[SystemSafety] Grenfell

[andrew at andrewbanks.com]

Thanks Peter

Once again, albeit on a very cursory scan through, the only conclusion that
can be reached is that this was an entirely preventable event, if only
people with responsibilities had done their jobs properly... but that many
of those people were so prevented by their grown-ups making commercial- and
political-based decisions.

Seven years after the event, I still cannot understand how the alignment of
the Swiss Cheese allowed a failing kitchen appliance to snowball into such
an inferno.

It's about time that lessons are actually learned.

Andrew

-----Original Message-----
From: systemsafety <systemsafety-bounces at lists.techfak.uni-bielefeld.de> On
Behalf Of Prof. Dr. Peter Bernard Ladkin
Sent: Thursday, September 5, 2024 2:04 PM
To: The System Safety List <systemsafety at lists.techfak.uni-bielefeld.de>
Subject: [SystemSafety] Grenfell

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-si
mply-explained-firms-chased-profits-ministers-sat-on-their-hands-innocents-p
aid-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

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