Grenfell learnings from the Marchioness disaster

August 20, 1989 is a day that sadly will always be remembered in the UK for the Marchioness disaster. After being hit by the 1,475-ton dredger Bowbelle on the River Thames in the early hours of the morning, the Marchioness sank in just half a minute.

The devastating collision resulted in the loss of 51 lives, all of whom were enjoying a birthday party on-board the 47-ton pleasure boat. Following the tragedy, an investigation by the Marine Accident Investigation Branch (MAIB) paved the way for a 1991 report that overhauled marine safety on the Thames. A number of safety recommendations were implemented, including navigation lights and improved lookouts on boats.

After significant pressure from the victims’ families in 1999, John Prescott, the then-Deputy Prime Minister, demanded an Inquiry into safety on the River Thames as well as an investigation into the factors that led to the sinking of the Marchioness.

Photo © PAUL FARMER (cc-by-sa/2.0)

The result of the 2000 Inquiry was a report that was published in February 2001 by Lord Justice Clarke, which made a number of river safety recommendations. They were all accepted by Mr Prescott.

Despite these reviews, recommendations and legislation, a shocking story emerged 30 years later from Port of London Authority (PLA) which has revealed that the ‘most basic’ safety recommendations made after the disaster have still yet to be enforced.

The PLA found a staggering number of the older and historical boats still operating on the Thames have not undergone necessary changes to improve their safety in the event of a collision. Some of these vessels have been in service for so long that they took part in the evacuation of Dunkirk in 1940.

The Maritime and Coastguard Agency (MCA) put forward safety proposals to improve buoyancy that would require hulls to be divided into watertight compartments to reduce the chance of sinking if the hull is breached with all existing boats to be retrofitted with these features. However, introducing these measures for historic boats would be costly and some owners have resisted, claiming the vessels would then become commercially unviable.

The Dangers of Complacency

Two years on from the Grenfell Fire and a year on from the Hackitt report, which was commissioned by the government following the fire to make recommendations on the future regulatory system, a similar situation exists.

Alongside a proposed change in control process and associated record-keeping requirements, Dame Judith Hackitt recommended what she called a ‘golden thread of information’ to ensure the transparency and compliance of fire safety equipment maintenance in residential buildings. Despite this call, the housing industry is slow to see the adoption of this recommendation, or any real movement on those set out by the report. Subsequently, most residents of existing large residential buildings are no safer than they were before the fire.

We simply cannot allow this to continue. The Marchioness disaster is a warning from history that complacency, such as that seen since the Grenfell fire, can continue to fester and prevent us from taking steps to ensure that history does not repeat itself.

“The Marchioness disaster is a warning from history that complacency, such as that seen since the Grenfell Fire, can continue to fester and prevent us from taking steps to ensure that history does not repeat itself”

Outdated Compliances Processes

Current compliance processes are not fit for purpose. Many authorities and landlords have little oversight over the safety equipment in their properties or how effectively they are being maintained. Landlords are also completely beholden to the contractors who control their records (of which many vary in quality). Some contractors are still using paper-based systems, whilst others have digitalised their records – but offer no insight into the bigger picture.

The risks of poor compliance and change control cannot be overstated. Lives depend on essential safety equipment being implemented and properly maintained – and within their expiry dates. The reputations and indeed freedom of those responsible all depend on the due care and diligence taken to protect these residents.

At the end of the day, it is the landlords who are ultimately accountable and responsible, whilst fires can, and often, happen. From March 2018-19, the fire and rescue services attended 29,570 dwelling fires. Eight hundred and twenty of those fires were in purpose-built, high-rise (ten plus storey) flats, which is a three per cent increase compared to the previous year (800). It also equates to at least two fires a day on average in properties of this type.

Seizing Control

Landlords need to take back control of fire safety compliance to ensure transparency, oversight and accountability. If records are entirely held by a contractor, as a landlord, can you be sure you are seeing an entirely accurate picture? And what happens if you move to another contractor: will the information be passed on in a way that the new company can seamlessly integrate with?

In order to take back control, landlords must have a holistic view of what equipment exists, what work needs to be done, what work has not been done, and what work is upcoming in a live and digestible way.

Make no mistake, keeping records is not the same as compliance. Paper records are antiquated and prone to loss, damage, illegibility and mistakes, but even digital records can be useless if not implemented correctly. Just because a form has been created to show a piece of work has been done, has it actually? Is there a GPS and time stamp that proves the contractor was actually at that location?

And if the information is correct, an isolated digital record or an Excel spreadsheet held by a contractor can also take significant resources (multiple full-time members of staff) to monitor and draw insights from, which can mean it takes months before issues are spotted. Clearly, there is a significant hole for mistakes to fall into, as there is no digital audit trail.

Only by creating a dashboard so that compliance performance can be monitored, and contractors can be held to account at any time, will landlords succeed.

Positive Change For a Better Future

Whilst Dame Judith Hackitt’s recommendations were focused on high-rise residential buildings, it is essential that this be implemented across all facilities and properties.

Anyone with responsibility for buildings where people work or reside must provide this transparency, oversight and accountability. After all, lives count on it.

Only when landlords have seized control can this transparency be extended to residents and the golden thread will be complete. Involving residents in the conversation, making them aware of the equipment in their buildings, and giving them proof that it is being effectively maintained is the only way to help them feel safe in their homes and rebuild trust within communities.

The parallels with Grenfell and the Marchioness disaster are clear. We cannot wait for another 30 years before we learn the lessons from Grenfell. The time to act is now. Before it is too late.