Catastrophic system failure and its implications

The term ‘catastrophic system failure’ (CSF) originated in the I.T. industry, but it has now come to mean any sudden and total failure from which recovery is extremely difficult or even impossible.  The fire at Greenfell Tower this week is the latest example of such a failure and my deepest sympathies go out to all those affected by this tragedy.

Before deciding to blog about this, I have pondered long and hard about whether to do so.  I have decided to go ahead because firstly the mission of this blog is for people to learn and understand all aspect of operations management and hence I want to make a positive contribution to the current contentious debate about this event.  Second I want to focus on a specific aspect of the fire that may not have been given the same level of media coverage as other aspects – specifically the effect this CSF may have on the firefighters who attended the incident.

Here I must reveal some personal bias.  My older son was a fully trained firefighter and served on a retained basis in a fire and rescue service on the South Coast.  Being interested in operations of all kinds (and in my son) I would discuss with him a variety of things related to how the fire service worked, such as training, rostering, response times, and etc. So I have some insight into their operations, but I do not claim to be an expert in this specific field.

What I do know is that firefighters go through a rigorous training regime and continually practice their procedures and routines for tackling any kind of incident.  This is how they are able to perform their duties in circumstances that members of the public find extraordinary.  They enter burning buildings to fight fires and rescue occupants because they have training centres that create the most severe conditions under which they can operate.  They have learned how fire behaves, how it moves, and why it burns with different levels of intensity.  They do not regard themselves as brave when tackling fires because they have the training, expertise and kit that assures them that they can succeed in completing whatever task faces them.

All of this was put to the test at Greenfell Tower.  The tower block was designed to have a ‘passive’ fire protection system.  This is based around the idea that any fire outbreak should be contained within one flat or apartment.  Doors should be closed to prevent the spread of fire.  Firefighters enter the building and fight the fire from within, using water from high rise mains located on different floors.  Residents should remain in the building and take action to stop smoke from entering their homes.   The emergency staircase is there not to evacuate them, but to allow the firefighters to get to the fire.  And over many years this system has been effective.  This is why some residents were initially told by firefighters to stay in the building.

But Greenfell Tower was different.  The senior fire officer who attended the blaze described it as “strange”, “fast moving” and “unpredictable”.  The fire was not contained within one flat, but moving up the outside of the building so that the whole building was quickly becoming engulfed in fire.  At this point, minutes after arriving at the scene, firefighters were faced with a situation they had not trained for and had never seen before. Thus to enter the Tower, as many firefighters did, took supreme courage and was truly heroic.  It deserves some special recognition.

Clearly there was a catastrophic system failure here and the public enquiry into the fire will identify how this occurred.  Right now another system needs to come into operation with regards to the firefighters – the fire and rescue service counselling system.  In years gone by they were left to cope with the psychological effects of attending tragic events and many suffered from post-traumatic stress.  These days it is routine for firefighters to have a debrief after attending any event, and to receive counselling if needed.  This is going to be especially important for those firefighters who attended Greenfell Tower, for I fear that they will feel that they failed and that had they performed better the number of victims would be lower.  They must be helped to overcome these dark thoughts, because it was the CSF that lead to the death toll, despite their valiant efforts to save residents.

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