Resident Pathogens

Hugh Pennington

I lived for several years on the 10th floor of a tower block in Cumbernauld. It swayed a bit in the wind, but had been strengthened after the Ronan Point disaster. Ronan Point in Canning Town was built from large prefabricated concrete panels. Ivy Hodge was one of its first tenants, moving into a corner flat on the 18th floor on 15 April 1968. At 5.45 a.m. on 16 May, she struck a match to light her gas cooker. A friend had fitted the cooker. He tested for leaks using a lighted match, but had used a substandard nut, and there was a leak. The explosion blew out the external load-bearing walls of her living room and bedroom. The corner walls of the flats above collapsed and fell. Their weight took out all the corners of the flats below. Four people were crushed to death.

The public inquiry, chaired by Hugh Griffiths, held its first hearing at Newham Town Hall on 30 May, took evidence from 108 witnesses, sent preliminary recommendations in a letter to the minister on 6 August, and published its report on 14 October. The collapse had exposed a design weakness in the building:

It is a weakness against which it never occurred to the designers of this building that they should guard. They designed a building which they considered safe for all normal uses; they did not take into account the abnormal …

the general approach of Building Regulations … giving freedom for the development and use of new techniques and designs is right… but if British Standards and Codes of Practice are used in this way, they must be kept up to date, and new ones must be promulgated as necessary. This is not always so at the moment.

Public inquiries into disasters in the UK are rare. Governments don’t like them. They take judges away from judging and bring them too close to politics. They are expensive and slow. The one I chaired into the 1996 E.coli outbreak in Scotland took three years and cost £2.3 million; our public hearings had to wait until the conclusion of police investigations and the outcome of a trial. But the main reason governments don’t like public inquiries is that they usually reveal unpalatable facts, come to uncomfortable conclusions, and make recommendations that cost money.

The residents of Grenfell Tower who stayed in their flats, as the fire regulations said they should, were killed. It wasn’t the first time such advice was shown to be lethally wrong. The Piper Alpha oil platform caught fire on 6 July 1988. Of the 226 men on board, 165 died. Two rescuers were killed. The rules for platform personnel were to assemble in the accommodation module and await rescue by helicopter – not to jump into the sea. All 79 workers in the module died from smoke and gas inhalation. Forty men jumped, some from 175 feet above the sea; 26 of them survived.

There were cladding fires in tall buildings before Grenfell Tower, but nothing changed after them because they weren’t so lethal. Similary, there were hundreds of escalator fires – or ‘smoulderings’ – on the London Underground before the King’s Cross fire on 18 November 1987, which killed 31 people (one of them wasn’t identified until 2004). The Fennell Inquiry said:

Because no one had been killed in the earlier fires they genuinely believed that with passengers and staff acting as fire detectors there would be sufficient time to evacuate passengers safely … They failed to appreciate the particular problems of smoke.

The lethal flashover that erupted into the ticket hall at 19.45 was unprecedented. The mechanics by which it developed were unknown, but Desmond Fennell concluded that the circumstances that led to it were foreseeable. It is hard to avoid the conclusion that it will be no different for the Grenfell Tower fire.

The accident theory concept of ‘resident pathogens’ – latent failures necessary but not sufficient to cause a disaster – is attractive to me as a microbiologist. They had been there for years in the E.coli outbreaks I investigated, including avoidance of the regulations, inadequate staff training, and incompetent inspectors. It seems likely that cladding specification and design, along with the complexity and obscurity of the language of regulations, were resident pathogens at Grenfell. The fridge-freezer fire was the trigger.

Mr Justice Sheen said in his 1987 report into the capsize of the Herald of Free Enterprise, which killed 193 people:

In every formal investigation it is of great importance that members of the public should feel confident that a searching investigation has been held, that nothing has been swept under the carpet and that no punches have been pulled.

His was one of the first disaster reports to focus not only on the immediate errors (the failure to close the bow doors) and design failures (including the lack of bow door position indicators on the bridge), but also on the corporate culture, diagnosing a disease of sloppiness that went right to the top.


  • 10 July 2017 at 3:37pm
    Graucho says:
    The concept of a "Black Swan Event" really raises my hackles. It became popular as a feeble excuse from the financial industry for the 2008 crash as though these things had not been happening since the days of the Dutch Tulip bubble and before that. "Ignored canary in the cage event" would more closely describe Grenfell and similar.

  • 10 July 2017 at 4:43pm
    sol_adelman says:
    The judge they've selected for this inquiry has already gone out of his way to say the scope of the investigation will be severely limited to determining the immediate cause of the fire and why it spread so rapidly. Answers to both questions are already known, so there's little reason it should take much more than a week.
    The years foreseen are simply time to allow the public outrage to die down and plans made as to how far the cover-up should extend. Sir Martin Moore-Bick seems well suited to the task. He was the magistrate in a controversial case wherein he determined that is was entirely fair and proper that a displaced recipient of disability benefits should be housed 60 miles from her previous residence, family, doctors and friends. She was black. His ruling was overturned by an appeals court judge who found his reasoning without merit.

    The Sir Inquisitor-to-be has given the game away in adding that “I do not expect everyone to be pleased by the conclusion of the inquiry” – yet to begin. No one is confused as to who the “everyone” he has in mind refers to. Zero chance it will include Sir Eric Pickles or May's right-hand man Gavin Barwell, the housing ministers who sat on recommended improvements to fire safety in local authority tower blocks following the Lakanal House fire of 2009.

    • 13 July 2017 at 6:49pm
      gary morgan says: @ sol_adelman
      Have a look at Private Eye July 14th and the interesting doubts about MacPherson before assessing Moore-Bicke precipitately. We might be pleasantly surprised; I think too much is at stake for a whitewash to be attempted. In any case, MacPherson attracted similar criticism in advance and did a good job. Let's hope things turn out like that, eh?

    • 14 July 2017 at 5:46am
      sol_adelman says: @ gary morgan
      He was handpicked by a Tory government that shares his appalling record when it comes to disadvantaged people. He's said that the scope of the inquiry will be extremely limited and that his conclusion will disappoint many.
      Too much at stake for a whitewash to be attempted? You may recall millions marched to protest the invasion of Iraq on a pack of lies, an invasion that caused hundreds of thousands of deaths and created Isis. Yet fourteen years and three inquiries later, the only public figures in the UK to have suffered repercussions are those who were forced out of their jobs for questioning the invasion: Greg Dyke, Andrew Gilligan, Piers Morgan and George Galloway.

  • 16 July 2017 at 8:10pm
    deuchars48 says:
    Seriously, do look at Private Eye. It gives plenty of examples of his taking, for want of a better term, anti-establishment decisions.