Catastrophe and Systemic Change

Gill Kernick is an internationally experienced strategic consultant specialising in safety, culture and complex change. She lived on the twenty-first floor of the Grenfell Tower from 2011 to 2014.

“On the day of the Grenfell fire, Kernick made a promise to make sure we learned. Her book was already the definitive way for us to do that, and this new edition in the light of the Inquiry is even more seismic, devastating and forensically analysed. Anyone looking to ensure that this tragedy can never be repeated needs to spend time with this book. The definition of ‘must read’.” — Lucy Easthope, author of When the Dust Settles: Stories of Love, Loss and Hope from an Expert in Disaster“Gill Kernick gives an authoritative account of inexcusable failures to learn lessons from catastrophic incidents. Those with power should read this book to understand their responsibility to drive evidence-based, robust and effective changes in our society.” — Her Honour Frances Kirkham CBE, coroner in the Lakanal House fire inquests“The first edition of this book was hugely impressive and this new edition takes it to a whole new level. The two big questions of ‘Why can’t we learn?’ and ‘How can we change?’ are, I think, the most important challenges faced by the whole of society, and Gill Kernick’s approach to them is so compassionate and intelligent. I have spent a lot of my career trying and failing to understand why public inquiries achieve so little, despite their devastating conclusions, and I think this book is one of the only things I’ve ever read that has explained it to me.” — Dan Davies, author of The Unaccountability Machine: Why Big Systems Make Terrible Decisions – and How The World Lost its Mind“This powerful book lays out starkly the many failings that led to the huge tragedy of Grenfell. In the immediate aftermath, Grenfell was expected to prompt significant change. Yet a decade later even the cladding issue is not fully resolved. Kernick describes why effective learning and systemic change do not happen – even in the face of events that make us weep with fury. I will respond to the book’s ask to take small steps toward change by challenging organisations to practise two things: error wisdom and chronic unease.” — Dame Kate Barker DBE, Trustee Chair, USS, and author of Housing: Where’s the Plan

• Preface to the revised edition Introduction: the book I wish I’d never had to write PART ITHE GRENFELL TOWER FIRE CHAPTER 1The Grenfell Tower fire: not just the cladding CHAPTER 2From safe to unsafe: moving away from goodnessPART IIANALYSIS AND REFLECTIONS CHAPTER 3Complexity, safety and systemic change: ‘making the water visible’ CHAPTER 4Foundational elements: ‘of bricke or stone’ CHAPTER 5Behavioural elements: ‘blame fixes nothing’ CHAPTER 6Relational elements: ‘I thought I will make happy both of them’ CHAPTER 7Contextual elements: ‘the patronizing disposition of unaccountable power’CHAPTER 8Making the water visible: of despair and hope Acknowledgements NotesIndex