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Risk Governance Management Specialists

Lessons From the Grenfell Inquiry

[Last amended: 09 Oct 20]


My interest in the public inquiry, under the Chairmanship of The Rt Hon Sir Martin Moore-Bick into the fire at Grenfell Tower on 14 June 2017, is the lessons it suggests we, as a society should learn from these events. My concern is that, while such inquiries may be the right way to judge the lawfulness of the decisions made, my previous research suggests that they are not an effective way of learning how to manage fast moving, complex and dynamic situations. In fact, in some cases such reports may do more harm than good.


When I read such reports what I am trying to identify is the mechanism of failure and the justification for the action proposed in the report's recommendations. From this I try to assess the probability that the action proposed will address the causal mechanism and will not  generate unintended adverse consequences. Finally I consider the cost effectiveness of the proposed action.


As I criticise the blinkered thinking of others, let me declare my own bias.  As a former operational commander my sympathies lie with the operational teams. This is not to say that they can do no wrong, it does however make me try to understand why they erred. In turn this means that I am looking for solutions that work not only in theory but also in practice. In technical terms I focus on Practical rather the Scientific utility of learning. This theme is at the heart of all of my work. As for this case, I have no connections with any parties to the inquiry and so do not have a stake in the outcome.


With these criteria in mind, I summarise below my assessment of the report produced on The Rt Hon Sir Martin Moore-Bick into the Grenfell Tower fire. My full paper can be downloaded here.


Executive Summary


The report states that in the early hours of 14 June 2017 a fire broke out in a domestic appliance and this caused a "perfectly foreseeable" kitchen fire. The London Fire Brigade (LFB) responded promptly and yet the fire escalated rapidly.  In just over half an hour the domestic fire had become a major incident that stretched the LFB to breaking point. While 227 residents managed to escape the building, 71 did not. In order to learn from these events, the UK government set up a public inquiry under the Chairmanship of The Rt Hon Sir Martin Moore-Bick to examine the circumstances surrounding the fire. My paper looks to examine the conduct of part 1 of that Inquiry as a vehicle for social learning. In particular, this paper focusses on how or whether such inquiries assist fire and rescue services to learn from such events.


The approach taken to this research positions it within the concepts of Scholarship of Application and that of Engaged Scholarship. The issue this paper addresses is how we make sense of our experiences in order to learn from them. The paper describes the use of two alternative analytical approaches; the first of these is in common usage (labelled the perfect world paradigm) and the second has been labelled normal chaos. The paper uses the Grenfell Inquiry Report (part 1) as a case study.


The basic proposition that underlies the perfect world paradigm is that if organisations recruit the perfect people, produce perfect plans, train them perfectly, supply them with exactly the right resources (including perfect unambiguous information) and execute the plan flawlessly (eliminating all slips and lapses) then the desired outcome will be delivered. Within this paradigm is the belief that individuals should be able to learn, retain and use the knowledge they require perfectly. Embedded within this construct is the desire to remove uncertainty and to control the world around us. The label perfect world paradigm is used to reflect the phrase often heard when discussing failure; that is “but in a perfect world …”. The paper then substantiates its assertion that the Inquiry team’s worldview is routed within this paradigm. In terms of lay theory, the perfect world paradigm can be seen as being a normative theory. The key and pertinent criticism of this paradigm is that it is an inadequate precept when used to grasp and understand the true complexity of everyday actions.


The paper offers an alternative analytical precept. This precept has been labelled the normal chaos paradigm. It is based on the key facets of complexity and chaos theory. These ideas have been assembled in a framework which gives analysts a different lens through which to view an issue and thereby make sense of it. In terms of lay theory, the normal chaos paradigm is a descriptive theory that enables the analyst to describe an issue in terms of a standardised metaphor provided by complexity and chaos theory. These lenses are grouped into structures, patterns and energy. Under structures analysts should consider scale, interdependencies and self-organisation. Under patterns, the analysts should consider the fitness landscape, fractals and the role of illusions. Under energy, the analysts should consider energy flow, attractors and the edge of chaos. Theory suggests that the triangulation achieved by looking at a single issue through multiple lenses, helps us to make sense of complex issues. This is at the heart of the normal chaos approach.


The paper examines the dynamics of the Inquiry, the substance of the Report, the way it structures it recommendations, the recommendations themselves and the Report's perception of what failed. The paper goes on to look at the implications for learning of some features of the perfect world paradigm, namely its reliance on rules, the clash of cultures that this created between the Inquiry team and the practitioners and how this affected keeping residents safe, and decision support systems including the decision to revoke the stay put policy on that occasion.


Finally, the paper provides a summary of its findings, a description of the perceived limitations of this research and its conclusions and recommendations for future research. In summary these are as follows:


As human populations move to more high-rise living, the questions raised by the Grenfell fire become an important topic for research. The desire to learn is paramount amongst fire-fighters. If the learning process was easy, then the fire-service would have perfected it by now. It is not easy and so they must continue their efforts. An important part of this process is the inquiry process.


The report produced by Moore-Bick into the events on the night of the fire is probably (within an acceptable margin of error) an accurate narrative of those events. The data they collected overall is likely to provide data for a wide range of future research. The value of this Inquiry is that it recognised the need to let the victims be heard as this process helps them to understand what happened on the night and so might set them on the path of coming to terms with their loss. Where this paper diverges from the findings of that report is in its analysis of the events and the recommendations produced.


The Inquiry Report shows clear evidence that the Inquiry team see the world as they would like it to be (a perfect world) as opposed to how it actually is (complex and messy). By way of example, this paradigm is encapsulated in the statement “It should be a simple matter for the owners or managers of high-rise buildings to provide their local fire and rescue services with current versions of such plans” [emphasis added]. In itself, as a single action, the Report is right that such an action should be relatively simple. However, it is a mistake to see any single action as an isolated event. Every action takes place within a context. The context adds complexity and complexity adds dilemmas (often in the form of conflicting priorities). In short, no action should be seen as being “a simple matter”: every action needs to be seen as being part of a chain of events that interact with other such chains. This is a clear divergence in perspectives between the Inquiry Report and this paper.


The reason for this divergence is the different paradigms used. The perfect world paradigm used by the Inquiry team is, at its simplest, looking towards delivering a perfect system; this worldview predominates management thinking. From studying the pertinent academic literature on organisational failure, it is reasonable to draw the opinion that such perfect systems are fantasies (illusions). They are impossible to produce and equally impossible to operate perfectly due to the innate complexity of life. An alternative paradigm is therefore required.


This paper offers an alternative normal chaos paradigm through which to examine these issues. This paradigm centres around the complexity of everyday interactions. It also focuses on the limited human ability and capacity to make sense of their world and then to act in the most appropriate manner. Normal chaos emphasises non-linearity in contrast to the linearity of the perfect world paradigm. Normal chaos recognises that systems will never be perfect and that humans are prone to slips, lapses and errors, and that misjudgements and mistakes are an unavoidable part of everyday life. The question that is at the heart of the normal chaos paradigm is, how can we best cope in such circumstances? To this end, normal chaos research looks to the work being undertaken to develop robust and resilient systems as being the way forward.


In order to enhance the learning from the activities of the emergency services in the long term, the international body of firefighters should consider developing an accident investigation body (modelled on the aircraft industry) to learn from the body of experience from all major incidents and to develop robust procedures to improve the way they are handled in the future.


This way forward should also be supported by a suitable programme of research.


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Risk Governance Management Specialists