Communication meltdown

We discuss communication all the time on our NEBOSH, IOSH and to some extent other courses too as part of the four ‘C’s to good Organisation. The others being control, co-operation and competence. However, most people find it hard to relate how communication really can affect health and safety management. There are always blank looks as many students consider why this matter seems to have such importance attached to it. I usually say it’s how an organisation considers the requirement for the retention and access to vital information and how information is transferred across the business vertically and horizontally.

Imagine this situation then as an example.

BT transfer over 170 calls received from inside a burning building to the Fire response control room who categorise these 170 or so calls as requiring “Fire survival guidance”. (These types of calls are very rare indeed).

Each call taken is written on a paper form and carried across the room to a coordinator who writes the calls on a white board before phoning or using radio (or both) to the location. Each entry is transferred to the fire fighters on the ground who write the information onto a form then carry over to the central point near the incident and written onto another white board.

The information is then written onto another form and carried across to the coordinated area, (set up on a parked car bonnet) to another set of fire fighters. These forward fire fighters write the information out onto another form before running across the front of the building as burning materials rain down, into the lobby of the building, where the information is written on the wall with a pencil. At this point, the information is yelled up two flights of stairs where it is written onto another piece of paper and carried to the ‘Bridge head’ or command centre, who then instructed the rescue fire fighters to various locations in the building.

The scope for human error in such a system is mind bending. There are at least 11 critical steps in this chain. If the Nuclear authorities assumption that 1 in every 1,000 critical tasks we do will be performed incorrectly is to be believed then a statistician would calculate that of the 170 critical calls taken, the final information would be wrong on at least one, more likely two occasions leading to loss of human life.

If you also add to this that there were no fire plans available of the building, staircases were unidentifiable, the rooms had all been renumbered and the fire fighters radios didn’t work above the 6th floor then you would have to assume that the actual error was far worse than the cold calculation above.

We are of course talking about the Grenfell Inquiry from 20th November 2018

. This information was presented at the inquiry on 20th November 2018 and can still be heard as a Radio 4 podcast, along with all the other podcasts from the inquiry.