Catastrophe and Systemic Change: Learning from the Grenfell Tower Fire and Other Disasters

By Gill Kernick

The Grenfell Tower tragedy was the worst residential fire in London since World War II. It killed seventy-two people in the richest borough of one of the wealthiest countries in the world. Like other catastrophic events before it and since, it has the power to bring about lasting change. But will it? The historical evidence is weighed against ‘lessons being learned’ in a meaningful or enduring way. In an attempt to understand why, despite enormous efforts, we persistently fail to learn from catastrophic events, this book uses the details of the Grenfell fire as a case study to consider why we don’t learn and what it would take to enable real systemic change. The book explores the myths, the key challenges and the conditions that inhibit learning, and it identifies opportunities to positively disrupt the status quo. It offers an accessible model for systemic change, not as a definitive solution but rather as a framework to evoke reflection, enquiry and proper debate. Catastrophe and Systemic Change is a must-read book for a wide range of readers including those interested in change management, leadership, policy-making, law, housing, construction and public safety.

• Language: English
• Publisher: London Publishing Partnership
• Release date: May 27, 2021
• ISBN: 9781913019310

Gill Kernick

Gill Kernick is an internationally experienced strategic consultant specializing in safety, culture and leadership. She lived on the twenty-first floor of Grenfell Tower from 2011 to 2014.

Book preview

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Catastrophe and Systemic Change

Perspectives Series editor: Diane Coyle

The BRIC Road to Growth — Jim O’Neill

Reinventing London — Bridget Rosewell

Rediscovering Growth: After the Crisis — Andrew Sentance

Why Fight Poverty? — Julia Unwin

Identity Is The New Money — David Birch

Housing: Where’s the Plan? — Kate Barker

Bad Habits, Hard Choices: Using the Tax System to Make Us Healthier — David Fell

A Better Politics: How Government Can Make Us Happier — Danny Dorling

Are Trams Socialist? Why Britain Has No Transport Policy — Christian Wolmar

Travel Fast or Smart? A Manifesto for an Intelligent Transport Policy — David Metz

Britain’s Cities, Britain’s Future — Mike Emmerich

Before Babylon, Beyond Bitcoin: From Money That We Understand To Money That Understands Us — David Birch

The Weaponization of Trade: The Great Unbalancing of Politics and Economics — Rebecca Harding and Jack Harding

Driverless Cars: On a Road to Nowhere — Christian Wolmar

Digital Transformation at Scale: Why the Strategy Is Delivery — Andrew Greenway, Ben Terrett, Mike Bracken and Tom Loosemore

Gaming Trade: Win–Win Strategies for the Digital Era — Rebecca Harding and Jack Harding

The Currency Cold War: Cash and Cryptography, Hash Rates and Hegemony — David Birch

Catastrophe and

Systemic Change

Learning from the Grenfell Tower Fire

and Other Disasters

Gill Kernick

Copyright © 2021 Gill Kernick

Published by London Publishing Partnership

www.londonpublishingpartnership.co.uk

Published in association with

Enlightenment Economics

www.enlightenmenteconomics.com

All Rights Reserved

ISBN: 978-1-913019-30-3 (iPDF)

ISBN: 978-1-913019-31-0 (epub)

A catalogue record for this book is

available from the British Library

This book has been composed in Candara

Copy-edited and typeset by

T&T Productions Ltd, London

www.tandtproductions.com

Back cover author photograph taken by

Mike Reynolds ([e-mail])

To the 72 souls lost in the Grenfell Tower Fire, including my former neighbours from the twenty-first floor:

Abdulaziz El Wahabi (52)

Faouzia El Wahabi (42)

Yasin El Wahabi (20)

Nur Huda El Wahabi (15)

Mehdi El Wahabi (8)

Logan Isaac Gomes (stillborn at seven months)

Ligaya Moore (78)

And to my beloved father

Louis Auret Kernick

(7 August 1930–24 June 2017)

Introduction: the book I wish I’d never had to write

We used to play in the hallways because it was pretty big. We had a nice little group on that floor.

Lulya, 12, survivor from the twenty-first floor of Grenfell Tower¹

It was like a burnt matchbox in the sky.

It was black and long and burnt in the sky.

Ben Okri, Grenfell Tower, June 2017²

Why this book?

I lived on the twenty-first floor of Grenfell Tower from 2011 to 2014. On 14 June 2017, seven of my former neighbours died in the fire. This book is dedicated to them.

But my interest in Grenfell is not only personal. Professionally I work in high-hazard industries, partnering with organizations to build their leadership capabilities and culture in order to prevent catastrophic events. As I watched the tower burn, I promised to ensure that we learned – to make those lost lives count in some way.

In the immediate aftermath I was hopeful.

Catastrophic events have the power to be disruptive and bring about lasting change. I worked in the oil and gas industry in the aftermath of the explosions at the Texas City refinery (2005; fifteen deaths) and the Gulf of Mexico Macondo well (2010; eleven deaths and the industry’s biggest ever environmental disaster). I travelled the world – from Australia to Algeria, from Jakarta to Oman – delivering training to help embed the cultural and leadership lessons from those tragedies. I have spent my career working with people who are courageous enough to look at themselves in the mirror and confront their own failings as leaders. I’ve heard too many stories of loss, of pain. And I’ve witnessed what is possible when people come together, authentically, willing to show their vulnerability and to learn and build robust cultures, in order to prevent more suffering.

I therefore naively imagined that the worst residential fire in London since World War II – a fire that killed seventy-two people in the UK’s richest borough – would engender a desire to learn and change.

I was wrong.

I went from being hopeful, to discovering there had been multiple failed opportunities to learn, to realizing that, far from being an isolated ‘bad building’, Grenfell revealed systemic failures in building safety and construction across the country, leaving thousands of people living in unsafe homes.

History predicted that we’d find out what happened, identify lessons and then fail to learn them.

Rather than focus only on Grenfell, I needed to understand why we don’t learn from catastrophic events more broadly. Whether it be the Covid-19 pandemic or the Boeing Max air disasters, there is an ‘awful sameness’ to these tragedies, a horrific unifying failure to heed plentiful warnings and change.

In an attempt to understand why our failure to learn makes sense, this book explores two questions.

Why don’t we learn?

What would it take to enable systemic change?

Both a personal and a professional account of my own investigations and reflections, its intent is to promote enquiry and debate in the hope that it will help us learn from – and therefore prevent – catastrophic events. I offer a model of systemic change, not as a definitive solution but rather as a framework to evoke reflection.

But first, let’s step back in time.

It was the sky that decided us

In 2011 my husband, Keith, and I had returned to London after living abroad, and we wanted to rent in North Kensington for a couple of years while we saved for a deposit. Sick of looking at ridiculously overpriced basement flats with no light or space, a high-rise apartment caught my eye.

It was on the twenty-first floor of Grenfell Tower.

I remember the precise moment I walked in: the first view of the bedroom and then down the hall to the open-plan living area, the dual-aspect windows, the light, the sky … the space. Breathtaking. Keith and I looked at each other, nodded, then turned to the agent: where do we sign?

It remains one of the most beautiful places I’ve lived, with the indescribably exquisite colours of the sunsets visible from its windows, and the views of the fireworks on New Year’s Eve and bonfire night – little jewels lighting up the horizon. Perched high, watching the slinky movements of the Tube trains as they pulled into and out of Latimer Road station. The jumbled network of cars and roads, and little stick figures walking around. We’d imagine it was a model railway set, like my grandad used to build. One of our windows looked directly onto the (in)famous brutalist ‘streets in the sky’ Trellick Tower. Falling in love with high-rise living, we’d dream of buying a flat there.

There were six flats on each floor at Grenfell. Three families lived on our floor; we’d chat in the lift, and always take in parcels for one another. The children used to play in the lift lobby, screeching and laughing. Sometimes we’d leave the door open and they’d sneak in, giggling, before running away as soon as they saw us. Teenager Yasin was curious about my work, and he used to tell me how he wanted to start his own business. He’d knock on the door to borrow our bicycle pump. Once, Andreia discovered it was Keith’s birthday and showed up with a cake.

Yasin is dead. Andreia’s son Logan Isaac was stillborn.

On 4 April 2014 we moved into an apartment on the fifteenth floor of Trellick. Huge windows, stunning views. Grenfell in the middle: a rectangular block of warm lights and memories.

14 June 2017

It had been a great day at work. We ate dinner outside on Golborne Road on that hot summer evening. We were happy. It feels like another life.

Later I was struggling to sleep, lying on the sofa in the living room, annoyed at the sirens and the helicopter, making assumptions about drugs and gangs. Then I walked into the bedroom.

The flames… A diagonal line of yellow and orange… Disbelief.

Grenfell. Engulfed.

Sitting on the bed with Keith, watching. Helpless. Work-related images ran through my mind: Piper Alpha, Macondo, fire, explosions, death.

And, the next morning, wandering the streets and sorting clothes. Staring at the tower, watching the astonishing bursts of intense multicoloured flames still coming from windows. People searching for families and friends, desperate, hopeful, hopeless. There were edgy and angry confrontations. Posters and pictures appeared, and thousands of people gathered. Flowers, grief, solidarity, love, pain.

Later that day I sat on our balcony with Matthew Price, a journalist covering the fire for the BBC, who had been interviewing my husband. Looking at the burning building, I thought again of Piper Alpha: on 6 July 1988, 167 people died in what is still the worst industrial accident in the UK. During a refurbishment of the platform, the original principle of ensuring that a North Sea oil rig’s accommodation block and muster point was as far as possible from the operating facility was compromised.³ Those who survived did so by jumping off the platform into the sea – defying policies that claimed that doing so would mean certain death.

I turned to Matthew and said, ‘I will do whatever it takes to make sure we learn, to make those lost lives count.’ That moment is as vivid for me as when I first saw the fire.

The realization of systemic failure

Over the coming months it became clear that, far from being an isolated incident, Grenfell was symptomatic of deeper failures. A failure to build safe homes. A failure to learn from past incidents. A failure to effectively respond to low-probability, high-consequence risk.

I recall the moment I discovered that there is no process to ensure that recommendations from public inquiries or other public investigations are implemented, or to assess their effectiveness.⁴ And the moment when, through tears, I read evidence given to a Select Committee in June 1999. Set up to investigate a fire in Scotland that killed Alexander Linton, the Fire Brigade Union said:⁵

The primary risk therefore of a cladding system is that of providing a vehicle for assisting uncontrolled fire spread up the outer face of the building, with the strong possibility of the fire re-entering the building at higher levels via windows or other unprotected areas in the face of the building. This in turn poses a threat to the life safety of the residents above the fire floor.

Later I discovered the other failed opportunities to learn, such as the Lakanal House fire in 2009, where a refurbishment wrapped the building in flammable cladding. Fire spread from the flat of origin in four minutes. Six people died, including three-week-old Michelle Udoaka.⁶

Perhaps most heartbreaking was reading a blog written by Grenfell residents and campaigners Francis O’Connor and Eddie Daffarn, written eight months before the fire:

Only a catastrophic event will expose the ineptitude and incompetence of our landlord … and bring an end to the dangerous living conditions and neglect of health and safety legislation that they inflict upon their tenants and leaseholders.⁷

Eddie was rescued while escaping from the sixteenth floor of the tower.

Three years after Grenfell, the scale of the building safety crisis was becoming evident.

Four hundred and fifty-five high-rise residential buildings have been identified as having similar ACM cladding to that on Grenfell: 155 social sector residential buildings, 206 private-sector residential buildings, 54 student accommodation blocks, 30 hotels and 10 other publicly owned buildings. As of June 2020, 246 (54%) had not had the cladding removed.⁸

The government has estimated that a further 1,700 high-rise buildings have other unsafe cladding; it has no data yet on materials on the 85,000 lower-rise buildings (those between 11 metres and 18 metres tall) and had no specific data on care homes under 18 metres. These are of particular concern as elderly and vulnerable residents exacerbate the risks associated with dangerous cladding.⁹

More than 500,000 people in the UK could be living in buildings with unsafe cladding.¹⁰ In addition to the issue of cladding, post-Grenfell inspections have revealed systemic failings regarding issues such as non-compliant fire doors and missing or incorrectly fitted cavity barriers that can compromise compartmentation. Social housing landlords estimate that the cost of making their buildings safe will exceed £10 billion.¹¹ The government estimates it will cost £15 billion to remediate all fire safety defects in England alone.¹²

Learning from Grenfell would require a much broader focus than the tower itself: the problem is systemic. This book maps and structures my observations and reflections about why we don’t learn from catastrophic events and how we might do so, beginning with Grenfell and extending out into other contexts.

Much of what I discovered was unsurprising. I had anticipated issues such as weak regulations, poor procurement and supply chain management practices, and a failure to understand low-probability, high-consequence risk.

But I had not anticipated concluding that we should not rely on those in power to affect change. I had not foreseen that the system is perfectly designed to ensure we do not learn. I had not envisaged the depths of the failings of governance and accountability, or how entangled political agendas and power are with our failure to learn. I had not anticipated how much an obsession with blame or blame avoidance drove the lack of political intent or will to ensure meaningful and systemic change.

But I have found hope. Not in the traditional hallowed halls of political, industrial or financial power but rather through the democratization of change that provides us all with the opportunity (or perhaps duty) to be change-makers – to positively disrupt the status quo.

We can create meaningful systemic change by moving beyond our reliance on simplistic, bureaucratic, command-and-control ways of operating and instead embracing complexity and ambiguity; by campaigning to ensure that consequences are fairly borne by those that contribute to disasters; by tapping diverse and distributed knowledge and by creating spaces for genuine enquiry and reflection.

For, it is in the thousands of tiny steps we take, whether individually or collectively – steps towards goodness – that hope lives. As we have witnessed living through a global pandemic in 2020/21, catastrophes, in all of their horror, do offer something unique. As Rebecca Solnit, author of A Paradise Built in Hell: The Extraordinary Communities that Arise in Disaster, says: ‘When all the ordinary divides and patterns are shattered, people step up to become their brothers’ [and sisters’] keepers. … And that purposefulness and connectedness’ is where the seeds of change are sown.¹³ My wish is that we will all become seed sowers, for what matters to us, for a world we cannot yet see.

Intent, boundaries and principles

While grateful for the opportunity to write this book, and thankful to those who read it, this will always be ‘the book I wish I didn’t have to write’.

To help navigate the complexities of doing so, especially before the official Public Inquiry and the inquests are completed, I’ve had to create some boundaries and principles.

My intent is simple: to offer my reflections in the hope that they will contribute to enquiry and debate that leads to meaningful change.

I finished writing three-and-a-half years after the fire, and it is yet to be determined how (or if) many of the issues I raise will be resolved. The book should be read as a ‘moment in time’ reflection, rather than as a definitive summary of what happened and the response.

The book is not intended to share the story of those most impacted by Grenfell. The grief of those directly affected is incomprehensible. It is not my place to share their story. Where I do provide examples from Grenfell, they are in the public domain and are shared for the intent of learning.

I don’t try to replicate or second-guess the work of the Public Inquiry. At the time of writing, the inquiry is ongoing and is unlikely to be completed for a number of years. While prompted to write by Grenfell, my intent is to reflect on the broader issue of why we don’t learn from catastrophic events.

I have not set out to provide a detailed technical account of what happened at Grenfell. I am not a technical expert and I therefore articulate what happened in a non-technical way. The broad scope of the book has necessitated delving into areas beyond my normal expertise. Any resulting errors are mine alone.

Likewise I have not attempted to cover every issue associated with Grenfell. I have made judgments on what to exclude based on whether it is critical to the overall picture and whether sufficient official and independent evidence is available.

I don’t seek to blame anyone. While I am critical of some actions, they need to be understood in context, and they are presented to illustrate points rather than to blame individuals. As discussed in chapters 3 and 5, blame fixes nothing.

And finally, I don’t present a party-political view. I am critical of both local and central government, but not in a party political way. All political parties – as well as the political system itself – contribute to our failure to learn.

I have included examples from my work in high-hazard industries; they have been adapted to ensure confidentiality.

When I lead workshops, I’m not so concerned about the workshop itself: rather, I’m interested in and intrigued by what participants might do once they leave it! I’m curious to discover how the conversations we have while together might spark new thoughts, insights and action later.

And the same is true for this book. My hope is that it will spark something in you, the reader, that might help those lost lives count. I’m curious about what you might do after reading the book.

The book’s structure

‘Part 1: The Grenfell Tower fire’ explores what we currently know about the fire and why it happened. Chapter 1, ‘The Grenfell Tower fire: not just the cladding’, summarizes what happened on the night. Chapter 2, ‘Before, during and after: getting in the tunnel’, summarizes what we know at the time of writing about the failed opportunities to learn before the fire, the emergency response on the night, and the response since then.

‘Part 2: Analysis and reflections’ seeks to understand why our failure to learn makes sense by exploring two questions: why don’t we learn, and what would it take to enable systemic change? As a starting point, chapter 3, ‘Complexity, safety and systemic change: making the water visible’, is intended both to create a shared language and to make transparent my own thinking and biases. I define what I mean by systemic change and explore the three lenses used in the analysis: complexity, safety and leadership.

Chapters 4–7 are structured around four elements: foundational, behavioural, relational and contextual. I share stories of other catastrophic events, consider widely held myths, reflect on insights from Grenfell, propose the conditions that prevent change, and look at the key opportunities to positively disrupt the status quo.

Chapter 4, ‘The foundational elements: of bricke or stone’, asks what foundational structures are in place to prevent catastrophic events, exploring issues such as known weaknesses in regulations. Chapter 5, ‘Behavioural elements: blame fixes nothing’, considers what mechanisms are in place to prevent and respond to catastrophic events; issues such as human error and failures to respond to concerns raised through government scrutiny mechanisms are explored. Chapter 6, ‘Relational elements: I thought I would make happy both of them’, considers how relational issues contribute to catastrophic events, arguing that our unwillingness to address power imbalances is central to our inability to effect change. Chapter 7, ‘Contextual elements: the patronizing disposition of unaccountable power’, explores issues such as trust and the impact of bias on decision making.

The concluding chapter, ‘The democratization of change: of despair and hope’, draws together the four elements – foundational, behavioural, relational and contextual – into the Grenfell Model for Systemic Change, creating a compelling picture about why our failure to prevent and respond to catastrophic events makes sense.

After sharing some personal reflections on grief and change, the book ends by suggesting some actions for organizations, the media, government, think tanks, and citizens and communities. I also offer up four areas of disruption for us all to focus on: developing our capacity to deal with complexity and ambiguity; ensuring fairly borne consequences; tapping diverse and distributed knowledge; and creating the space to challenge deeply held, and often invisible, assumptions and biases.

Finally, I conclude that the biggest hope lies in the democratization of change, in individual and community actions that, as Rebecca Solnit says, ‘remake the world, and … do so mostly by the accretion of small gestures and statements and the embracing of new visions of what can be and should be’.¹⁴

Thank you for reading.

---

1 Katie Razzall, Nick Menzies and Sara Moralioglu. 2017. The 21st floor. BBC News, 28 September 2017 (www.bbc.co.uk/news/resources/idt-sh/Grenfell_21st_floor).

2 Ben Okri. 2018. Grenfell Tower. Poem, June, 2017 (https://benokri.co.uk/news/grenfell-tower-2017-poem-ben-okri/).

3 Maritime Executive. 2018. July 6, 1988: the Piper Alpha disaster. Article, 7 May (www.maritime-executive.com/article/july-6-1988-the-piper-alpha-disaster).

4 Emma Norris and Marcus Shepheard. 2017. How public inquiries can lead to change. Report, Institute for Government, December, p. 8 (www.instituteforgovernment.org.uk/sites/default/files/publications/Public%20Inquiries%20%28final%29.pdf).

5 Memorandum by the Fire Brigades Union. 1999. Minutes of evidence to the Environment Sub-Committee of the Environment, Transport and Regional Affairs Committee. ROF 28, 20 July, paragraph 2.2 (https://publications.parliament.uk/pa/cm199899/cmselect/cmenvtra/741/9072002.htm).

6 BBC. 2018. Grenfell Tower: the fires that foretold the tragedy. BBC News website, 30 October (www.bbc.co.uk/news/uk-england-45982810).

7 Eddy Daffarn and Francis O’Connor. 2016. KCTMO – playing with fire! Blog, Grenfell Action Group, 20 November (https://grenfellactiongroup.wordpress.com/2016/11/20/kctmo-playing-with-fire/).

8 Ministry of Housing, Communities & Local Government. 2020. Building safety programme: monthly data release for June 2020. Report, issued 16 July (https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/901051/Building_Safety_Data_Release_June_2020.pdf).

9 National Audit Office. 2020. Investigation into remediating dangerous cladding on high-rise buildings. Report, 19 June, paragraphs 2.5, 2.7 and 2.8 (www.nao.org.uk/wp-content/uploads/2020/06/Investigation-into-remediating-dangerous-cladding-on-high-rise-buildings.pdf).

10 Martina Lees. 2020. Grenfell cladding scandal: Manchester residents clash with government over who pays for remediation works. The Times, 14 June (www.thetimes.co.uk/article/grenfell-cladding-scandal-manchester-residents-clash-with-government-over-who-pays-for-remediation-works-9zwzkcn68).

11 Robert Booth. 2020. Social landlords ‘face £10bn bill to fix fire safety problems’. The Guardian, 2 March (www.theguardian.com/society/2020/mar/02/social-landlords-face-10bn-bill-to-fix-fire-safety-problems).

12 UK Parliament. 2020. Communities and Local Government Select Committee Report: progress of remediation. Report, 12 June, section 1, paragraph 34 (https://publications.parliament.uk/pa/cm5801/cmselect/cmcomloc/172/17205.htm#_idTextAnchor003 ).

13 Rebecca Solnit. 2016. How to survive a disaster. Literary Hub, 15 November (https://lithub.com/rebecca-solnit-how-to-survive-a-disaster).

14 Rebecca Solnit. 2019. Introduction. In Whose Story Is This? Old Conflicts, New Chapters. London: Haymarket Books.

Part I

The grenfell tower fire

Chapter 1

The Grenfell Tower fire: not just the cladding

In the event of any internal fire starting near a window, there was a disproportionately high probability of fire spread into the rainscreen cladding system.

Dr Barbara Lane, Grenfell Inquiry Expert Witness¹

If a fire is ignited in a cladding system such as this made of these materials under any circumstances, we have to expect it to spread quickly and catastrophically because of the nature of the materials involved.

Professor Luke Bisby, Grenfell Inquiry Expert Witness²

The fire

Two-hundred and ninety-seven people were in the tower on the night of the fire, including sixty-seven children under the age of eighteen. Two-hundred and twenty-seven escaped. ³

Twenty-five men, twenty-nine women and eighteen children died.⁴ The youngest victim was Logan Isaac Gomes, stillborn at seven months. The seventy-second victim of the fire, Pili Burton, never recovered from her escape and died some months later.⁵ The median age was forty, the oldest victim was eighty-four, the youngest (after Logan Isaac) was six months.⁶

Based largely on expert evidence heard during Phase 1 of the Grenfell Tower Inquiry, and on the Phase 1 report, this chapter describes what happened on 14 June 2017. After providing some background about the building, it explains the key aspects of the 2012–16 refurbishment and explores their consequences.

Background

⁷

Grenfell