My brother in law is a recently retired airline pilot who has not only been flying planes since he left school 40 years ago but has been training the pilots of tomorrow for some years now. Yesterday we ended up talking about Grenfell, the Challenger disaster, the floods of 2015, drinking water pollution and airline safety. Apparently unrelated subjects one might think; but think again about how those things are investigated and the link becomes clear.
Let me start with a short personal story about drinking water pollution – people ill, huge costs and disruption and a serious possibility of prosecution of the company. My job was to conduct an investigation into the causes of the incident and suggest remedies. I completed my investigations and made my recommendations and presented them to the relevant Directors, leading to a ‘discussion’ with my Managing Director when I refused to put any names into the report or to assign blame to anyone. He wanted somebody to point a finger at, to sack. But would the people who so willingly helped me investigate a very tricky incident have been so helpful had they feared for their jobs? I suspect not.
What about the Xmas 2015 flooding? Well, as Chairman of The Aire Rivers Trust, I have been heavily involved in the aftermath of those floods looking at the causes, effects and future remedies. What has been especially ‘disappointing’ has been the amount of overt and covert politicking (with both lower and upper-case ‘p’) surrounding the whole process. This politicking, much (maybe most) of which as come from elected councillors does little to further the cause and only serves to demoralise the committed officers working on the schemes. Moreover it sows doubt about the accuracy and veracity of the various reports and recommendations, in turn feeding rather than calming the understandable public concern about what happens next time it rains.
Finally the Challenger disaster, which was rigorously investigated and which was ultimately held to be essentially ’caused’ not by the technical failure of a o-ring that had been identified and for which a ‘No launch’ recommendation had been made by the technical experts, but by the managers who decided to over-ride the engineers’ advice in order to protect their company’s position.
The similarity in all of these seems to be a desire by some parties to investigate rigorously, butting up against a wish by others to point the finger, to blame. I will come to Grenfell in a minute, but by now my point may already be coming clear.
For many years, the airline industry has had a ‘no jeopardy’ form of investigation. One which has led to continuous increases in the safety of an already very safe form of transport. The purpose of an investigation should be to establish all of the facts and the inter-relationships between them in order to prevent repetition. For any investigation to be able to establish the true facts of an incident it is necessary that the participants can ‘have their say’ and report their understandings and for the investigators to be able to dig into every detail and nook and cranny without ANY of them prejudicing their career or the possibility of legal action against them.
Will, even can, this happen for the tragic fire at Grenfell Tower? We have Politicians of one ‘colour’ blaming the other, and the other blaming the one; we have debate raging about the Fire Safety Assessments, about the Building Regulations (and who is responsible for enforcing them in the light of them being ‘privatised’); we have some pointing the finger at illegal sub-letting (as if illegal sub-letting justified the occupants to be burned to death), the companies responsible for supplying and then fitting the cladding are covering their legal arses, the officers who commissioned the work will be feeling very uneasy (especially those who encouraged the cost-saving measures that may have resulted in less safe cladding being fitted), we have a local authority absolving itself of responsibility because it was social housing run by a housing association not themselves…add your own complicating elements to the list.
Amidst all this we have at least 76 dead, grieving relatives, annoyed survivors and thousands more in similar accommodations who are not only seeking answers but looking to find fault. We seem to have a natural tendency to want to find someone to blame when accidents occur and that is playing out big-time here. But will that help in the long-term? Even if blame could be allocated, would it bring back the dead, would it sooth the anguish and the fears? And would the prospect of blame being allocated inhibit individuals and corporations from being completely open in their collection and giving of evidence?
When you run into the back of the car in front, it is usually ‘he braked suddenly’ rather than ‘I was going too fast, too close, not looking ahead of the car in front for possible emerging hazards’. When my house floods it is not because I failed to take the many resilience measures that I could have done but ‘because they didn’t build proper flood defences’ or ‘the farmers are causing increased runoff’ or even ‘climate change’ (as if we were not all contributing to the latter). It’s psychologically ‘safer’ to find someone to blame than to accept my own failings.
So back to Grenfell. Will the public inquiry set up a ‘no jeopardy’ process – no, because much of its’ evidence will be held in pubic and so anonymity (an essential part of a no-jeopardy process) cannot be guaranteed. How can this be set up? Sorry but I do not know, what I do however believe is that such a no-blame process is necessary if we are to truly identify and learn the lessons from this tragic event. Maybe just highlighting the issue and asking the question might help someone else to pick up the baton and see what can be learned from the air transport industry’s processes.