[SystemSafety] Grenfell

[Prof. Dr. Peter Bernard Ladkin]

So the Grenfell Inquiry report is now out. 1,700pp of what I take to be distressing reading.

I recall there was some bickering over the appointment of Sir Martin Moore-Bick to lead the inquiry. 
But the UK has a venerable tradition of judge-led inquiries into safety (Piper Alpha, Ladbroke 
Grove, King's Cross fire) and Sir Martin seems to have added to it. His words on release of the 
report were uncompromising. This Guardian comment by Peter Apps, a housing expert and journalist, 
sums up the scope of the enterprise well 
https://www.theguardian.com/commentisfree/article/2024/sep/04/grenfell-is-simply-explained-firms-chased-profits-ministers-sat-on-their-hands-innocents-paid-with-their-lives 


I get particularly distressed when work I have done turns out to be useless. Here were entire 
engineering companies (Kingspan, Celotex, Arconic) who (Sir Martin tells us) knew they had products 
which fire safety people would deem to be unsafe, and who sold them anyway while attempting to 
manage the PR. Even after the fatal Lakanal House fire in 2006, the "building fire safety culture" 
continued apparently as it was, until 2017 and Grenfell. In this kind of culture, our skills are 
useless. Because the industrials involved and their clients (city council agencies) simply appear 
not to have cared much, if at all. And, in safety, you need the people involved to care.

I find this barely fathomable. This, in a land in which, 50 years ago, Parliament enacted HSWA 1974.

As people may remember, we had some discussion here in 2017 at the time of the fire. People may be 
aware that accident and incident analysis is one of my specialties. I don't think I had ever 
encountered a situation in which pretty much everything I looked at in the way of safety in those 
first few days turned out to be a chimera. This was not Piper Alpha; this was not Ladbroke Grove; 
this was not King's Cross; this was in another league entirely.

It requires governments to change such a culture. Which means, first and foremost, the will to do so 
must be there (I understand Sir Martin has shown that it wasn't). Let us hope it now is.

PBL

Prof. Dr. Peter Bernard Ladkin
Causalis Limited/Causalis IngenieurGmbH, Bielefeld, Germany
Tel: +49 (0)521 3 29 31 00