Most man-made disasters and violent conflicts are preceded by incubation periods during which policy makers misinterpret, are ignorant of, or flat-out ignore repeated indications of impending danger
(Boin & t’Hart: ‘Public leadership in times of crisis: mission impossible?’ 2003:547)
The Grenfell Tower tragedy has been described as a unique event, unparalleled in modern London history in terms of the scope and scale of its tragic impact. But whilst the uniqueness of the event might explain the multiple failures at every level to respond in a timely, appropriate and effective manner, both to the immediate event and to the management of its aftermath, it does not excuse them.
The Grenfell Tower fire was exactly the sort of complex, high-impact, multi-jurisdictional event that crisis management procedures have been developed to handle, and to give responding agencies, including local councils a framework and a guideline that could be used to prepare for, and then respond to exactly such an incident.
Whilst this paper is based on information in the public sphere, and therefore is not privy to decisions that have been made in private and behind closed doors, there is enough information available to build a strong picture of what did and did not happen in the immediate aftermath of the fire, and to identify significant failures in the management processes that were directly linked to the organisational failures that became a critical and central part of the disaster itself.
The Nature of a crisis
A crisis, as opposed to a major incident or a routine emergency, is by its very nature something that falls outside of normal management frameworks, and which because of its scope, scale and impact goes beyond the capabilities of normative response frameworks to respond to it.
Just as a person will freeze when faced with a sudden and unexpected situation which is beyond their capacity to comprehend, so will an organisation. It is for this reason that there should be a series of automated processes associated with the initial response to a crisis event that will mean that the organisation can maintain critical functionality even when the situation itself can seem overwhelming.
One aspect of a crisis that should not have been an issue with the Grenfell Tower is whether or not a crisis situation existed. In many cases, such as the Kings Cross Fire, one of the causative factors was the disinclination of the management of the station to recognise the fire as a major incident, and to put in place the necessary response measures that would have allowed it to be managed in a more effective manner – which in itself would have had a significant impact on minimising the loss of life. In the Grenfell Tower fire that was not an issue, and it should have been clear to the local council management that this was a crisis that required the immediate initiation of a strategic multi-agency crisis management framework at the highest level.
Crises are, by their very nature, rare events. Therefore, it is always likely that crises are going to challenge management frameworks beyond what they are used to or capable of. For this reason, it is important that organisations prepare themselves to deal with the organisational and emotional impact of responding to a crisis by ‘normalising’ that process through repeated practice, and the utilisation of the opportunities thrown up by the real world to trigger at least the initial stages of a crisis response capability. This is the doctrine that has been at the heart of the success of both the national COBR crisis management framework, and the London Resilience crisis management framework that has underpinned London’s crisis management capabilities. Both organisations recognise the value of being an ‘all hazard’ response mechanism that can utilise frequent potential incidents and ‘near misses’ to practice their moves in as realistic a setting as possible.
Whilst the Grenfell Tower fire may have been unique, the necessity to respond to it was not, and an initial question would be as to how ready the council was to respond to exactly such an incident with an effective utilisation of the full range of crisis management frameworks and stakeholders.
Sense-Making – What has happened?
It is a truism of crisis management that the first question that needs to be asked is not ‘What shall we do’, but rather ‘What has just happened’? In the Grenfell Tower, that became almost immediately clear, but what was not clear was what the implications of that situation were. However, within the earliest stages of responding to the situation, it should have become apparent that this was a significant event that was going to have a long-term impact on the lives of the residents of the tower block as well as the surrounding community.
Even though the final scale of the tragedy may have been unknown, there should have been an understanding as a result of the first information that came in, that it would require significant levels of resources from multiple agencies, both formal and informal, to create an effective response mechanism. From that perspective, it should have been clear that as well as responding directly, it would have been the responsibility of the local council to put in place a coordination framework that would have acted as the central focus point of the local response operation, that would have been run as a ‘coordination centre’ rather than a ’command and control centre’, which would have been more appropriate to the response to the actual fire rather the management of the community response.
Lack of management capability
From a classical crisis management perspective, it can be predicted that when an actual crisis situation does occur, there will be three significant shortages – of manpower, resources and, perhaps most critically, management capability. The simple reason for this is that there is usually not enough manpower to manage even normal operational activities, so there is no spare capacity in terms of personnel that can be utilised to manage the crisis event. From a resource perspective, there is never enough spare capacity to prepare for the full range of potential crisis events, so there is a lack of necessary supplies, whether basic (food, bedding, accommodation) or specialist (decontamination units, search and rescue equipment, communications systems). Finally, from a management perspective, most managers are exactly that, people tasked with managing the procedures and protocols associated with their management roles, but who have not been given the training or preparation that would have enabled them to take an appropriate leadership role when faced the sudden and potentially catastrophic challenges associated with a full-blown crisis event.
Establishing the Crisis Management Team (CMT)
Any crisis is, by its very nature, complex and multi-dimensional. It requires the establishment of a management framework that will allow the multiple teams associated with the immediate and longer-term response operations to share information, develop plans and identify needs on an on-going and collaborative basis.
There is a well-established protocol for the establishment of such a team, and it would be expected that this would have been a central part of the crisis management capability development process covered in various training, exercising and validation processes.
Each member of the CMT would themselves been connected to their own networks, which would allow the speedy and effective collation of information, supporting the development of a Common Operating Picture (COP), which in turn would have allowed a cohesive, integrated response plan to be developed and put into play, recognising that, at least in the early stages, the information itself would have been partial, unverified and rapidly changing.
The establishment of the CMT at the earliest stage of the crisis would not only have allowed the highest level of effective management of information during the critical first few hours, but would also have demonstrated that the council leadership was able to assume the responsibility that was expected of them, and could take the leadership role that would have allowed many of the other aspects of the response operation to be managed in a timely and effective manner.
Given the nature and scale of the disaster, it became clear that rather than the council providing the necessary resources to support the immediate victims of the fire, the surrounding community would become the immediate first responders in terms of offering comfort, shelter, support and physical amenities such as food, clothing, and other support services. This is something that could and should have been expected, but once the level of community support that was being offered became apparent, then it was the role of the council to become the coordinating agency that would allow the most effective utilisation of the overwhelming level of support that was being offered, by every section of the community.
The fact that such support was not given, and the ability of the community to respond immediately and in overwhelming levels was not met with the same level of agility, adaptability and initiative by the local council, in itself became the central story within hours of the incident itself.
It is almost always said of crisis events that they are complex, chaotic, and with no clear solutions, or even a clear understanding of the basic problems. This cannot be an excuse for systemic failures across an organisation, and especially at the leadership levels. It is precisely those qualities that define a crisis, and the fact that the council as a whole and the leadership on an individual basis, seemed to have little or no understanding of what their role should be, never mind as to how to manage those roles, is in itself a damning indictment of their capabilities, and their attitude to their responsibilities.
In fact, the challenges facing the leadership in the first few hours were exactly those that they should have expected to be facing, and should have been able to respond to in an effective manner.
Those challenges included
It is an integral part of a crisis of this nature that there will be a high level of personal disruption and dislocation amongst survivors, as well as those who were not caught up in the initial event, but were affected by its impacts as they rippled out across the community. There are also those within the wider community who are affected by physically and psychologically, and who also require the support of the formal response agencies.
It is a truism of emergency response of this nature that it is the people who live in the community who are the community, and it is the role of the support teams to actually support them. In reality, in the event that there is a breakdown in trust, as often happens when the initial response is not managed effectively, then the whole relationship can become defined though a worsening spiral of mistrust, alienation, aggression and then active opposition.
Whilst it is true that such antipathy is often based upon decades of perceived injustice and alienation, the crisis event itself, if managed properly, is an opportunity for the community to come together under a unifying leadership. As stark examples of both the dangers and the opportunities associated with crisis leadership, President George W Bush, in the aftermath of Hurricane Katrina, was an example of a leader who was clearly out of touch with the realities on the ground. However, Mayor Michael Bloomberg, following Hurricane Irene in New York, was able to become both a spokesman and a symbol of the unity of the city, and created a feeling that, in this case at least, they were ‘all in it together’.
Crisis management preparation
The role of the crisis managers is not only to offer leadership during a crisis, but to ensure that all aspects of the organisation have an understanding of the challenges of crisis management and have the necessary skills and capabilities to respond effectively as part of a multi-agency crisis management operation on personal, team and organisational levels. Given the failures of the council to respond effectively from the very first moments of the crisis, it is relevant to ask what preparation they had been through, what scenarios they had practiced, and what training and exercising they had received in order to prepare themselves for that task.
The Civil Contingencies Act 2004 lays out seven duties that local authorities have in terms of emergency preparedness.
There are also two significant documents concerning multi-agency emergency response – JESIP (Joint Emergency Services Interoperability Principles) and LESLP (London Emergency Services Liaison Panel). Although both of these documents are primarily aimed at emergency services responding to emergencies, rather than local authorities acting as a support agency to the community affected, both would presume that appropriate council representatives, up to and including the chief executive, would have been aware of these plans, and would have participated in a range of training and exercising programmes.
Although the tragedy associated with Grenfell Tower may have been unique, the challenges created by the aftermath of it were not – and in fact, were not only predictable, but could be considered to have been fundamental to any major incident that would have caused widespread impact and disruption. In that sense, the failures of the council to have accepted their responsibilities in preparing themselves as an organisation to have appropriate levels of crisis management skills and capabilities, as well as the failure to respond effectively to the specific challenges of the Grenfell
Tower disaster, can fit into a well-known pattern of behaviours that can come under the headings of a failure of leadership and initiative (Hurricane Katrina Congressional Report) and a failure of imagination (9/11 Congressional Report).
However terrible the events of the night of 14th June, and whatever the institutional failures that led to the situation that allowed the fire to become so devastating so quickly, the failure of the local council to accept its responsibility to take leadership in the immediate aftermath of the event is inexcusable. Whatever the specific details and horrors of Grenfell Towers, seen purely from an emergency management perspective, there was nothing in the hours and days following the event that could have been considered unthinkable, unexpected or unforeseeable. In fact the challenges associated with housing and safeguarding the wellbeing of traumatised victims, utilising the resources of the council and collaborating with formal and voluntary agencies, as well as the community itself, is at the heart of any major incident scenario.
The ability to provide succour and support to those most impacted by crises is at the heart of the modern government’s responsibility, whatever level it is operating at. The fact that a failure of this nature can happen in the richest borough in London, in the absence of any other challenges or distractions, is once again an indication of just how fragile the crisis management frameworks are that we so heavily rely on.