The duty of learning from errors

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The blackened shell of Grenfell Tower has become a familiar image in the months since a catastrophic fire swept through the residential tower block in west London during the early hours of 14 June 2017, killing 71 people and destroying the homes and lives of hundreds more.

This shocking image is a stark reminder of the ongoing impact of the disaster and the need to ensure that lessons are learned and applied to mitigate the likelihood of recurrence.

A number of inquiries and investigations were launched in the wake of the incident to identify learning and remedial action, but with particular concern surrounding the way that the fire spread so quickly through the structure of the building, Judith Hackitt, former chair of HSE, was asked to lead a fundamental review of building regulations and fire safety.

The review was tasked with taking a future-focussed approach, reviewing the regulatory regime and making recommendations to ensure that this will be robust in assuring the safety of residential buildings in the future, rather than retrospectively reviewing the specific circumstances that led to the Grenfell Tower fire. The team was asked to report swiftly, and their interim report, issued on 18 December, makes sobering reading.

Even at this early stage, the review has been able to conclude the regulatory system for building and fire safety is not fit for purpose.  The report says that regulations and guidance are too complex and unclear; clarity of roles and responsibilities is poor; the means of assessing and ensuring the competence of key people is inadequate; the enforcement and sanctioning process is weak, and the process to allow residents to escalate concerns is also inadequate.

Having completed the first stage of the review the team will now work closely with stakeholders to develop a set of recommendations to drive positive change. The final report will be issued in the spring.

The next phase of work will focus on six key themes; regulation and guidance; roles and responsibilities; competence; process compliance and enforcement; residents’ voice and raising concerns; and quality assurance and products. The team will hold a series of meetings to gain input from stakeholders and subject matter experts from the industry.

In her forward to the report Judith Hackitt says: “This tragic incident should not have happened in our country in the 21st century. We now all have the opportunity to respond in a way that makes people safer in the future.”

The summary section goes on to say that “this is a call to action for an entire industry and those parts of government that oversee it. True and lasting change will require a universal shift in culture... and this culture change needs to start now.”

It’s a strong message and a call to all key stakeholders to unite in the pursuit of a system, which allows people to feel safe in their own homes – surely a reasonable expectation in 21st century Britain.

Throughout history major disasters have been followed by significant improvements in health and safety.  For example, the Bradford City fire and the Hillsborough disaster led to major changes in the way that sporting and events venues are managed, the Piper Alpha explosion led to an overhaul of health and safety in the offshore industry and the Ladbroke Grove and Potters Bar train crashes drove a fundamental review of arrangements for railway maintenance.

We can’t do anything to mitigate the impact of the Grenfell Tower fire on those involved, but we have a duty to ensure that lessons are learned and applied to minimise the risk of a similar incident occurring in the future.  This needs to be the start of a step change in the way that we approach the safety of residents in multi-occupied buildings, but this must be handled sensitively.

The tools and approaches used to drive safety improvement in workplaces and public buildings will not necessarily be appropriate when dealing with the people in their homes and private lives. Collaboration and engagement will be key so that key stakeholders can work together to drive real improvements in this important area, honouring the memory of those who lost their lives at Grenfell Tower.


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