No Fit State

The sixth anniversary of the Grenfell Tower fire of 14 June 2017, in which 72 people needlessly died, has recently passed. I wrote an angry article about it at the time. I've spent a sad and solemn, but productive, weekend reading an excellent but chastening book: 'Show Me the Bodies: How We Let Grenfell Happen' by Peter Apps, published at the end of the public inquiry, in advance of the inquiry report expected early next year. I recommend it to anyone working in an industry with safety criticality, government oversight, politics, high costs, and delivery through contracting: to colleagues in rail; and those in construction, power, gas, social and health care, and many other fields.

It brought Observer architecture correspondent Rowan Moore (and me) to tears, and not just for the colossal tragedy. You can get a feeling for the human horror by walking around the area, overshadowed by the shrouded building, and six years on still festooned with countless symbols of love and loss. There are wistful tears also for the things the disaster tells us about the way our country has been run in recent decades.

It's a story of complacency, heartless ideology, wilful ignorance, greed, incompetence, cynicism, unwillingness (or inability) to learn from other countries or even experience in our own, sneering condescension for the poor, injustice, and not a little racism. I don't want to live in a country with these things, and for years have argued that I don't. London, I thought, was special - well-run, tolerant, diverse, and properly managed.

The civilised and decayed versions of London and Britain exist alongside each other, in maddening coexistence, but in 'Show Me the Bodies' most of the many organisations involved were shown to be rotten and decayed, and not civilised at all. Was this an unlucky confluence of events and bad organisations, or a true reflection of the way Britain is? Virtually every page has shaming revelations, big and small. The book is 337 pages long. Opening it at random, we read that:

• Behailu Kebede, in whose kitchen the fire started when a fridge caught fire at night, raised the alarm promptly and tried to wake neighbours. He was praised in the inquiry, but newspapers falsely scapegoated him and he was driven into hiding [p10]
• Even though the London Fire Brigade (LFB) attends on average one fire caused by white goods every day, fridges sold here can have plastic backs whereas in other countries they must be metal [p11]
• The LFB's control room in Stratford was undersized and underequipped. It had a screen for linking up to TV news and a helicopter feed but it wasn't working. Call handlers at Stratford, with no visuals, thinking the fire was confined to a flat on the 4th floor, consequently continued to tell residents to stay put for hours, almost until the end, resulting in many needless fatalities [p12]
• An emergency lift override key switch for the lift did not work, perhaps because the council fitted a more complex one than standard citing anti-social behaviour, and which was filled with building debris. What's the point of an emergency switch which doesn't work in an emergency? [p16-17]

I planned to continue like this for the whole article, but the task is too daunting: there are another 300 pages with horrors on nearly every one. Read the book, or wait for public inquiry report. Before I get to the main target of my rage let me pick out some secondary culprits for dishonourable mentions.

The civil servants and government departments involved knew that fires in buildings with this type of polyethylene-cored cladding were a grave fire risk and appear to have worded the building regulations so that they could simultaneously reassure different stakeholders that, on tall buildings, it was both banned and not banned. Whether this wording was wilfully misleading or just incompetent, they were aware of the ambiguity and for years did not address it. A civil servant is said to have used the phrase 'show me the bodies' to justify his reticence to act: since the numbers of people dying in fatal building fires had been reducing over the years, primarily due to the demise of smoking and chip pans, it was argued there was no need to strengthen regulations. This is despite there having been many similar cladding fires in tall buildings all over the world, including the UK, such as at Lakanal House, Camberwell (2009) in which six people died.

Neither government agencies nor the council were able or willing, in any case, to enforce the regulations. They were under-resourced and to some degree 'captured' by various parts of the building industry. The council body responsible for the tower, Kensington and Chelsea Tenant Management Organisation (KCTMO) was especially criticised in the inquiry for almost venal incompetence and a deeply unpleasant internal culture. It had been rotten for years. Tenants who pointed this out, accurately foreseeing the risks KCTMO's long-term mismanagement engendered to themselves, were ignored and castigated. One of them (Ed Daffarn) contributed to a blog which foresaw a 'catastrophic' fire. He was described, along with a supportive councillor, as a 'negative force' in KCTMO board notes.

The material suppliers (especially Arconic, Celotex and Kingspan) and their managers and sales reps displayed consistently cynical and callous behaviour, deliberately frigging fire tests, covering up results, and misleading their customers and regulatory authorities. Some of the individuals who featured in the inquiry, with their emails and other actions exposed to scrutiny, must, I hope, be truly ashamed. At least they showed up: several French employees of Arconic refused to attend the inquiry. I hope the legal process which will presumably follow the publication of the report (in 2024, probably) is fair but very firm. Future company men and women should always have in their minds this terrible example before they are tempted to put profits before people.

The LFB had many brave people who were prepared to endure extreme discomfort and fatigue, as well as risk their lives. They nevertheless were chronically unprepared for this fire, and (on the evidence given to the inquiry and recounted in the book) consigned many people to death because of institutional and dogmatic adherence to their 'stay put' policy for hours after it became clear it was invalid in this case.

None of these incompetents and malefactors merits the scorn, however, that the state deserves. It is there to protect us. Of course, government can't be responsible for every incident and accident. But it is responsible for the framework, structure and ethos, the regulation, of civil society. This was a publicly owned building built, managed, and refurbished to public standards.

It is tempting to pick out Eric Pickles, subsequently ennobled, the secretary of state for housing at the time. Pickles had earlier in his career, as one of our elected representatives, a minister of state, spent his time rejecting windfarms and promoting 'localism' whilst insisting that local council meetings opened with Christian prayers. He reluctantly attended the inquiry, urging it to use his time wisely so he could get away to a more pressing appointment, arguing on technicalities (I believe falsely, the inquiry will decide) that the government's virulent anti-regulation ideology did not apply to building regulations or fire safety. He had previously (according to a fellow minister) described recommendations from the Lakanal House fire report, for sprinklers and tougher regulations on cladding, as 'regulatory madness' and those advocating them as 'Guardian-reading pinkos'. He rounded off his testimony by conflating Grenfell with the Hillsborough football disaster, mixing up the number of victims, whom he wrongly described as 'nameless'.

(Baron) Pickles would be a figure of fun were it not for the deadly unfunniness of the situation. I think history will judge him harshly. But really, he's not personally to blame. The rottenness which he merely personified is the ethos of deregulation and contempt for expertise and experience which was a core ideology - almost the only one, apart from Brexit - of the government. At the time there had recently been a 'bonfire of quangos' (including experienced bodies which could have prevented Grenfell) and for every regulation introduced one (subsequently two) had to be withdrawn. This reduced civil servants to tears. Pickles epitomised this dogma but he neither invented it nor elected its disciples. He was not the Prime Minister. There is a collective responsibility which must be shared, not just by the state and its machinery, but also by the media and us, the voters.

Deregulation, like all populist, simplistic ideas has an appeal. Who wants rules and bureaucrats? 'Elf and safety'? Pubs shutting at eleven? Parking tickets or speed limits? The reality in a complex, modern society, of course, is that regulation is another word for civilisation, a framework which allows us to do even quite dangerous things safely, such as living in buildings in the sky, tearing along a ribbon of rails at 125mph, or even driving to Tesco. We need to agree on which side of the road we will drive, and enforce that agreement.

Good regulation facilitates trade and economic growth. It does not constrain it. The absence of it does. Nor is it even expensive, set against the costs of disaster. The post-Grenfell rectification costs for the country, the building industry and flat owners is colossal and probably uncountable. One estimate is ￡50bn, enough perhaps to finish HS2.

Curiously, the government of late appears to have rediscovered its zeal for regulation: cigarettes will be permanently unobtainable for those below a certain age; councils will be subject to national rules on speed limits; borders are overrun with red tape; voters now need photo ID; men will have to be men and women women irrespective of what those individuals themselves think, and so on endlessly. This points to the problem, and the solution: beware of any ideology. Ideologues think they know best, but they don't. Society instead needs to be run by people with experience, common sense, kindness, circumspection and professionalism. Experts in their fields, ideally. Spurn ideologues, and do not encourage them. Above all, do not vote for them.

I have been reflecting on the lessons of this tragedy for rail. The government has it seems belatedly recognised the flaws in the complex structure it imposed on the industry back in the last century, and casually tossed the bits up into the air, but then walked away having apparently lost interest in implementing any reform. Its most recent contribution has been to throw long-term and complex plans for new infrastructure into further disarray.

Despite this, all railway people recognise the primacy of good regulation, a rule book. Railways cannot be run otherwise. I have never (since around 2000) experienced (or even heard stories of) things like the sequential catastrophes and disastrous, intellectually flawed errors or plain callousness which led inexorably to Grenfell. A supplier which touted products it knew to be unsafe would not last long in rail. I'm not aware that the DfT has attempted to stifle safety regulation, and in fact in the past (with slam doors or TPWS for example) it led a reluctant industry to clean up its act. A state body, the ORR, has a proud record of safety oversight. Our infrastructure managers and train operators may occasionally moan but are in practice highly receptive to safety improvement. The GB railway could be safer, but is amongst the safest in the world, and immeasurably safer than roads.

Some people argue that 'gold-plated standards' and over-zealous safety regulation increases costs and decreases performance. In my experience that's sometimes true, though often the expensive measures needed to improve safety pay for themselves through better performance and avoided disasters. Standards can be, and regularly are, challenged and developed. What is perhaps lacking in GB rail is a proper way of valuing benefits such as better performance and lower lifetime costs. There is, in fact, a rather good framework - Fatality Weighted Injuries - supported by RSSB and ORR. In my experience it is often not used when it should be. The complex structure of the unreformed industry doesn't help, since costs, benefits and risks usually fall at random across different contractual boundaries. Anything that increases rail costs or decreases performance will most likely decrease net safety as more people drive. We need to make it easier to do the right thing.

The complex structure of GB rail today is demonstrably not in itself unsafe - the sharply improved safety record of rail since around 2000 proves that. But we always need to be circumspect and fight against complacency, especially as memories of past disasters fade, money pressures multiply, and a half-reformed structure causes confusion. Should an ideology emerge which threatens rail safety we must oppose it with passion and vigour. I'm not saying this has happened, but it may by stealth, only to become obvious to all in hindsight. A lesson from Grenfell is that hindsight wasn't necessary: a disaster was, to many of the protagonists, becoming inevitable. This terrible state of affairs continues. London's mayor noted in 2022 that so far none of the 2019 interim recommendations of the Grenfell inquiry had been implemented.

We only have to pore over the Kings Cross, Clapham, Ladbroke Grove, Southall, Potters Bar or Hatfield accident reports a generation ago to recognise that our world was once much like the one in which Grenfell happened. The rail industry can take a collective pride in having left that dangerous world behind.

We should never, ever, forget those bitter lessons, or the people who lost their lives or limbs in them. Nor, either, the 72 people who died at Grenfell.

[references on request]