No 3
SYSTEMS-BASED LEARNING MODULE
When Change Escapes Control:
Lacrosse Tower
When Change Escapes Control: Lacrosse Tower
A systems-based learning module using the Lacrosse Tower fire to explore how design choices, product substitution, contractor interfaces and assurance arrangements interacted across a construction project.
The focus is not simply on the fire. Participants examine how change was controlled, how roles and responsibilities became fragmented, and what similar patterns might look like in their own projects and organisations.
About this module
Lacrosse Tower explores how compliance assumptions, procurement decisions, inadequate change control, limited product understanding and weak assurance combined across design, construction and approval stages.
It examines why the wider system did not recognise the accumulating vulnerability created by combustible external cladding.
What the module examines
Design changes | Product substitution | Contractor interfaces | Fragmented accountability | Weak assurance | Combustible cladding
Applying the learning
Participants consider how design and product changes are reviewed, how responsibility is retained across multiple parties, and where comparable weaknesses could remain hidden within their own projects or building portfolios
Looking to strengthen how building safety works in practice?
I work with organisations that want a clearer view of how their current arrangements are functioning and where the next stage of development should focus.