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Playing with Fire - the importance of learning lessons

On 14th June last year a fault in a refrigerator caused a small fire in a fourth floor flat in north west London.

Within minutes an entire skyscraper of flats was ablaze and Britain’s worst health and safety disaster of this millennium occurred.

Eight months earlier, the Grenfell Tower residents action group wrote of serious concerns on their web site  that they firmly believed "that only a catastrophic event will ... bring an end to the dangerous living conditions and neglect of health and safety legislation" within the tower.

They added that "only an incident that results in [the] serious loss of life of ... residents will allow the external scrutiny to occur" and that "a serious fire in a tower block or similar high density residential property is the most likely reason that those who wield power.... will be found out and brought to justice."

It seems that warnings were repeatedly made, lessons ignored from other fires, and nothing was done about it.

Before I start on the awful events of the Grenfell Tower fire, let us pause for a moment in reflection.

As you do, do not think of what happened that night, don't think “it won’t happen to me”, but think what do you do in your job and life that could cause you or others harm, and what can you do now to prevent that harm from happening.

A few weeks ago the Public Inquiry opened into the events at Grenfell Tower that led to the deaths of 72 people and the loss of homes to hundreds more.

In his opening remarks, it’s chairman, Sir Martin Moore-Buck, said "The inquiry can and will provide answers to the pressing questions of how a disaster of this kind could occur in 21st century London."

And it will, and must provide answers, and it will and must change legislation, and people will more than likely eventually go to prison for Corporate Manslaughter and for other serious health and safety offences.

The same happens and has happened with every major health and safety related tragedy throughout history. We learn, we act - sometimes too late, but we never do enough.

Because of the ongoing investigations and legal processes into the fire, I do not wish to speculate or apportion blame today, but what has happened at Grenfell Tower is a perfect example of what I am talking about.

As a human race, we are learners. And learning has played a pivotal role in our evolution and dominance as a species.

From the earliest cavemen learning to make spears to hunt and learning to light a fire for warmth and to cook, everything we do has been as a result of learning from errors and mistakes.

But when it comes to our safety, we ignore lessons from our past and lessons from our ancestors.

As a result accidents and disasters still happen. We rarely learn, and when we do, we don't always learn enough. We pick and choose.

In our modern society we see far too often children being prevented from playing out or being adventurous. They are mollycoddled and shrouded so much that they do not learn danger - danger that can protect them later in life. We have become too much of a risk averse society.

Health and safety professionals get a bad name - often because people are risk averse. Schools making children wear safety goggles to play conkers gave the industry a grilling in the press about ten years ago - even though it was a head teachers decision based on some bad advice he had received. Our professional body, IOSH, has since sponsored the World Conker Championships in response to that bad press.

Please let children play and experience some hazards. Let them have the same knocks and falls that we had as children - so that they can learn from their mistakes and so that, as they grow older, they will be less risk averse.

I often hear, generally from the older generations, “when I were a lad there were no such thing as health and safety.”

I am sorry but yes there was. Health and safety has existed as long as humans have existed.

Those cavemen on first discovering fire will have probably suffered injuries and smoke inhalation and over time would have learned how to control their fires, and where to put them. They will have learned what food is safe to catch and eat, and what would give them the runs or even kill them.

Health and safety best practice can even be found in the Old Testament Book of Deuteronomy, believed to have been written in the 7th century BC. Chapter 22 verse 8 says:

“When you build a new house, then you shall put a railing around your roof, so that no one may fall from there and bring guilt of blood upon your house.”

Yet despite this people still fall from roofs nearly three millennia later. We do not learn!

Jump ahead to Tudor times - 1540 to be exact - when a report was written into the death of a child:

 "a yonge childe… standing neere to the whele of a horse myll… was by some mishap come within the swepe or compasse of the cogge whele and therewith was torne in peces and killed. And, upon inquisition taken, it was founde that the whele was the cause of the childes death, whereupon the myll was forthwith defaced and pulled downe.”

The report did not suggest any ways of making the other horse mills of the time any safer to prevent such incidents happening again. Lessons were not, it seems, learned.

Throughout history it is the poorer working classes who have suffered more than the wealthy as a result of health and safety misdemeanours. Even the earliest pieces of health and safety and environmental legislation were only put in place to keep the wealthy happy.

Many do not realise that some of the first laws on the subject were in our

local area of St Helens, where noise levels and pollution from alkali works caused inconveniences to local Parliamentarians 200 years ago. The laws implemented did nothing for the poor workers, but it protected the wealthy nearby.

Some have suggested that one of the secondary causes of the Grenfell fire was the mismatch in social status between rich and poor in North Kensington. I will let the Inquiry decide that, but is history repeating itself? Again have we ever learned?

It was really only in the early twentieth century, with some of the Factories Acts that proper health and safety laws were introduced to protect ALL workers in specific industries, and it was only on 1 January 1975 with the implementation of the Health and Safety at Work, etc. Act 1974 that ALL workplaces became obliged to meet legal health and safety compliance.

And yet, still, serious accidents and deaths occur. Admittedly, the numbers are dropping year by year, but with around 2,500 deaths through asbestos related illnesses each year, they are still far too high.

There have been major fires throughout history. Inquiries and inquests have been held. Laws have been changed. But there is always a reason to lessen the impact of those laws. Usually political, economic or money related. So what value is there on life?

On 8th May 1979, a fire was reported in what was said to be the largest

Woolworths store in Europe in central Manchester. There were around 500 customers and staff inside the store and in total ten people died in the fire, 26 were rescued by the fire brigade and 47 were taken to hospital.

It is believed that the fire was started by either a damaged electrical cable that had polyurethane foam filled sofas stacked in front of it, or by a discarded cigarette. This foam filling was highly inflammable and had burnt at 700C, releasing a deadly cyanide gas. A single breath had been enough to kill.

As the flames took hold, acrid smoke rose to the ceiling, obscuring the exits and giving people under a minute to get to a place of safety. For some this was not long enough. Some doors were locked.

Sprinklers and smoke detectors were discretionary. Their compulsory installation was recommended in the reports that followed.

So how is it that 39 years later, people are still asking why Grenfell Tower had no sprinkler system? Lessons again appear to have not been learned. Money should not be an excuse when it comes to protecting life.

Having said that, some lessons were learned from Woolworths. Better fire retardant furniture was introduced, along with the requirement for fire marshals and basic fire risk assessments. These lessons learned have undoubtedly saved countless lives since.

During the FA Cup Semi-final of 1981 between Tottenham Hotspur and

Wolverhampton Wanderers at the Leppings Lane end of Hillsborough Stadium in Sheffield,  an incident occurred after two perimeter gates outside the ground were opened.

Thirty-eight supporters sustained injuries, including stitches, two broken arms, one broken leg and some head grazing due to crushing within the stadium.

We all know what happened eight years later in the corresponding fixture at the same place when the same gates were opened by the same people.

Lessons yet again were not learned, and tragically 96 people lost their lives.

The Hillsborough Disaster Inquests and investigations over recent decades have shown one of human nature’s biggest failings. That human beings go into self protection mode when errors are made. The truth gets hidden and as a result lessons cannot be learned and mistakes rectified to prevent reoccurrence.

The same happens every day in workplaces across the country. Workers stumble but don’t fall over trip hazards. They do not report them. Reporting near misses can mean problems get resolved and sorted before the next worker trips and breaks an arm or worse.

A serious injury occurs and those who are at fault hide evidence or lie when investigations start to protect their own skin. I have seen it far too often.

In one case I dealt with about four years ago, an employee of a particular company pulled an electrical fan heater out of a cupboard one autumn after it had been thrown in the cupboard that spring. On plugging it in, the employee suffered an electrical shock, and shot across the room sustaining internal injuries. The building's electrics shorted as a result.

A manager had purchased the heater a year before despite it being against company policy. Realising she was in the wrong, the manager refused to allow the first aider to call for an ambulance, tried to force witnesses to change their stories, and tried hiding the damaged heater.

The injured employee ended up three months off work and successfully sued the employer. The manager was dismissed, and stricter controls on the use of unauthorised electrical appliances was introduced.

We need to learn lessons, follow procedures and heed warnings and act upon them to prevent further injury in the future.

Earlier, I asked you to reflect for a moment to think about what you could do in your job or everyday life to prevent injury to yourself or others.

It could be as simple as reducing the speed you drive at. Thousands have been killed due to speeding motorists. Yet we still speed. Don’t be the latest statistic. Let’s start a trend of learning from other’s and our own errors and misfortune.

In your workplace, do you or your company ignore near misses and accidents, or fail to report them?

Does your company ignore health and safety compliance issues and legislation?

Have you got suitable first aid provision in place?

Does everyone know what they should do in the event of an incident?

Are all complaints, incidents, accidents and near misses investigated?

Are control measures fully implemented without cutting corners?

If not, why not? Are you sitting on a disaster or serious incident just waiting to happen? Are you playing with fire?

I hope that the Inquiry and legal cases into the events at Grenfell are thorough with nothing left unturned. I hope full lessons are learned from all aspects of that awful night and the lead up to it. And I hope that we can now see a turning point in our culture that allows us to learn and be safer in all that we do.

An accident is a lesson not learned.

Good Health and Safety Management is no accident. It is a lesson learned.

If you need help and support ensuring that your company complies with relevant health and safety legislation, or needs guidance on any issues raised in this article, contact KSH Safety Services today.

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