Newsletter of New Build Database - Issue #6 Catastrophe and Systemic Change

Our latest newsletter is co-authored with Nichola Venables CEO of New Build Database and Gill Kernick, a former resident of Grenfell Tower and author of ‘Catastrophe & systemic change: Learning from the Grenfell Tower fire and other disasters. Gill works with organisations in high hazard industries to develop the culture and leadership to prevent accidents.

Nothing in this newsletter constitutes advice.

Permission is given freely for any aspect of this newsletter to be re-published as long as credit is given to the authors

The Grenfell Tower tragedy was the worst residential fire in London since World War II. It killed seventy-two people in the richest borough of one of the wealthiest countries in the world. Like other catastrophic events before it and since, it has the power to bring about lasting change. But will it? The historical evidence is weighed against ‘lessons being learned’ in a meaningful or enduring way.

In an attempt to understand why, despite enormous efforts, we persistently fail to learn from catastrophic events, this book uses the details of the Grenfell fire as a case study to consider two questions.

• Why don’t we learn?

• What would it take to enable real systemic change?

The book explores the myths, the key challenges and the conditions that inhibit learning, and it identifies opportunities to positively disrupt the status quo. It offers an accessible model for systemic change, not as a definitive solution but rather as a framework to evoke reflection, enquiry and proper debate.

NV: Gill please start by telling us a little more about yourself and your work?

GK: I am a strategic consultant partnering organisations in high hazard industries to develop the culture and leadership needed to prevent accidents. I have a particular interest in low probability, high consequence (or catastrophic) events.

Safety is the outcome of a complex socio-technical system and our typical, siloed focus on compliance and technical issues is insufficient.  We need to create environments where the complex social aspects of safety are given as much attention as the technical issues. Where avoiding the devastating human impact of accidents is a core motivation and where constantly searching for vulnerabilities and speaking up about concerns is valued.

I view safety as a driver of broader, purpose and values-driven organisational change. When viewed from this perspective, distributed ownership and leadership of safety is critical. From board members to finance teams, everyone has a role to play, and the voice of the front line is a strategic cornerstone. The role of safety professionals is as much about enabling change as assuring work.

NV: And can you tell us about your connection with Grenfell Tower.

GK: I lived on the 21st floor from 2011-2014. Seven of my immediate neighbours died in the fire, including the youngest victim, Logan Isaac, who was still born at seven months.

Having moved back to London from working abroad, my husband Keith and I were looking for an apartment to rent in North Kensington for a couple of years. Sick of looking at dingy and overpriced flats, an advertisement for Flat 185 in Grenfell caught my eye.

We walked in, took one look and signed the lease. It remains one of the most beautiful places I’ve lived, my memories are of the indescribably exquisite views and the sounds of children playing in the lobbies.

Falling in love with high-rise living, in 2014, we bought an apartment in nearby Trellick Tower, our views of Grenfell.

NV: Four years have passed since the Grenfell disaster; do you feel like we have learned from what happened?

GK: This is such a loaded question, and I don’t think we spend enough time unpacking it. How will we know we’ve learned? How do we assess progress?

It’s helpful to look through a socio-technical lens.

From a technical perspective, I would expect that four years after the fire we would, at a minimum, at a national level, understand the fire risk of all high-and-medium-rise residential buildings, and effectively be co-ordinating risk mitigation and remediation.

This would have required auditing all buildings, identifying the fire safety hazards, such as the materials used in facades, understanding the effectiveness of layers of protection in place such as fire doors, cavity barriers, ventilation and evacuation routes. And then holistically assessing the risk of the building (considering the likelihood and consequence that the hazards pose and how effective layers of protection and mitigation would be).

Doing this would enable a co-ordinated national response where we could target resources at remediating the most at-risk buildings first.

But rather than a holistic crisis response from government and industry, our approach post-Grenfell is siloed, overly focussed on cladding and facades, and is neither transparent nor co-ordinated.

Mitigations such as waking watch are unproven and don’t leave residents feeling safe in their homes.

And astoundingly, the burden of funding remediation is unfairly borne by leaseholders.

From a social perspective, I would expect that across the housing sector residents would say that their voices were central to change, and that attitudes to social housing tenants had altered dramatically.

I don’t believe this to be the case. And we repeatedly hear criticisms from Dame Judith Hackitt - the author of the Building a Safer Future review of building and fire safety – about the race to the bottom culture and the slow pace of change across the sector. Over and over again I hear stories of bad practice continuing and large contracts being procured on cost alone.

The government, developers and housing sector appear to accept near-miss after near-miss and I don’t believe are operating with the level of urgency needed to prevent further loss of life. Luck and hope are not good mitigation strategies.

So, no, we haven’t learned from what happened. We might have made piecemeal incremental changes, but we haven’t learned.

NV: Your book is titled Catastrophe and Systemic Change. What do you mean by systemic change? What is needed for systemic change?

GK: There are two young fish swimming along, and they meet an older fish, who asks them ‘How’s the water?’. The two fish continue swimming along for a while and then one of them looks at the other and says, ‘What is water?’

This parable, attributed to author David Foster Wallace, is a good way of understanding systemic change.

The table below shows the key differences between piecemeal and systemic change.

To effectively learn you need both piecemeal and systemic change. But our response to catastrophes tends to be piecemeal. So, in the case of Grenfell, we will alter some regulations and change what products can be used on high rises, and it’s critical we do that.

But will we alter the conditions holding in place our negative bias against social housing, or our continued failure to ensure diversity of representation at board and senior executive level, or our reliance on the myth that regulations guarantee safe outcomes?

‘Making the water visible’ is a first step in enabling systemic change. That is what I attempt to do in the book - to make visible why our failure to learn makes sense.

In terms of how to enable systemic change, this requires disrupting the system, which will demand experimenting, innovating and learning, all of which require a move away from a command and control, rules-based leadership style.

NV: Do you think we will see systemic change in the next decade?

GK: There is little evidence that the kind of bold, courageous, principled leadership needed to enable systemic change is present within key stakeholders, from government to corporates to the housing sector.

The one ray of hope for disruption is residents. We are seeing co-ordinated efforts across the country from those caught up in the building safety crisis. And they will not stop until they see change.

So, perhaps we will, but I don’t believe systemic change will come from within government or industry.

NV: What do you think is achievable in the next 3-5 years?

GK: Well, that would be 7 to 9 years after Grenfell. 

I would like to answer this purely from an outcome perspective. It has to be achievable that within this time frame:

People are either

·        Living in a knowingly safe home. 

·        Or if a home is not safe, then clear, affordable and innovative mitigations are in place that ensure residents are, and feel, safe.

And the funding of remediating historic safety issues sits with those who created them, not with innocent leaseholders and residents.

But we are in no way on track for this. 

NV: Do you think there is a real desire for change from both the corporate and government worlds?

GK: No.

Commitment and desire for change shows up in outcomes and actions, not in spin or rhetoric.  While there are some examples of good practice and change, these tend to be the exception, not the rule.

In four years, we have completed remediation on only 35% of the 455 high rise buildings with ACM cladding (the same as on Grenfell) and we have no national data available on the scale of safety issues faced nationally. We are facing a crisis. We do know that there have been nearly 3,000 applications from private high rise residential buildings for help with other types of dangerous cladding, and we know there are multiple issues with cavity barriers, fire-doors and ventilation systems.  I hear estimates that between 25% and 75% of high and medium rise buildings have serious safety issues.

When the government says it’s given an unprecedented 5.1 billion to remediation – that is only for limited work on façade remediation and only for high-rise buildings – estimates range between £15 and 50 billion being needed to remediate historic errors. Where is this money coming from?

That the government and corporate worlds have not come up with a workable solution for funding remediation – and have been willing to leave leaseholders to pay for historic errors is an action that betrays any spin about a commitment to change.

NV: What has your experience of working with Senior Executives been to date?

GK: Well, I’m very fortunate in my work. By the time I’m working with an organisation they are authentically committed to change and understand that their own leadership is critical to that.

So, I have a very positive and very skewed experience of working with Senior Executives.

One where they are willing to look at themselves in the mirror and be bold and courageous in creating environments where people feel safe to raise concerns and willing to invest in correcting systemic issues such as overly burdensome procedures versus simply blaming the front line for errors.

It is a privilege to partner executives who are authentically committed to change. 

NV: What has your experience been of working with national government?

GK: Well, until fairly recently at a national level, all I met with was closed doors. I attempted to participate in working groups post-Grenfell but was either politely fobbed off or ignored. That has changed somewhat, probably due to having more of a profile.

It does concern me that there is a very small, elite and closed group of people who are involved in solutions post-Grenfell. And in many cases, they were in positions of power and influence pre-Grenfell.  There does not seem to be a welcoming of diverse voices and views.

NV: Do you think enough has been done to engage with residents on necessary political change?

GK: No.

I have been appalled at the consultation process. They are inaccessible, tick-box exercises that I’ve stopped participating in. The same can be said of the numerous surveys done under the guise of gathering residents views.

Why have we not seen the use of citizens forums, or the creation of a national body of residents’ associations?  Or trained and paid a cadre of residents to gather the views of their neighbours.

NV: How can residents raise their collective voice?

GK: At a local level, through vibrant residents’ associations. My husband co-chairs ours at Trellick Tower and they are able to put pressure on the council. They work strategically with other resident associations, businesses and organisations to present a united front to drive change when working with the RBKC.

At a national level, join and support those caught up in the cladding scandal and building safety crisis. Whether it be supporting them on twitter or joining a local protest. They have a large presence on twitter.

And follow and support Grenfell United and other organisations calling for justice post-Grenfell.

Also – VOTE! Get more informed and vote. Your voice counts and you have no right to complain if you didn’t.

NV: What key messages would you like to convey from the book?

GK: That our current system is perfectly designed to ensure we won’t learn from catastrophes, from Grenfell to Covid. And relying on government to change is a flawed strategy.

If we’re to disrupt the status quo we need to engage in some different and challenging conversations.

Hope lies in the democratisation of change. In the tiny steps we, as citizens take, every day to move us to a new place. It lies in the green heart on Grenfell and the red hearts on the embankment for the pandemic.