The utterly appalling sight of our fellow citizens being burnt alive, trapped in a tall building, naturally fills all of us with deep sorrow, and for many anger.
How could this happen? Could it happen again?
There are two sort of questions that need examining. The first, and by far the most urgent, is how did this happen in the technical, proximate cause, sense? How could a tower block that’s stood for 4-5 decades suddenly turn into such towering disaster?
Immediate ‘Air Accident Investigation Branch’ type investigation?
If this was an aircraft crashing and killing a hundred people we know how these questions would be answered. The Air Accident Investigation Branch (AAIB) would be on the scene with a rapid, expert, investigation to establish:
- What was the immediate cause of this specific incident?
- Why did the fire spread so quickly?
- Why did the passive fire containment fail?
- What are the immediate lessons for other buildings of the same type?
- Is immediate action needed to prevent this happening again?
It’s obvious why we have the AAIB – any airplane crash may be an idiosyncratic one-off or it may be a structural or systemic failure that means all aircraft of this type are at risk.
We need quick, expert, and independent answers to these immediate questions and recommendations about what needs to change.
We don’t really have a body with the powers and expertise of the AAIB for a fire like this, but a temporary Task Force could be created very quickly to do the job. Experts from fire services, the Fire Service College, private sector fire-safety companies, academic experts, architects, etc could be pulled together quickly to undertake this task.
The second phase of investigation which would focus on responsibility and accountability – of authorities, individuals and regulatory system. This will take much longer because it needs to be open, provide opportunities for all the interested parties to give evidence and present their side of the story, etc. It would take place undere the terms of the Inquiries Act 2005.
This will probably take 3-4 years.
It’s important it happens, but it will not meet the immediate need for answers and, if necessary, action like, for example, banning the type of cladding used in this case if it was a major contributory factor?
2 thoughts on “Grenfell – we need an ‘Air Accident’ type investigation, now”
There are at least surface parallels with the Flixborough Disaster in 1974. The Court of Inquiry that Michael Foot appointed a few weeks after the disaster https://goo.gl/V1Au2n [big PDF] reached conclusions that had beneficial effects on the regulation and control of workplace safety and health that are still with us. The Health and Safety at Work Act was already enacted, but had not yet come into force; but the conclusions of the Inquiry changed the way that people thought about workplace safety, as well as highlighting how an organisation does not need to be crudely “putting profit before safety” for the financial environment to lead to corner cutting and to a generally brainless lack of foresight that can cause a lot of death and destruction. One has to hope that analysis of the Grenfell Disaster (and that should be what it is called – not a fire, not an incident, not an accident) will produce similar long term beneficial change in building standards, and in their enforcement.