In a recent installment of our monthly webinar series, we were joined by Gill Kernick, a high-risk industry safety consultant, talking about the Grenfell Tower Fire of 2017 in West London. Gill is not only a safety consultant but was also a former resident of Grenfell, watched it burn from the flat she lived in at the time, and personally knew a significant number of the 72 people who died in the fire or as a result of it. After the fire occurred, she dedicated herself to trying to help us find ways to prevent similar incidents again, and her efforts including writing the book Catastrophe and Systemic Change: Learning from the Grenfell Tower Fire and Other Disasters and recording the Catastrophe podcast series, which addresses Grenfell but also the Boeing 737 Max aircrafts, the Costa-Concordia incident, and more.
In this article, we’ll summarize the webinar, although you’re also more than welcome to listen to the now-recorded, on-demand webinar here.
At Vector Solutions, we offer safety management, risk management, and training for industries related to the Grenfell tragedy, including training and continuing education for the Architecture, Engineering & Construction industry; training for the Facilities Management and Facilities Maintenance industry; and training (as well as other safety management tools) for occupational safety and health, so naturally we were interested to learn more from Gill and invited her in to speak with us and our listeners.
Gill’s primary message is that we need to use a systems thinking approach so we can learn more and apply those learnings to help prevent similar incidents from happening again in the future. You may find this quick introduction to systems thinking helpful along these lines, and many of these same issues are also covered in our Guide to Applying New Safety.
We’ll get on with the summary of what Gill said in the webinar below.
Gill works as a safety consultant for high-risk industries. She had lived in the Grenfell Tower (which later burned) and knew many of the people who died that night, including people who lived on the same floor she had lived on. On the night of the fire, Gill was living in a nearby high-rise and woke to see Grenfell on fire. She has worked tirelessly to help us learn from the Grenfell disaster and similar disasters since then, including writing a book, producing a podcast series, and doing interviews and webinars such as this one.
Although Gill’s primary point is that a series of inter-related factors led to the fire, its spread, the deaths, and the continuing negative consequences residents suffer today, she provided a quick overview of how the fire started and spread.
The fire began with a small fire in the kitchen of one resident. The fire was in a refrigerator, and the refrigerator had a plastic backing which did a poor job of containing the fire. It took only 15 minutes for the fire to spread beyond that unit and to spread through 19 floors of the building.
The fire broke compartmentation by escaping out of the windows and/or extractor fan, which had been replaced since the building was built. The new windows including uPVC frames that melted, allowing flames to exit the building. From there, the flames leapt to a flammable cladding, which had also been installed somewhat recently on the building. So at this point, compartmentation of the fire was broken, the fire spread throughout the building very quickly, and the scene was set for a disaster.
The firefighting strategy relied heavily on a “stay-put” rule, meaning residents should stay put in their flats until firefighters could save them. According to Gill, this stay-put rule became untenable and unwise when compartmentation was broken at 1:14 am, but firefighters didn’t reverse the stay-put order until 2:47 am, about 90 minutes later. Gill notes that it’s the residents who defied the stay-put order who lived. It’s interesting that earlier in the webinar, Gill noted that the workers who survived the famous Piper Alpha oil rig fire were also those who violated a similar rule—the ones who left the platform and dove into the water, although doing so was a rule violation.
Gill also notes there were a series of internal controls failures that contributed to the tragedy as well. These included non-compliant fire doors that didn’t resist flames as longer as they were supposed to; doors that should have closed automatically but did not due to improper maintenance and other issues; the failure of the ventilation system; the lack of a dedicated firefighting lift (elevator); the lack of a wet riser (the building had a dry riser instead); and improper floor numbers on the doors within stairwells, which contributed to confusion for residents and firefighters.
Gill points out that the risks of flammable building cladding were known before the Grenfell Tower catastrophe, and lists multiple similar fires that people SHOULD have learned from but did not.
Gill also notes many problems with the regulations, with gaming of product testing, and with a lack of clear accountability that contributed to the fire and has acted to prevent us from learning lessons and applying them after the fire.
As Gill explains, building residents had been warning about safety concerns related to the risk of the building catching fire for some time before the actual fire occurred. These concerns were not acted on and, Gill claims, the voices and concerns of the residents were dismissed by creating narratives of “rebel” residents, “aggressive” residents, and “vocal” residents. Once these labels were applied to the residents raising legitimate safety concerns, it was easier to dismiss the concerns and not implement change.
One of Gill’s primary beliefs is that while it’s important to make piecemeal change after a disaster such as Grenfell (for example, changing a specific building regulation or reconsidering the specific “stay put” firefighting rule), piecemeal change on its own won’t help us avoid similar tragedies in the future.
Instead, Gill argues, we need to make systemic change. She tells a story to help us understand what she means by the “system” that needs to be changed, and which is sometimes hard for us to even recognize. In her story, one fish swims by another fish and asks “how’s the water?”, and the second fish asks in return “what water?” That water is the system (or context) we exist in, and it can sometimes be so omnipresent that we’re unaware of it. The system can allow for conditions that lead to tragedies such as Grenfell and, if kept in place, can actively work against our efforts to make systemic change to help avoid future similar tragedies.
To help us “make the water visible,” learning from tragedies (and near-misses), and enact systemic change, Gill has created a four-quadrant model that she’s named after Grenfell. She argues two of the quadrants are obvious, two are obscure, and we tend to neglect the obscure ones (discussed briefly below).
She discusses this in more detail in the webinar, and we encourage you to listen and watch as she discusses it herself, but here’s a simple explanation.
Gill defines the two “obvious’ quadrants as behavioral and foundational. By behavioral, she explains, she means “The mechanisms in place to prevent & respond to catastrophic events. E.g., regulators, scrutiny mechanisms, inquests & inquiries.” By foundational, she explains, she means “The elements in place to prevent catastrophic outcomes. E.g, regulations, guidance, governance & accountabilities.”
She defines the two “obscure” quadrants as relational and contextual. By relational, she explains, she means “how interactions between stakeholders contribute to catastrophic events. E.g., regulatory capture, revolving door, and speaking truth to power.” By contextual, she explains, she means “The contextual aspects that impact our ability to prevent and learn. E.g., culture, trust, bias, unquestioned assumptions and beliefs.”
During Q&A, Gill briefly discussed two recent building-related catastrophes in the US, the 2021 Surfside condo collapse in Miami, FL and the 2022 Bronx, NY apartment fire. She notes that in both cases, many of the same contributing factors that were problematic at Grenfell were problematic with these buildings as well.
With the Surfside condo collapse, in particular, Gill said one of the biggest systemic issues we’re facing is the aging of the housing stock. She also identified some specific issues with the initial construction but also recurring maintenance-related issues.
With the Bronx apartment fire, Gill called out maintenance issues again but also the voice of residents being ignored (as they were at Grenfell).
One final point that Gill makes in the recorded webinar that we’d like to underline is her call for considering low-probability, high-consequence risks when performing risk assessments and risk management activities.
We hope you found this introduction to Gill’s work, to the Grenfell Tower fire, and to some ideas about improving learning so we can make systemic change and better manage risks in a complex world.
Be sure to listen to the whole webinar and let us know if you have any questions.