How we learn lessons effectively from fire tragedies and near misses was the subject of a cross-industry panel discussion at the Fire Conference 2023, held in October. Ron Alalouff reports.
Opening the discussion in response to the question “How do we currently learn from fires?” Steve McGuirk, Executive Officer of the Fire Safety Federation and former fire chief, said the NHS, for example, was riven with so-called opportunities for learning, but that previous mistakes often happen again.
Learning is not just changing a few policies or training, and the evidence that we are capable of learning isn’t great.
The 1973 Summerland leisure centre fire on the Isle of Man [in which 50 people died] was 50 years ago – the subsequent media coverage raised the question of whether new plastic materials used in the construction of the building had been independently tested.
Delivering the consequences of what we learn requires resources, commitment and tenacity on the part of leaders across multiple sectors, he explained.
Image credit: designer491/AlamyStock
Echoing that response, Howard Passey, Deputy Managing Director of the Fire Protection Association, said that the evidence of learning is not great. For example, many of the gaps identified in the Hackitt Report were already evident, and a lot of learning is done in ‘pockets’ without sharing it properly – for example by the design community or by the fire and rescue community.
“We need something joined up to make sure that action is taken.”
He went on to give the example of lithium-ion batteries, where he said there was “lots of research, but nobody is distilling that information to provide easily understandable advice on how to deal with these things in the real world”.
Mark Hardingham, Chair of the National Fire Chiefs Council, said there was a difference between having information and learning from it.
You start with information, then create knowledge and then learning, where we actively do something with that. There has been a national operational learning mechanism for fire and rescue services in place for more than 10 years, which enables fire services across the country to share operational learning that comes out of incidents.
Increasingly, there is the international perspective to learn from our international colleagues – but that is not as good as it could be.
Neil Gibbins, Fire Lead of CROSS-UK, remarked Dame Judith Hackitt had her finger on the pulse when she said that the system for confidential reporting of incidents in structural engineering should be extended to all branches of engineering, including fire safety.
That is what CROSS does – share information on a confidential basis for the benefit of others. As an example, the RAAC [Reinforced Autoclaved Aerated Concrete] issue which came to light this year was first raised by CROSS in 1995. There are mechanical elements to learning but in the end it’s about the culture, and confidential reporting is an element of a positive culture.
Steve McGuirk added that he was not sure people could always agree on what to unpick in order to learn. For example, the proposed new furniture and furnishings regulations can be seen as a trade-off between the use of potentially carcinogenic chemical fire retardants to inhibit fire, and firefighter cancers from the products given off in a fire.
A culture of learning doesn’t necessarily lead you to a conclusion or a decision about what to do with what you’ve learnt.
We need a public inquiry level of analysis, said Mark Hardingham, with ‘drop-down’ reports of specific incidents, and then a resource that carries out a sample analysis on a range of incidents to identify emerging trends.
How do we learn from near-miss fires and tragedies? (Image credit: Steve_Jolicoeur/AlamyStock)
Howard Passey agreed, saying it was all about collecting and organising data. “The FPA collects data from insurers on large loss fires – we can share that information in an anonymised way. Unless we have a mechanism for dealing with it, it’s just data in the end.”
Learning from other sectors is also important, explained Steve McGuirk. “We have a lot of data already, but maybe there is a better way of stitching it all together. There isn’t really a think tank convening body to bring it all together.”
On the question of whether there is the potential to learn more from near-misses than actual incidents, Mark Hardingham said that although the focus tends to be on what went wrong, there is also plenty of evidence of things going well. Some of the learning comes from why something went well, rather than always flipping it around to what went wrong.
How important is learning collectively and how prepared are we to invest in a reporting system, such as that in the airline industry?
Neil Gibbins said anytime the fire service has to get involved to save people is a near miss. But the fire service doesn’t own all the knowledge about fire safety – it’s a huge sector. Steve McGuirk warned that outcomes can “sometimes be hijacked in order to justify greater investment”.
On the question of risk, Neil Gibbins said most of the legislation is about high-rise residential buildings, but that’s not necessarily where the biggest risk lies.
Steve McGuirk added the problem of applying the term ‘risk’ to everything was that although the calculation of some risk can be really scientific, most risks are subjective and qualitative.
“We’re all pulled towards a risk matrix. But the NHS is full of competent and professional people, yet that doesn’t stop scandals such as Mid-Staffs, East Kent and Morecambe Bay from happening. Competence is only part of the answer – the bigger answer is how people perform professionally in the real world.”
Mark Hardingham concluded that responses to organisational failure are often to add a layer of process or level of supervision, but that can lose sight of the outcome you’re trying to achieve.
Sometimes the challenge for us is to do exactly the opposite and to take out a layer of process or supervision.
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