Why do decision makers never learn?

Friday was a depressing day for anyone concerned with fire safety and the fire & rescue service.

http://www.bbc.co.uk/iplayer/episode/b08wv2wc/south-today-evening-news-07072017

First, we learnt from local news that, following last year’s fire, the Trust running the Selsey Academy does not intend to fit sprinklers when they rebuild the school. Professional advice and common sense say that sprinklers should be fitted, but TKAT (The Kemnal Academies Trust) say they won’t, because they are “not a requirement”. Well, it is not a requirement to look for traffic before crossing the road, it is just a recommendation, but only a fool does not do so.

TKAT claim, “Our pupils are at the heart of everything we do”, but this shows that they are not. They may believe their procedures will protect the lives of pupils, but major school fires have many other consequences. Studies have shown that they have a detrimental effect on pupils’ education, which leads to lower than expected achievement. They cause emotional distress for staff, pupils and the wider community. They also have a negative impact on the school’s social life, and an economic impact on the school, local authority, parents, staff and community groups.

Not forgetting of course, that such fires pose a danger to firefighters and to nearby property. All these negative effects and risks can easily be avoided by fitting sprinklers, which is comparatively cheap in a new building. This selfish and short-sighted decision begs the question, what other recommendations and good practice do TKAT ignore, simply because they are “not a requirement”? TKAT, who run a dozen schools in West Sussex, must reconsider and do the right thing for pupils, staff, local residents and firefighters.

http://www.bbc.co.uk/iplayer/episode/b08xk42y/newsnight-07072017

The second shock was the revelation, on BBC Newsnight, that firefighters might have saved everyone in Grenfell Tower, if senior managers had made different decisions before the incident.

Crucial amongst them was the policy decision to no longer automatically send an aerial appliance to high-rise building fires. Firefighters had to request one, which meant it arrived over half an hour after the first call. I believe that there was every possibility that the external fire spread could have been stopped, if the aerial appliance had arrived in 11 minutes (time it took to arrive after being requested), instead of taking 32 minutes to get there.

The other fundamental issue, which the presenter easily recognised, but ex-Chief Fire Officer Ronnie King failed to recognise, was the absence of a plan B. We know that fires in this sort of building are supposed to stay in the flat of origin, but we also know that things can sometimes go wrong. Yet, it seems fire service planning, procedures and equipment only ever allowed for plan A. If everything and everyone does what is expected, then that is fine, but if not you need a plan B. I have to say that Ronnie King’s comments were very disappointing and illustrated by his comment, “I wouldn’t want to criticise any policy of London Fire Brigade”.

This fire appears to have spread beyond the flat of origin because of alterations, but there are many other situations where plan A will not work and a plan B becomes essential. For example, explosions that damage the structure. These can result from gas leaks, gas cylinders, illegal drug labs or bomb making. They can range from something as simple as fire doors not being shut, or fire spreading via open windows, to damage caused by a light aircraft hitting the building.

Cuts made in 2014 inevitably slowed the response to the Grenfell Tower fire. Six central London fire stations were closed and other fire stations lost their second fire engine, so reinforcing fire crews had to travel further and took longer to arrive. There was also a delay in getting extended duration breathing apparatus to the incident. With a high probability of it being needed in a high-rise building fire, why was it not on the initial response?

Both the aerial appliance and extended duration breathing apparatus issues suggest a worrying complacency amongst senior fire service managers, or a lack of experience, or inadequate risk assessment, or a blinkered mindset, or all of those.

The communication problems resulted from both equipment and procedural limitations, but these are not new. So why has nothing been done to overcome them? As for water supplies, I am not surprised that Thames Water claim there was no problem. It would not be the first time they denied responsibility and then later, when that did not work, claimed it was someone else’s fault. However, unlike other countries, there are no legal requirements for water companies to provide a specific quantity and pressure of water for firefighting in the UK. This was not such an issue when water supply was in public ownership, but things seem to have deteriorated with privatisation. Perhaps another issue in need of reform.

So, how would West Sussex cope with such a fire? Well, I understand that WSFRS do send an aerial appliance as part of the initial response to a high-rise building fire. A positive, but tempered by the fact that, for many parts of the County, the response time could be over 30 minutes and in worst cases over an hour. With greater distances, fire station closures and the removal of a quarter of frontline crews in West Sussex, standard fire engines would also take much longer to arrive than they did in London.

I am not aware of WSFRS having any extended duration breathing apparatus, or where the nearest would be. Water supplies and communications are unlikely to be any better and could well be worse than in London. If anyone can clarify these points, I would like to hear from you.

As for plan B, I don’t have confidence that this has been considered in West Sussex. Risk assessment seems to have been focused on finding excuses to cut resources, rather than reasons to ensure that the public and firefighters are properly protected. When you realise that someone in WSFRS looked at the problems posed by larger aircraft, with more passengers and fuel, and then decided to reduce the service’s response to aircraft emergencies, it is difficult to have confidence in plan A, let alone plan B!

I believe one of the significant problems in relation to both stories is applying business planning methods to the public sector. In the business world, if it will cost more to produce something than you will get back in sales, then you don’t do it. If you are already doing it, then you stop doing it. In the public sector there are no sales, so in the cost/benefit analysis the costs are easily worked out, but the benefits are less tangible.

So, for the Selsey Academy, did they include in the benefits column not damaging pupils’ education, not causing emotional distress to staff, pupils and the wider community, not harming the school’s social life, avoiding an economic impact on the school, local authority, parents, staff and community groups, not putting neighbouring properties at risk, and not endangering the lives of firefighters? I suspect not.

In the case of the Grenfell Tower tragedy, were assessments prepared regarding the decision to no longer send aerial appliances to high-rise buildings, and before cutting the number of aerial appliances in LFB? If they were, I am sure that the benefits column did not include avoiding dozens of fire deaths. It is also telling that in every city in the rest of Europe and in North America, one or more aerial appliances would have been sent immediately to a fire in a building like Grenfell Tower.

It is simply not good enough for anyone, be they property owners, fire service managers or politicians, to increase the risk to the public and firefighters. Lessons must be properly learnt, acted on, and never forgotten.