With today’s announcement of the appointment of Sir Martin James Moore-Bick PC to lead the public inquiry into the Grenfell Tower fire, the formal process to find answers to the many important and systemic questions that this terrible incident has generated can now begin in earnest.
RoSPA welcomes the start of this absolutely critical process.
The role of inquiries into disasters is to establish clearly not just what happened, when, where, how and with what consequences, but crucially to ask “why?” Asking “why” enough times and at each stage of the inquiry process is necessary to understand both the immediate and root causes.
For it to be able to go deep enough it will be important that the inquiry’s terms of reference are not too restrictive and that suitable technical assessors are appointed. The right experts are needed to help Sir Martin and these should include not just people with fire safety and building expertise but people with understanding of organisational risk management and safety culture.
The inquiry could usefully learn from approaches adopted by similar exercises into other fire tragedies and also from those adopted by previous disaster inquiries, particularly Piper Alpha (Lord Cullen), Zeebrugge (Mr Justice Sheen) and Ladbroke Grove (Lord Cullen).
The announcement that there is to be an early interim report is welcome but there should be no sacrifice of depth of inquiry into underlying causes of this disaster because of the pressing need to address immediate causes and necessary short-term remedial actions. Indeed, it should go wide enough and deep enough to yield lessons for improving public safety that go beyond fire safety and encompass other settings where large numbers of members of the public might be at risk.
If the inquiry reveals a formulaic, “tick box” compliance approach at various points along the chain of safety decision-making around Grenfell Tower – rather than a proactive, risk-based approach – it will need to delve deeply into this syndrome and identify the extent to which corporate risk committees are really taking their responsibilities seriously.
And, if the negative atmosphere surrounding health and safety created by more than a decade of deregulation and “light touch” risk management and enforcement played a significant part in this awful tragedy, then the inquiry should not shrink from examining this in some detail and laying bare the facts.
We all owe it, not just to the victims of Grenfell Tower but also to the countless others who could well be harmed by accidents due to the same underlying “safety pathogens”, to get this inquiry right.
Roger Bibbings MBE, RoSPA’s partnerships consultant and former occupational safety adviser
Posted: 6/29/2017 10:54:39 AM