Wider Lessons on Facilitating Systemic Change Learned from the Grenfell Tower Fire Inquiry

The Grenfell Tower tragedy 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?
Wider Lessons on Facilitating Systemic Change Learned from the Grenfell Tower Fire Inquiry
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The Grenfell Tower fire that shook London, and the world, in June 2017 killed 72 people. A small kitchen fire entered the external cladding system and spread up 19 floors in 20 minutes, breaking compartmentation and engulfing the building. 

The ongoing Grenfell Inquiry has revealed multiple failures, such as: the use of materials that did not comply with regulations; product manufacturers keeping secret failed tests and knowingly selling dangerous products; and successive ministers failing to act on recommendations to improve guidance in the face of a previous fatal high-rise fire. It has become clear that to prevent a similar event in the future will require tackling complex governance, political, and human issues, and biases.

Prior to Grenfell, I was unaware of the level of regulatory vulnerability and the breadth of weaknesses in governance and accountability, I was also unaware that traditional public investigations, such as public inquiries, are fraught with challenges, including that they are called at the discretion of ministers and that there is no accountability mechanism in place to ensure that their recommendations are appropriately implemented or effective. Neither did I fully understand how subtle relational issues such as ‘hero and villain’ and ‘rebel resident’ narratives silence voices, thereby inhibiting our ability to learn, or how little understood and explored the contextual and cultural elements are.

More on the Forum Network: Conformity: The Power of Social Influences, by Cass R. Sunstein by Robert Walmsley University Professor, Harvard ; Author, Conformity

For each of us, conformity is often a rational course of action, but when all or most of us conform, society can end up making large mistakes. Well-functioning institutions take steps to discourage conformity and to promote dissent, partly to protect the rights of dissenters but mostly to protect interests of their own, highlights Cass R. Sunstein in his book 'Conformity: The Power of Social Influences'.

I now believe that the framework used in the analysis of Grenfell has broader application. It is offered as the Grenfell Model for Systemic Change (figure 1). It considers the four elements – foundational, behavioural, relational, and contextual – and further categorizes them into operating and governing frameworks and obvious and obscure elements.

Figure 1: The Grenfell Model for Systemic Change:

My hope is that using this model will help us to look more holistically at catastrophic events, and particularly that we will pay more attention to their obscure and more challenging relational and con-
textual elements. As we have seen throughout the book, there are four specific areas that work to hold the status quo in place. Let us now turn our attention to these.

I had not anticipated the breadth and depth of failures nor how relevant the issues and challenges would be to Covid-19 and the many other intractable challenges we are facing into today.

The myths

One way of ‘unlearning’ or shifting contextual beliefs is to explore myths: the things that we hold to be true. Based on my observations, there are four of these that contribute to our inability to learn.

  • The myth that regulations keep us safe keeps in place simplistic linear thinking and solutions that fail to deal with increasing complexity and ambiguity and the need to build resilient systems.
  • The myth of the perfect, error-free world sees human error and deviation as an anomaly that can be corrected by removing the ‘bad apples’, thus restoring order.
  • The myth that the softer relational issues aren’t that important rationalizes our apparent unwillingness to confront or develop the necessary leadership capabilities to address complex issues such as regulatory capture, groupthink and herd behaviour.
  • The myth that you can create change without shifting deeply held assumptions and beliefs stops us exploring and ‘unlearning’ deeply held, embodied and often unconscious beliefs, assumptions and biases.

Hanging onto these myths justifies an over-reliance on the obvious and reactive regulatory responses that fail to address deeper systemic issues, grounded as they are in a bureaucratic command-and-control mindset. These myths form a web that surrounds the conditions holding the status quo in place.

We need diverse views and voices to be heard, but failing to rebalance power means these voices cannot be fully expressed, and their knowledge remains untapped.

The conditions holding the status quo in place

Based on my analysis, there are four conditions that hold the status quo in place – that anchor our inability to learn.

The first condition is weaknesses in parliamentary governance and accountability, characterized by a lack of clarity over who is responsible, there being no consequences for performance (whether good or bad), and a lack of transparency. This is further complicated by having to keep up with the complexity of change within government and the high turnover of ministers and civil servants.

There is also our obsession with blame, which plays out on two levels. Politicians practise blame avoidance through strategies such as spin, scapegoating and not doing anything too risky, and all of us are obsessed with blame allocation after an event. Learning requires a willingness to look at actions honestly and take lessons from mistakes. Blame narratives make this kind of enquiry at best very difficult and at worst impossible.

Learning from and preventing catastrophic events in increasingly complex environments requires drawing on the available tacit and distributed knowledge and wisdom. Solutions will not be created in ivory towers. We need diverse views and voices to be heard, but failing to rebalance power means these voices cannot be fully expressed, and their knowledge remains untapped.

Given the long period over which many of these issues have repeatedly been raised, with no effective resolution, a lack of political intent and will is the final condition that I believe is holding the status quo in place.

One way of viewing these is as ‘givens’, where change is either too hard or would disrupt power too much and would be too threatening to undertake. Waiting for the four conditions, listed above, to alter is problematic, as changing them would require extraordinary political will and leadership, which are markedly lacking in our current world. Without a change in political will or intent, there is likely to be little more than snail’s pace and piecemeal change in these areas.

I offer the following four ideas that might disrupt the status quo.

The method of disruption does not have to be forceful. I have found kindness to be more disruptive than harsh words. 

The disruptors: opportunities to disrupt the status quo

We often have a negative bias against disruption: we think that somehow it is bad. But change requires disruption. If a system is operating stably, you need something to disrupt it to allow for change. I find biological metaphors useful. So cells mutate: many of these mutations are ineffective but some stick and enable change. The outcomes can be positive and lead to evolution or negative and lead to, for example, cancer. We don’t know what actions will work; we don’t know what the tipping point will be. The method of disruption does not have to be forceful. I have found kindness to be more disruptive than harsh words. There are many people committed to change post-Grenfell. I like to think of us as a tribe of disruptors, each doing what we believe in to enable change.

 As we expand our capability to manage complex change, we might alter our negative views of disruption and embrace it fully. There are four areas, in particular, that offer disruptive opportunities.

  • Developing our capacity to deal with complexity and ambiguity would develop our understanding of how to create change and safety in complex contexts.
  • Ensuring fairly borne consequences after catastrophic events would send a strong symbolic message about what is or is not deemed to be acceptable. Consequences are too often borne by the innocent (such as leaseholders post-Grenfell) or the bereaved (such as after Hillsborough, the fatal human crush during a football match at Hillsborough Stadium in Sheffield, South Yorkshire, UK, on 15 April 1989 ) and not by the people accountable for contributing to failures. Consequences could be legal, such as being found liable and paying fines or serving prison sentences, but equally they could be financial or reputational, such as a levy on developers and the construction industry in the aftermath of Grenfell to cover the remediation of historic safety issues.
  • Tapping diverse tacit and distributed knowledge would move us away from the siloed, ‘ivory tower expert’ solutions that are often ineffective on the ground, as demonstrated so vividly by the responses of many governments to Covid-19. With increasing complexity, ivory tower expertise is insufficient, and a failure to tap tacit and distributed knowledge will make us increasingly ineffective.
  • Finally, creating safe spaces in which to explore our deeply held values, assumptions and beliefs would help to enable cultural and systemic change. Any small action that contributes in any of these areas will move us forward, towards ‘goodness’. No one can predict the impact, and I am not advocating for massive macro projects, just simple daily actions that begin to shift these areas.

Making the water visible, the messy kaleidoscope

I set out to make the water visible: to reveal the messy kaleidoscope inside of which our continued failure to learn make sense. Researching and writing Catastrophe while continuing to hear new revelations from the Grenfell Inquiry and watching many of the same issues play out in relation to Covid-19 has left me in no doubt that our failure is systemic. That it in fact makes complete sense. At times, it has left me in despair.


To learn more, read the OECD report: A Systemic Recovery

New economic thinking and acting through a systemic approach could outline policy alternatives to tackle the global-scale systemic challenges of financial, economic, social and environmental emergencies, and help steer our recovery out of the current crisis. A systemic recovery requires an economic approach that balances several factors – markets and states, efficiency and resilience, growth and sustainability, national and global stability, short-term emergency measures and long-term structural change. To achieve this, we need to think beyond our policy silos, comprehend our interconnections, and build resilience into our systems.

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