The Grenfell Tower fire occurred on 14 June 2017 at the 24-storey, 220-foot-high (67 m), Grenfell Tower block of public housing flats in North Kensington, Royal Borough of Kensington and Chelsea, West London. It caused at least 80 deaths and over 70 injuries. A definitive death toll is not expected until at least 2018. As of 12 July 2017, 32 victims had been formally identified by the Metropolitan Police. Authorities were unable to trace any surviving occupants of 23 out of the 129 flats (roughly 18% of the flats in the tower block) and their occupants are believed to have died in the fire.

The fire started in a fridge-freezer on the fourth floor. The growth of the fire is believed to have been accelerated by the building's exterior cladding.

The tower was not equipped with sprinklers which may have mitigated the effects of the fire and enabled more residents to escape.

In the Process Safety Management Fundamentals course which I teach, there is a section on Learning Lessons - Accident & Incident Analysis. In it I describe the usual steps which a traditional incident investigation will take, a route which we can see has been assiduously followed in the aftermath of Grenfell:


  • Assess Immediate Causes – Flammable exterior cladding allowing fire to spread and trapping inhabitants in upper floors.
  • Prepare report – UK News Media vilify authorities for ‘allowing’ other tower blocks to be built with similar cladding
  • Take immediate steps to stop similar problems ‘about to happen’ (before analysing causes) – Authorities swiftly react by evacuating residents from these tower blocks while technical solutions to the cladding issue are implemented
  • Blame and Punish – UK News Media decides that the chair of the London borough where Grenfell is located should be castigated. He resigns.
  • Issue proclamation that problem has been dealt with – any day now….


So far, so predictable. And all very satisfying too.

However, key stakeholders used the tragedy in a more elliptic and constructive way. They were able to harness the outrage felt in response to the incident to focus attention on related but non-associated issues – in this case school sprinklers. On the 31st of August 2016, the Independent reported that:

Government ministers have been heavily criticised after quietly abandoning the requirement for fire sprinklers to be fitted in new schools, in what has been called a “retrograde step” by fire chiefs.

An update to the Department of Education’s (DfE) Design in Fire Safety in Schools stated that “Building Regulations do not require the installation of fire sprinkler suppression systems in school buildings for life safety”.

“Therefore,” it added, “[guidelines] no longer include an expectation that most new school buildings will be fitted with them.”

On the 24th of June 2017, the Observer was able to report that this requirement had been re-instated, thus reducing the risk of fire escalation for future pupils and probably saving lives in the process.

In our own industries, it is important to look beyond the immediate trigger for an incident to consider underlying factors and root causes. I led a post incident HAZOP at an Edible Oils processing facility in 2014 where overpressure had caused a 500 kg lid to blow off a filter press and land 4 metres away. The immediate trigger was a blocked outlet causing an overpressure as the steam pressure was incorrectly regulated. Easily fixed. However, the underlying cause was poor maintenance and operational discipline and the root cause poor safety culture and inadequate leadership. These latter issues are more diffuse and harder to resolve, but if ignored will lead to other seemingly unrelated incidents going forward.

So, it is important to be rigorous and determined in our incident investigations such that the rage energy is focused on highlighting and addressing the underlying and root causes to achieve sustained benefit.