When It All Goes Wrong: Part 1

When It All Goes Wrong: Part 1: Grenfell

12 March, 2020

In this series, we are looking at a range of situations where the symptoms of Complexity – and of inappropriate responses to Complexity – are particularly striking.

Whilst most Complexity-driven situations (and most of the inappropriate responses made) will never escalate this far, you may well recognise many elements of your own situation in these examples.

Part 1: The Grenfell Fire Tragedy

In the early morning of 14th June 2017, a fire broke out in the 24-storey Grenfell Tower block in North Kensington, West London – a residential building that was housing almost 300 people at the time.

Tragically, 72 people died – either at the scene or in hospital afterwards – and the incident was headline news around the world.

As well as media reporting and analysis of what happened, an official inquiry was launched in September 2017, with the first major findings released on 30th October 2019.

What was clear from the outset was that the background to what happened was highly Complex.

The Complex Makings of a Tragedy

Within two days of the fire, the Daily Telegraph published a piece identifying at least eight contributing factors that contributed to the building being susceptible to fire and making loss of life more likely.

A multiplicity of overlapping factors, stakeholders and priorities is a key element of Complexity, and it could be seen here that there were various competing interests and interest groups – national regulations, local government, building management, residents, etc – and that expert warnings were ignored.

Residents had also warned on a blog about some of these factors, and The Guardian reported in March 2019 how a government watchdog considered that the residents’ rights had been infringed, criticising both local and central government.

Without in any way downplaying the roles of negligence or culpability, difficulty in fully accounting for, and weighting, all the contributing factors – and in identifying root causes – is another telling symptom of Complexity.

And the subsequent criticism of different groups, recrimination and search for responsibility and accountability reflected this.

Complexity-Inappropriate Responses Compounded the Tragedy

Particularly prominent in the aftermath were questions raised about the response of the London Fire Brigade.

The fire was obviously not of their making and the bravery of the firefighters involved has never been questioned.

However, there were strong criticisms levelled about how they handled the Complex situation, and how this added to the death toll.

The BBC reported in September 2018 how the chief of the London Fire Brigade, Dany Cotton, in giving evidence to the inquiry, said she “would not change anything we did on the night”, that the building “behaved in a way it should never have done” and that there had been no specific training on the type of incident because it would have been deemed an “unrealistic scenario”.

The sheer inability to accept that a situation could “legitimately” arise that didn’t fit preconceptions was summed up when she said “I wouldn’t expect us to be developing training or a response to something that simply shouldn’t happen.”

However, on 29th October 2019 – the eve of the inquiry’s initial findings being published – the BBC damningly reported that“The London Fire Brigade (LFB) has been condemned for “serious shortcomings” and systemic failure” and that the inquiry had “…found many “institutional” failures that meant the LFB’s planning and preparation for the incident was “gravely inadequate”.”

Reuters similarly reported that “some lives that could have been saved were lost” and that “…there would have been fewer fatalities if the decision to tell residents to evacuate had been made an hour or more earlier than it was. “The ‘stay put’ concept had become an article of faith within the LFB (London Fire Brigade) so powerful that to depart from it was to all intents and purposes unthinkable”.

Even then, though – and reflecting the ambiguities and lack of clarity around understanding a complex situation – the head of the Fire Brigades Union said that “…the public inquiry was “back to front” and should have first looked into the deeper causes of the tragedy”.

In Conclusion

Overall, though, what has become extremely clear is that there was a tragically inadequate appreciation that the situation was Complex, and a correspondingly and completely inappropriate response to it – one that had assumed things should happen in particular ways and that predefined protocols should be followed at almost any cost.

As The Guardian reported in March 2020, the inquiry continued to unearth troubling evidence, with the architect responsible for the refurbishment admitting that he neither consulted nor knew about relevant regulations, and that procurement rules had been deliberately broken, with bitter disputes about where responsibility then fell.

But the Grenfell Tragedy nevertheless serves as a tragic example – albeit an extreme one – both of Complexity and of using the wrong approach to respond to it.