How Small Things Stack Up To A Tragedy. And What You Can Do About It.
It started in a 4th floor flat. A broken refrigerator caught fire in the early hours of June 14th, 2017. As the fire grabbed hold, it grew and spread rapidly. Very soon, the fire in Grenfell tower had lit up the London skyline. 72 people lost their lives that night with 70 injured and everyone in the building people rendered homeless. It was the worst residential fire since the Second World War.
The only thing that I wanted to understand was that how is it possible for a small fire to turn into such a disaster?
While a minor problem with a faulty fridge may have started the fire, the situation escalated quickly. As it turns out, there was a series of severe mindset mistakes at play. There was no sprinkler system in the building due to their cost, for example. Additionally, the outside of the building had a type of cladding that had failed safety tests, leading to the fire spreading very fast when it reached the outside wall.
The safety policy for the building was strange too. It stated that residents should stay inside their homes and wait, instead of evacuating immediately. The assumption was that the fire would be contained behind fire doors until the firefighters could put it out. Grenfell only had one stairwell, and it filled with toxic smoke when the fire started to spread. By the time the residents decided to abandon the safety policy and their homes, it was already too late.
The phrase ‘fire-fighting’ is often used in businesses, factories or processes to describe a situation where problems keep popping up and taking up valuable resources, and as a result, there is no time for putting out the root causes.
If you look at the story of Grenfell, it is clear to see that the point where firefighters get involved, it’s too late. Much too late.
The opportunities to prevent the Grenfell disaster were missed in the months and years before for whatever reason.
One of the key roles of the fire service is that of prevention. They go to buildings, check them, test the systems and make recommendations so that the risk of a fire getting started or out of control is reduced.
Still, on weekly basis, I bump into software teams in the ‘firefighting’ mode. I bet the same applies to any other industry as well.
The story of Grenfell is a grim example of what can happen by neglecting the pre-emptive work that’s sometimes called firefighting. As it so often seems to be, the big disasters are an outcome of those minor things.
In order to pre-empt tragedies, a shift in the whole mindset of your organisation needs to happen. Someone must dare to step up and start incepting the ideas of better quality on your clients, colleagues and bosses. Someone needs to become the champion of Upstream Thinking.
So, only one question remains. Could that champion be you?