The Grenfell Enquiry Disaster

It is coming up to 3 years since the Grenfell Tower Enquiry commenced work with only a preliminary report published and phase II of the enquiry now stalled due to Covid 19.  it is painfully obvious to this Root Cause Analysis expert that the process is very slow and that actual Root Cause is so far not truly found, nor IMO is it the expectation. But then that is how enquiries under the Public Enquiry Act are designed to be.

The main conclusions to date are summarized thus:

• The resident of the flat where the fire started was not at fault. Not a Cause but a rejected cause candidate
• The principal reason the fire spread was the aluminium composite cladding filled with plastic used on the building exterior. An immediate cause with no development to the root (after 3 years)
• Firefighters showed “courage and devotion to duty” and 999 call operators were “unstinting” in their efforts to help trapped residents. Not a cause at all but this prepares us for who will be taking the rap, irrespective of the cause.
• Incident commanders were not trained to cope with the fire No further depth as to why and there was no contingency plan for evacuation. Not true as far as I can see. All such buildings have prescribed evacuation plans.
• The LFB failed to lift the “stay put” advice when the stairs remained passable, which cost lives. But the reason why is that the world wide, standard safety plan for this type of building is to “stay put” a decision which is Fire Brigade standard procedure and training. 
• The brigade suffered “significant systemic failings”. Why?
• Communications systems failed and there were serious deficiencies in command and control This is the equivalent of blaming the sinking of the Titanic on the radio equipment of the ships that responded
• Pictures transmitted on the night of Grenfell could not be viewed by the LFB because the encryption was incompatible with its receiving equipment Did you really need video to see what was going on

The stay put procedure is well established for this building design and indeed the two go together, the design dictates this procedure from the architect`s drawing board.  The reason it didn`t work was because that rationale and plan had been defeated by the installation and materials used in the post-construction up-grades. The cladding, which was not to fire code. To get to the root of that, you need to keep asking Why? What aspects of procedure, materials, equipment, environment,  people behaviour and management allowed this to happen? That would be called determining Root Cause, something, I very much doubt many retired Judgs are qualified in.

Now, the recommendations for corrective action (to prevent re-occurrence) should always flow directly from the determined Root Cause(s).  They are, according to retired judge Sir Matin Moore-Bick:

• A law requiring owners and managers of high-rise residential buildings to provide their local fire and rescue service with information about external wall materials and building plans. There already are laws and regulations which are in effect at the planning stage. This recommendation is trying to divert attention from that fact by pretending that extra laws are needed, which in fact would be redundant. If the current regs had been followed this fire would not have happened. The irregular cladding is the primary cause of this tragedy and if you drill down further on that failure you would get to the root cause.  
• Fire brigade inspections of high-rise buildings to be improved and crews trained to carry out more thorough risk evaluations. Regular inspections of lifts intended to be used by firefighters are needed. Is it really the fire brigades responsibility to go up  ladders and inspect not only the installation but the specific materials and specs of said materials for every project in London? No, if anybody, that would be the job of the council to inspect construction that they have approved on paper, however this particular failure would have been caught at the submission stage, IF they had not approved the cladding as specified.
• Communications between fire brigade control rooms, where emergency calls are received, and incident commanders must improve and there must be a dedicated communication link. Blah Blah, on secondary issues – they should increase all  boat speeds so that shipping could reach the Titanic faster?
• Government should develop national guidelines for carrying out partial or total evacuations of high-rise residential buildings. Already totally in place but they rely on buildings to be approved within code.
• Fire doors in all multi-occupancy, residential properties should be urgently inspected. Point, but not primary cause.
• Improvements should be made to the data links provided by helicopters of the National Police Air Service. Tertiary cause at best. Look over here!

So, why did the Local Council approve this installation as submitted or allow the submission to be amended without sufficient review? Not addressed- because that has political ramifications. Instead they blame the fire brigade in that a) All commanders at the scene should know the details of every construction upgrade project in London and b) Not realizing in time, during a raging inferno that the building had been modified not to code, with significant consequences with regard to how they were trained to deal with that type of structure. They are apparently supposed to figure out on the scene of major fires that someone in the local council has made decisions that rendered their training and procedures useless.

Poster-(Marco) is an independent consultant and has investigated facilitated and/or supervised hundreds of significant event investigations and Corrective actions initiatives in the Medical and Pharma industries. Is extensively trained in, and teaches: Root Cause methodologies such as 5 Whys, Fault Tree analysis, Ishikawa Cause and Effect, Kepner-Tragoe Problem Analysis, Assignable vs Special Cause determination, Failure Modes & Effects Analysis, 6-Sigma.