Was the Grenfell Tower fire a black swan event?

In his excellent article in Inside Housing reflecting on the sad five-year anniversary of the dreadful Grenfell Tower fire Peter Apps quotes one commentator describing such an event as being the result of an “unknown, unknowns.”  In crisis communications we use the term “black swans.”

A black swan is an event thought to be unthinkable and therefore unpredictable.  The example I often use is that of the German Wings flight back in 2015.  The co-pilot, who we now know was suffering from mental health issues, decided to take his own life by flying the plane with all 150 crew and passengers on board into a mountain.  Such an event, if it was thought about at all, was not really prepared for perhaps on account of it being thought to be too awful to imagine.

If the Grenfell Tower fire was a black swan-type event, then as the Inside Housing analysis demonstrates the same could not be said if anything similar ever happened again.  Whilst there has been progress in removing one type of cladding from buildings higher than 18 metres there are still thousands of others with different but possibly equally dangerous cladding at lower levels where little or nothing has been done at all.

There are still lessons to be learnt.  The UK in particular is often criticised for a so-called “health and safety culture.”  But where was that in the run-up to the Grenfell Tower fire?  Evidence at the inquiry into the fire clearly show that employees at the manufacturers of the insulation and the cladding that fuelled the fire knew how unsuitable their products were on buildings such as the Grenfell Tower, but they continued to market them.

There are obvious lessons around corporate culture to be learnt here.  Crisis management is not just about a manual on how to proceed in a crisis.  It should also be about engendering a corporate culture that that has a moral compass.  It is also around ensuring employees have clear policies to escalate concerns and protection when they do so.  In this way crises can be prevented in the first place.

There is also a point around what is coming to be known as “regulatory capture.”  This is when the bodies that are put in place to regulate an industry become far too close to that industry.  At the Grenfell Tower inquiry it was revealed that the materials used on the outside of the building had been approved by various regulators when clearly, they should not have been. We saw similar issues being raised around the Boeing Max 737 crisis. Poorly resourced regulators who come to rely on those they regulate for insight and expertise cannot really do the job properly.

The first part of the Grenfell Tower inquiry concentrated on the actual response to the fire. Criticisms were voiced of the actions of the London Fire Brigade and as we know the Commissioner at the time, Dany Cotton, subsequently resigned.  We now know that the strategy to instruct residents of the Tower to stay put as the fire raged was a disaster.  But it was a long-standing policy for high rise buildings drafted in a time of concrete construction and sturdy fire doors.  Today an estimated three-quarters of fire doors across the UK do not meet the required standard, according to experts quoted in the Inside Housing article.

Now that it looks as if we cannot always rely on “stay put” thought must be given as to how to communicate to residents that they should leave the building in the event of a fire.  There are obvious logistical problems.  Many flats in the UK do not have a fire alarm system.  Even if an alarm was going to be used, then residents would need to be communicated to as to how to leave the building safely.  Academic thinking tends to conclude that individuals do not panic in an emergency.  In fact, sometimes people are slow to react at all. In behavioural psychology we talk about “social proof” which is the tendency to look for cues from others in terms of how to react in uncertain circumstances. When there is a need to evacuate people will wait until they see others doing it. It will always be a communications challenge just to ensure residents in tower blocks react quickly.

If we look at disasters, we see that evacuation plans are not simple at all.  When Hurricane Katrina hit New Orleans it soon become clear that the plans to get people out did not take into account people who were too ill to evacuate, those who were disabled and needed special help, those who refused to leave their pets, those who did not have cars or money to leave, those who had heard warnings before and decided to simply sit it out and those fearful looters would move in as they moved out.  Individual needs and responses in an evacuation can be complex and in disaster after disaster are often overlooked.

Thankfully yesterday’s fires were brought under control.  News reports also showed the London Fire Brigade using new technology which allowed a 999 caller to livestream the Queensdale Crescent fire to the call handling centre.  But still urgent thought really does need to be given to the communications around evacuating hundreds from a tower block possibly with no fire alarm, no obvious way of communicating with each and every resident and with residents of very differing needs.  The alternative is too awful to imagine.