The fire started by an electrical fault in a refrigerator on the fourth floor but that is not what this fire is about. So often in safety some sort of cause satisfies the simplistic notion of ‘root cause’ that has nothing to do with what an incident is about. Root cause is a mythical distraction for any authentic safety investigation.
Yeah, but don’t go looking for blame because ‘blame fixes nothing’.
The Grenfell Tower Fire occurred in June 2017 and seven years later there has still been no-one brought to account or any criminal charges have been laid for this disaster. Seven organisations are still under investigation with so much hidden corruption and inter-blaming ‘duck shoving’ going on, it is likely that nothing will happen.
Yeah, but don’t go looking for blame because ‘blame fixes nothing’.
The tower block underwent renovation from 2015-2016 using aluminium composite cladding. It was well known at the time by all concerned that this cladding was highly combustible with cases of fire disasters reported from around the world eg. Lakanal House 2009, Bucharest fire 2009, Lillie 2012, Melbourne 2014.
The cladding was made by a subsidiary of Alcoa, Arconic. The cladding was installed by the cheapest contractor Ryden and engaged by the Kensington and Chelsea London Borough Council. Other companies involved include Celotex, Whirlpool and Kingspan. The safety slogan at Arconic was ‘Safety First’.
Yeah, but don’t go looking for blame because ‘blame fixes nothing’.
A range of cultural issues preceded the fire including the reduction in regulation for safety in the UK by the conservative Cameron Government (https://www.theguardian.com/uk-news/article/2024/sep/08/grenfell-survivors-david-cameron-claim-inquiry-red-tape-ex-pm; https://www.theguardian.com/uk/2012/jan/05/cameron-targets-health-and-safety-rules). In addition, the fire service undertook no training in the nature of cladding fires nor understood the nature of Polyisocyanurate cladding. Indeed, information on the nature of this cladding was intentionally withheld from the fire services.
Moreso, the policy for tower fires was to ‘stay put’ which was the advice given to residents on the day of the fire. It seems that trusting orthodox policy given by authorities about safety led to the death of many. Those who didn’t follow the advice of the authorities and took the stairs down to the ground, lived. The fire burned for 60 hours and had the advice been to leave in the early stages of the fire, most would have lived.
Yeah, but don’t go looking for blame because ‘blame fixes nothing’.
The fire is the subject of police investigation, a public enquiry and a Coroner’s inquest. I wonder what these inquiries are looking for? I wonder what they want to learn?
Yeah, but don’t go looking for blame because ‘blame fixes nothing’.
This nonsense slogan of the HOP group (which they mis-attribute as a ‘principle’) is one of the most dangerous slogans that exists in Safety. The HOP Group offer no articulation of an ethic of risk neither engage in any discourse about moral meaning.
The slogan ‘blame fixes nothing’ emerges out of the mythological gobbledygook of Just Culture, a discourse (https://safetyrisk.net/the-discourse-of-just-culture-in-safety/) that spruiks nonsense grammar about a ‘no-blame culture’ where people are still held accountable for their actions. That nasty thing called ‘blame’ must be avoided so that no-one is to blame, just systems are to blame. Afterall, safety is all about fixing those nasty fallible systems.
Just Culture mythology is also perpetuated by the binary discourse of Dekker that proposes that Just Culture is a choice between restoration or retribution. Tackling the complexity of risk is NOT about such binary choices indeed, any binary discourse about risk that is packaged in black and white language in safety should be avoided. Seeking Justice is not about binary discourse or simplistic formulas. It is so amusing in this discourse on Just Culture (as well as Reason’s other silly notions of culture) that Justice and Culture are so poorly defined. Most often the discourse is simply an aspiration for ‘fair systems’.
The notion of Just Culture comes from James Reason who leaves the safety industry with a host of legacies (https://safetyrisk.net/you-get-what-you-expect-in-safety-or-how-the-burden-of-james-reasons-ideology-bogs-down-safety/) and myths (https://safetyrisk.net/faith-in-reason-and-unreasoned-faith-as-safety-myth/) that limit critical thinking, methodology and methods about risk (https://safetyrisk.net/hopkins-dekker-on-reason-and-other-laughs/). There is nothing more mindless than the linear swiss-cheese of Reason.
Yeah, but don’t go looking for blame because ‘blame fixes nothing’.
If you are looking for some kind of linear cause in the Grenfell Tower Disaster, you won’t find one. The complexity of cultural causes like the desire to re-clad the building itself is tied up in many unconscious forces that cannot be detectable in any orthodox safety investigation. Didn’t you know, culture is ‘what we do around here’.
What also accompanies this tragedy is the lack of support or follow-up for victims. There has been censorship of complaints, blame shifting by organisations and discourse gobbledygook sprouted by any organisation or person accountable for their part in the tragedy. If blame fixes nothing, why are so many executives articulating that they are not to blame?
Meanwhile the victims’ families that want answers, learning and compensation, restitution and justice, get nothing.
Of course, none of the executives of the companies responsible have taken any responsibility for their part in the tragedy despite their known complicity in hiding facts, corrupt conduct and prioritising profits over safety (https://www.theguardian.com/uk-news/article/2024/sep/04/grenfell-tower-fire-report-public-inquiry-key-players-cladding). But let’s not target well-paid executives who told lies, were deliberately and knowingly dishonest. Let’s not target executives who hid behind nonsense slogans like ‘Safety First’ and other useless safety speak. Let’s not make accountable any PCBU for their part in unethical and immoral conduct. Just make sure they get a huge pay-out, shift to another organisation on a multi-million dollar salary and start again. The last thing we want to see under the work health and safety regulation is unethical individuals going to prison.
Yeah, but don’t go looking for blame because ‘blame fixes nothing’.
The Grenfell Tower Fire is the deadliest structural fire in the UK since Piper Alpha in 1988. The trauma experienced by those who responded, families and volunteers are immeasurable. It was reported that at least 20 suicides were attempted during the fire by those trapped on upper floors. More than 150 homes were destroyed in the surrounds of the fire. You can read more detail about the tragedy here: https://en.wikipedia.org/wiki/Grenfell_Tower_fire
You can read Phase 1 Report on the Investigation into the fire here: https://webarchive.nationalarchives.gov.uk/ukgwa/20250320040117/https://www.grenfelltowerinquiry.org.uk/phase-1-report The fallout of costs from the fire exceed 1.2 billion pounds.
I wonder why the inquiry goes so deep and hard in seeking blame? Afterall, blame fixes nothing.
I wonder why there is now a cladding crisis in Australia (https://scecorp.au/what-is-the-australian-cladding-crisis-understanding-the-problem-and-its-implications/)? Afterall, blame fixes nothing.
I wonder why there are so many cladding remediation programs going on in Australia (https://www.nsw.gov.au/departments-and-agencies/building-commission/replace-flammable-cladding-through-project-remediate)? Afterall, blame fixes nothing.
What the safety industry needs more than anything is a well-articulated ethic of risk. Not the deontological nonsense of the AIHS BOK Chapter on ethics but a genuine ethic of risk that keeps away from the gobbledygook of ‘just culture’ and the delusional slogans of HOP.
Prof. Robert Long
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