see what government did as a result of the inquiry. 

It seems sensible to want to apportion blame to a single mistake or error. “I was tired.” “I didn’t see the sign.” But mistakes can have big consequences.  It is absolutely vital to move beyond a simple explanation to understand the deeper systemic cause(s).  How was it that the tired train driver was allowed to get into the cab?  Could the ‘Give Way’ sign not have been made more prominent before the coach driver failed to spot it?  Blaming an individual or group’s mistakes and errors leaves us emotionally satisfied.  We can say … ‘Grenfell happened because of the cladding…’, ‘we’ve banned the cladding’ – lesson learned… let’s move on.

But this approach fails to understand the nature of the complex socio-technical system we operate in.  Cause and effect relationships are not clear and defined. The unintended consequences of our actions are wide reaching and often not understood or explored.  If we’re serious about learning lessons and preventing so called ‘black swan’ events, we need to get better at understanding and exploring this complexity. 

The causes of most disasters can be better explained by identifying those pre-existing conditions which lined up together at a single disastrous moment in time.  Evidence given to Phase 1 of the Grenfell Inquiry has already shown that no-one need have died.  But they did die because…  

  • the cladding system was combustible
  • AND compartmentation failed as the fire broke into other apartments
  • AND the architectural crown led to the entire building being engulfed in fire
  • AND it forced residents to flee through their front doors which didn’t close behind them (as they should) so allowing toxic smoke into the lobbies and single staircase
  • AND the smoke ventilation system did not work as intended
  • AND this created internal conditions (heat and smoke) that inhibited residents from safely evacuating the building on their own
  • AND the Fire Brigade failed to realise that the rapid spread of the fire meant that ‘stay put’ advice was no longer appropriate
  • AND they could not effectively fight the fires or rescue people because there was no wet riser delivering water to the top of the tower (although there should have been)
  • AND the Fire Service could not take control of the lift as it was not a Fire Lift as it should have been, and the override switch did not work
  • Etc. etc.

Note, by the way, that these failures have been of little interest to most commentators or the media.  Where is the clamour to check the sealing around windows, or the effectiveness of internal ventilation systems; or the availability of wet risers and Fireman’s Lifts?  There is some discussion about ‘stay put’ advice, but only because the combination of the cladding and the failure of ‘stay put’ offers the chance to say we’ve found the root causes, and know who is to blame.

But even the above list does not truly identify why the disaster happened.  Phase 2 of the Inquiry offers the opportunity to move beyond simplistic cause and effect explanations and understand the complex socio technical issues at play.  If done well, it will begin to focus on the truly vital question of the culture and leadership of the bodies responsible for the building, and of the relevant regulators that allowed such decisions to be made.  Were they truly worried about the risk of fire, and did they take residents’ and other warnings seriously?  

There is already some evidence that the Council and the Tenant Management Organisation may have exhibited a complacent, transactional, one-way leadership style that did not welcome or fully understand the views and concerns of residents.  We may also learn that there was a failure of accountability.  Who or what was responsible for ensuring that the building was safe, and to whom were they accountable? Why did their decisions make sense to them?

Assuming that the Inquiry does indeed identify these or similar systemic failings, how do we ensure that such lessons are learned? The Phase 2 report will not emerge until four or five years after the fire.  Will anyone take any notice?  Will anyone learn lessons that will prevent future ‘black swan’ events in other settings?  

We already know that high hazard industries such as petrochemicals and aviation require their senior managers to demonstrate ‘chronic unease’; they must imagine and fear the worst thing that could go wrong.  We also know that safe cultures require equality of life (you should no more risk a junior employee’s life than that of the Chief Exec) and equality of voice. All voices must be heard, particularly the voices of those without power and authority. 

Perhaps, in addition to ensuring that the Inquiry does indeed delve into the complex questions regarding culture, leadership and decision making, we should begin to shift the conversations and questions that we ourselves are asking…

  • Where are we not ensuring equality of life?
  • Where are we not ensuring equality of voice?
  • Where are we not practicing chronic unease?

Perhaps an additional consequence of the complex socio technical world we live in is that we should stop relying on official Inquiries to tell us the ‘root cause’, we should stop relying on the expertise of lawyers closeted in rooms for years to tell us what went wrong.  We should start holding a mirror up to ourselves and start asking some uncomfortable questions about our own leadership, the culture we are creating and operating in and the agendas and biases influencing our decision making. 

Perhaps then we will begin to learn…

The views and opinions expressed in this post are those of the author(s) and not necessarily those of the Bennett Institute for Public Policy.


Martin Stanley

Martin Stanley

Martin Stanley is the editor of Understanding Regulation – – a website written for legislators, journalists, academics and others who wish to understand the recent rapid growth of the...

Gill Kernick

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:...

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