Exploring practical systems change: why are we not learning all the lessons we could about fire safety?

Benjamin P. Taylor
5 min readOct 3, 2021

“Institutions established to serve the public can over time, become insular and increasingly focussed on self-preservation. Against this, a changing world posing new risks and opportunities, an absence of competition or change catalysts, and limited public input can then create a growing gap between what is, and what could be. When the gap and cost become intolerable it is time to act. This describes the current situation of reliance on a professional response model for fires. It is now time to disrupt the current model by amplifying the public voice and creating a space for innovation.”

David Wales

Why is this — and what can we do about it? Your thoughts would be welcome in the comments — and there’s an opportunity to participate:

Fire services have learned — a lot. This is possibly because their imperative is to save lives — both incredibly motivating and really really tangible and measurable.

I use them as an example of organisational learning at three levels:

  • getting better at the heroic task of literal firefighting; better kit, better doctrine, better training — rich learning
  • prevention: from the first moment someone said ‘wouldn’t it be better if houses didn’t go on fire?’, the game changed. In the UK, awareness-raising and regulations on fire safety, unattended chip-pans, wiring and especially electric blankets, smoking in bed — just the examples I remember most vividly — have changed the game from purely rescuing to prevention. And, apart from the horrific realities of the Grenfell fire, reduction of deaths in accidental house fires has been a huge public service success story
  • identity; as fire fighters spent less time training for crisis situations and more time checking the smoke alarms in old people’s houses, the macho saviour image has changed somewhat, and fire services are often amongst the most collaborative local public services — they are trusted, they can check for trip and slip hazards, CO2 risk, signs of food and fuel poverty and abuse.

By doing the original task better, learning to ‘go upstream’ to prevention, and looking for other opportunities, the modern fire fighter and fire service

But. When I met David Wales, I learned from his deep research and insight that UK — and international — approaches to fire safety offer real opportunities to do better.

See these reports for part of the story:

To discover that we have evidence of what works in fire safety that we are systematically unable to learn from and build on, that we are optimising part of the system but not focusing on overall outcomes, that things learned at Kings Cross were seen again at Grenfell, that engineers are not engaging effectively with the evidence on the role of humans in situations, that governance is a systemic barrier to change and excludes real public engagement and influence… is frustrating and disappointing.

The convening call

Grenfell continues to shine a light on the multiple failures of the current fire safety model and the lack of systems or evidence-based approaches.

Perhaps most notable within this is the limited role and influence of the public voice in shaping the services established in their name. This can at least be partly explained by reference to the legislation and regulations by which it is easy for the fire service and others to see the Government and its various agencies, rather than the public, as their primary customer.

When legislation, policy, standards, or new practices are proposed, the fire service and fire safety sector have organised and visible bodies that are able to exert a strong influence. There typically represent an engineering perspective, which underpins the sector and provides many benefits. The system is largely designed to maintain the status quo. It is not surprising then that there has been little, if any real innovation, in fire safety and services for decades.

However, the public does not have the same opportunities and influence. Academia poorly represents in volume and content the public and there are very few social scientists active in the field. As a result, the quantitative/engineering model continues to be the default.

The absence of a strong public voice continues to be very detrimental to credible and effective fire safety arrangements and will do little to avoid further avoidable disasters or harm from everyday events.

The future presents many new and complex risks, balanced by the potential of innovative technology to facilitate different solutions. But these will continue to be impaired or ineffective unless the public is better represented. Ensuring a shared purpose with the public, and making sure the services provided reflect the needs and capability of the communities is unlikely to be an outcome from the current trajectory.

Understanding fire as a human experience, rather than the technical process of fire safety and extinguishing is absent from the existing infrastructure. Further, some studies already show that far beyond the obvious harm, fire represents both a social and health inequality, affecting some of the most vulnerable.

Grenfell has provided seen new interest in fire safety by the public and also enhanced the profile of those with an existing interest in the citizen perspective. There is a potential opportunity to create a means by which these currently fragmented sources can be harnessed to leave a positive legacy, that will ensure the public voice is heard.

It is proposed to hold a kick-off event to discuss the issues described above, and if there is general agreement, to then consider how the public could be effectively represented and heard.

This may include options for how to enhance the research and evidence base for policies/governance/media, how to support innovation, and a resource for public education and support.

Please join us:

The aim of the session

My interest is in supporting this learning to achieve systemic breakthroughs and, in doing so, in learning something about how to assist people like David to achieve their systems transformation goals.

Proposed agenda:

  • Check in
  • David to outline his current position
  • Clarification question to David
  • Discussion (in small groups depending on numbers) on potential next steps — with opportunities to go back to David with further clarification
  • Report out with clear identification of commitments / offers / suggestions
  • Check out


Benjamin Taylor

RedQuadrant, the Public Service Transformation Academy, and Systems and Complexity in Organisation (I’m acting personally in this, but it aligns with my personal and professional interests as reflected by the organisations I’m part of).