The current count of those missing and presumed dead from the Grenfell Tower fire on June 14, 2017 stands at 79. A large fire ripped through the 24-story residential building located in west London in the early hours of the morning.
Whenever an incident of this magnitude occurs, it is important to understand not just the initiating event, but also what were the additional causes that led to the impact becoming as large as it was. In other words, not just what started the fire, but what allowed the fire to become as large as it did, as fast as it did, and what limited the ability of residents to evacuate from the building in time. Identifying all the causes that contributed to the severity of the incident, or the degree of the consequence, allows us to look at all the options for mitigating the risk for this magnitude of an incident in the future.
Initial reports indicate the fire initiated in a fridge freezer inside an apartment on the fourth floor of the high-rise building. The initial fire could be considered the initiating event and understanding why the initiating event occurred should be part of the investigation. But in addition to what caused the initial fire, we should also ask why the initial fire became a larger fire in a short amount of time, engulfing the entire 24-story building and reducing the time allowable for evacuation.
There are conflicting reports, but possible causes include lack of sprinkler system (it was not installed during original construction in 1974 and not added post original construction – why?). Another possible cause that has been mentioned in news reports is the cladding used in the recent 2016 refurbishment of the building. During the investigation into this issue, it is important to understand if the cladding meets current regulations for fire-proofing and whether the installed cladding produced a chimney effect that allowed the fire to spread more rapidly. In addition, there are conflicting reports about whether fire alarms provided timely warning to the residents. The questions about the adequacy of alarms is particularly relevant because of the time of the fire which was reported at 00:54AM BST, meaning that a large number of residents were home and likely asleep.
Any incident with this magnitude of impact, challenges us to ask not just what was the cause of the fire, but to dig deeper to understand what caused the fire to be as big as it was, leading to as much damage and loss of life as it did. That’s how we learn from this. That’s how we save lives in the future.
For your larger incidents – don’t just ask the question what was the initiating event/failure/issue, continue to question what allowed that initiating event/failure/issue to become as large as it did. What layer of protection did not do what we wanted it to? What did not go well in our response to the initiating event? What mitigation should have kicked in and didn’t? What would have been different if we had been aware of the initiating event sooner?