Saturday, 17 June 2017

140 questions I would like answered about The Grenfell Tower disaster. And that's for a start

So many people are asking so many questions about Grenfell Tower disaster but to date few have been answered, and those largely by the media doing its research.  As the days go by more evidence is appearing of bureaucratic delays and prevarication, of inappropriate policy decisions and of money either causing problems directly or in an indirect way underlining the causes of the disaster and public sector responses.  To the outside observer the authorities, those ostensibly in control of the situation, seem to be frozen, like rabbits in the headlights.  In reality, they may be working away hard but this is not enough if they fail to communicate effectively with all involved, the victims, their neighbours, the general public, the media. 

I have watched the news unfold, to the extent that I no longer want to turn on the radio or television because I know what I will see and hear.  It did not seem appropriate to go to West Kensington to help on the ground, from the TV it was apparent there were plenty doing that, probably too many, so I did the easiest, and laziest, thing; I sent money, which is probably what people need most at the moment anyway.  Lets hope the millions that have been donated reach the right people at the right time to be of help.

I woke up this morning with so many questions in my own head.  The biggest question of course is why the Grenfell Tower disaster happened in the first place, and what should have been done differently to have prevented it (and who was responsible because holding people to account, and making it clear they will be in future, is part of the response).  The other big question is about how well, or otherwise, the authorities responded to the disaster.  There is a systematic way to address an emergency like Grenfell Tower and if Kensington and Chelsea Borough and the British government were prepared they should be following such a process.  So were they prepared? 

But here are the 140 questions, that I have thought of so far, that I would like the answers to.  You will no doubt be able to add many more.

Building Regulation, refurbishment and maintenance

Have Kensington and Chelsea (LA) carried out a risk assessment on this building?
What did it say about the adequacy of fire protection and responses?
Did the LA undertake a fire risk assessment when planning the refurbishment both of the refurbishment project, and of the proposed changes to the building? What does it say? 
Who undertook the risk assessment?
Were the refurbishment plans approved by the Council?
What were the building specifications, including for the cladding, in the refurbishment contract? What was the process for selecting contractors?
Was the work carried out in accordance with the original contract, if not what changes were made and how were they approved?
How did the LA oversee the contract to ensure that it was carried out in accordance with the contract?

Why was the contract awarded to one company but then terminated and replaced with a contract to another?
What arrangements were in place to manage sub-contracts?
What does the refurbishment contract (and sub-contracts) say about responsibility, indemnity, warranties, liability etc?
The press have indicated that the refurbishment company was in fact a pre-pack purchase of the business following administration of an earlier entity owned and managed by the same person.
  Did the LA evaluate the company to determine if it was financially and technically qualified to carry out the work?
Following on from the previous question, is it right that a person should be able to put his or her business into administration, avoid its debts and continue to trade under a different name?
  Why are directors of insolvent companies not treated like Bankrupt persons, particularly if they own and manage the businesses themselves?

How did the LA consult with the residents regarding the refurbishment? 
What was the communication process between refurbishment contractors and residents? 
How do residents feel about how this was done?

Who is responsible for routine maintenance of the building? 
How often were inspections carried out and how often?
Who decides what work is carried out and when (contractor or LA)?
How is maintenance work financed? 
What problems did the residents know about? 
What was the process for reporting faults and defects? 
What problems did the resident report?
How were residents’ reports of defects managed and how quickly were issues dealt with?
How were decisions communicated to the residents?
Is there a residents’ association, if is its role and relationship with the Council such that its concerns are taken seriously ad acted upon?
Did Councillors or LA officers meet with residents and if so, how often and what was the result?
Are residents satisfied with the way their concerns are dealt with?
What is the escalation process if they are not satisfied and were issues escalated?

Lots of tower blocks have been refurbished in the last 10 – 20 years. 
What is being done to assess the risks in these buildings by the responsible parties (LAs)?
When will the results be known?
What communication is taking place with residents and local communities?
What action will be taken if any in response to these investigations and over what time period? 
If work is required how will it be financed? 
What is the government’s position and what instructions has it issued to LAs to undertake this work and report back (if any)? 
What undertakings have been given (public and private, formal and informal) regarding follow through? 

What are the responsibilities of contractors and suppliers with respect to materials used? 
In the Chemicals industry a “responsible care” framework means suppliers are responsible for ensuring that products are only supplied for purposes that are legal and safe, and that dangerous products are transported, stored and managed safely.  Why are vendors of building materials and contractors working with them not responsible for ensuring that they are only used legally and safely?

Regulatory framework

What are the national guidelines and legally binding regulations regarding health and safety and building regulations in residential buildings, both in the private and public sector? 
Who is responsible for establishing these?
How have these guidelines been reviewed and amended over the last 20 years?
Who reviews them how often and on what basis? 
What decisions have been made regarding fire safety in this time (including decisions not to implement recommendations)?
If there are no national guidelines, then who is responsible?
When accidents do happen is there an investigatory process to learn lessons and adapt? 
How are learnings addressed, both in the short term and in the long term?  (compare with aircraft safety procedures, where the aim is to learn and implement lessons so that issues do not recur).

What are the UK regulations regarding fire safety in residential buildings, especially tower blocks?   
Do they differ throughout the UK and why?
How do they apply retrospectively (ie: to older buildings)?
Why are they not applied equally to old as well as new buildings?  If it is not practicable to apply them to older buildings, then who makes this decision and on what basis?
How do regulations for public buildings, offices, commercial premises differ from those for residential buildings, and why?
What standards are applied in other countries, how do ours compare, and why?
What rules are there about installation of sprinkler systems, fire detection systems and fire extinguishers?

What advice has the government been given over the last 20 years on improvement of fire risk management, particularly in residential buildings?
What have fire authorities and Parliamentary All-Party committees said on this topic?
How did government respond to this advice and to learnings from previous tower blazes, both in the UK and overseas?
If non-UK fires and other governments’ responses were / are not taken into account why?  
What positions have various governments taken on the use of flammable cladding material?
Why have flammable cladding materials not been banned in this country, where they are banned in other countries?

Does the government think that current arrangements for overseeing building standards and fire risk management are fit for purpose? 
If not, what needs to change? 
Similarly, what does the LA think?  (since responses are likely to be party political, better ask opposition parties as well)

Risk Management and Emergency Response

Processes and controls should be in place to manage risks on a day-to day basis so that they are avoided, eliminated or sufficiently mitigated (normally part of operational activities).  In the case of Grenfell Tower, this will include the processes mentioned above relating to routine maintenance and periodic building refurbishment.  But when an emergency arises it will normally go through several phases and responses should be appropriate.  A lot of questions being asked right now suggest that this was, and is, not the case in Kensington and Chelsea. 

While terminology may differ in different organisations, effective frameworks are remarkably similar.  They should involve
Resilience – being ready to respond to issues as and when they arise in an appropriate way
Crisis Management
  - a process for managing specific incidents, including initial emergency response, public relations and communications
Continuity Management – how to maintain ongoing activities in a crisis, or to reinstate them as soon as is practicable.
Questions relate both to the existence and effectiveness of these processes generally, and also to what is happening specifically now in Kensington and Chelsea.

Does the LA undertake effective risk reviews?
Who is responsible for them?
Are they discussed and approved by Councillors?
When was the last review undertaken?

Does the LA have crisis management process?  
Does the LA have an appropriate emergency response plan?
Has it ever considered how it will respond to a major incident such as the Grenfell Tower fire?
Do plans include appropriate communication plans for people directly affected, and for their relatives (eg: relatives emergency telephone lines), emergency services, the public and the media?
How are such plans communicated to the people affected? Have plans for this kind of incident been tested and if so, when?
What were the results? 
How were lessons learned addressed?

Does the Government have similar plans and if so how so they consider that something like Grenfell Tower? 
Do they consider this a major incident that requires HMG attention, and if so what do the plans say they should deal with it? 
The same questions apply to the Department of Environment, which has oversight of LAs.

Grenfell Tower

What guidance was given to residents on how to respond to fire both in their own flats, in others or in public spaces? 
How and when did people evacuate the building?  
What advice were people given on how to deal with heat and smoke? 
Are smoke hoods provided to people living in high rise buildings?
If not, should they be?
What were evacuation instructions?
Does the LA have policies on fire drills and training?
Has there ever been a fire drill in Grenfell House? 
Was there an assembly area (appropriate for families in the middle of the night)? 
Were there any nominated fire wardens and what were their duties?  

Why were main gas pipes fitted in the stairs and corridors?  Not only are they unsightly but dangerous in the event of an emergency. 
Why were the pipes not boxed in during the original installation, with fireproof material?
Should gas pipes be installed in in the only escape route?

When did the fire start? 
When was the fire reported to emergency services and by whom? 
Were fire alarms activated in the building and by whom?
If not, why not?
Were fire alarms broken or could residents not hear them?

Emergency Response

Who advised the LA that there was an emergency? 
What did the LA do when it received notification? 
Was an emergency response coordination team set up, when and where? 
If not, why not?
What arrangements were put in place immediately to receive people evacuated from the building and provide assistance in the aftermath of the fire?
What process was put in place to deal with enquiries from relatives or friends?
Who was coordinating responses between LA, charities, NGOs, emergency services?
Who was in overall charge of the emergency response?
What plans were put in place to communicate with neighbours and local residents, other LAs?
Were all these matters part of the emergency response plan? If not, why not? 
Or were they only determined in response to the incident itself? (NB: From the lack of communication from Kensington & Chelsea Borough Council and officers, it appears that a process to deal with such major incidents had not been planned in advance, and a coordination team was only, finally, put in place until Saturday, 3 days after the incident).

When did the Fire Brigade arrive at Grenfell Tower? 
Did they have access problems (residents have said that they had earlier expressed concern about this)? 
What did they find once they arrived, when they initially entered the building and subsequently when they searched the building? 
What is the fire service’s view about the building and about LAs position on fire risk issues? 
Had the fire service carried out any reviews on this building, or other council owned properties in Kensington & Chelsea, in the last 3 years, and what did they conclude? 
Have any of these buildings been found to be unsafe or require urgent and important rectification?
If so, what recommendations were made and what did the Council do about them?
Had their views been expressed publicly or, if no appropriate response received, escalated?

Who was coordinating emergency response on the ground?
What communications process was put in place to advise the public and media of what was happening on a routine and regular basis as the emergency response took place?
Were residents represented in the emergency response team or otherwise were their views taken into account?

Immediate Response

What is being done about housing people displaced from Grenfell Tower both in the short term (day 1), medium term (first 3-4 weeks) and thereafter? 
If no empty Council properties are available what privately owned property can be requisitioned/rented to assist (including student hostels, which may be empty at this time)? 
Who is going to pay for this?
Are there emergency funds available to underwrite this kind of response in the future?
If so, who holds the funds and how are they accessed? 

What arrangements are in place to ensure that residents have access to cash (directly or via their banks), can communicate with concerned relatives and friends, have sufficient clothes, food and shelter, etc…if they don’t have access to their own property (including wallets, phones)?
Who is coordinating this effort (largely charitable I guess) with the emergency response team in the LA?
How are the Red Cross and other charitable organisations being involved efficiently?

When and how will the search of the building be complete?
Why did this not happen straight away?
If there are good reasons (eg: building safety), why were these not adequately explained to the general public?
When do the fire brigade anticipate being able to report on the cause of the fire, how it spread, what they found during their inspection?

Is the position regarding survivors, deaths and injuries being communicated to all stakeholders on a frequent basis, and if not why not?
Is there a central enquiry line for relatives to call?

Longer Term response

How will the LA provide appropriate accommodation for the former residents of the block, where and when? 
Will the authorities re-imburse people for loss of property urgently (so they can buy what they need for their new homes)?  (Many people are unlikely to have sufficient insurance to cover the loss of property but even if they do the insurance companies will be looking to recover from liable parties, that may well include the LA.  The residents of Grenfell House should not be asked to wait while this wrangle goes on).

What is going to be done about similarly-clad blocks that are now clearly a fire risk and worrying for the residents, both in Kensington and Chelsea and in other LAs?
Will replacement of any non-fire-retardant materials be made the number 1 priority?
Will people be re-housed while further refurbishment takes place?
Will the government, which holds the purse strings, pay for this enormous cost?
  If not, why not?

What will be done by LAs to implement known weaknesses in fire protection in similar properties and in response to recommendations made by previous investigations? 
Will the Department of Environment take responsibility for ensuring that building control standards are mandatory and updated to reflect current knowledge? 
If not, what is their excuse this time?

What will the government do to ensure that in future it is prepared to respond to emergencies such as this in a coordinated way on day 1, not after a delay of 3 days? (imagine if the oil companies delayed 3 days before responding to Piper Alpha). 

What will the LA and government do to ensure that its response is not only technocratically correct but also show humanity and empathy for those involved? (this has been a major public relations disaster for Theresa May, which could have been avoided, just like the fire itself).

Will we receive answers to these and other questions as soon as possible?
When will we receive answers?
Will answers be public and if not, why not? (there is no good reason).

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