At yesterday’s opening of the Grenfell Tower Inquiry, Sir Martin Moore-Bick set out the way he intends to conduct proceedings.
At one level, his decision to proceed in two parts seems quite logical and sensible; to establish (in part one) the “what”, “when”, “how” and “consequences” of the fire is essential if the broader questions (in part two) are to be answered – “why” the events and circumstances unfolded as they did.
However, all these dimensions are closely interlinked and thus questions as to why failures and weaknesses uncovered by evidence in phase one “were as they were” will start to rear their head as soon as hearings begin.
Sir Martin is right in asserting that the immediate need is to establish as soon as possible what lessons can be learned to prevent recurrence and to safeguard those who continue to live and work in high-rise buildings, but the work of phase two in uncovering what are likely to be termed “root causes”, is also important in protecting people from preventable tragedies of other sorts. On June 14, it was a truly terrible fire. In the future, the same kinds of weaknesses in organisational safety culture (that affect similar organisations) could express themselves in other potentially disastrous ways.
Sir Martin faces an enormous challenge of conflicting expectations. Quite rightly, he points to his prime duty which is to establish the truth (regardless of its consequences for criminal and civil liability) about what happened and why. He emphasises correctly that it is not his role to apportion blame. He has placed great emphasis on the need for witnesses to be treated with care and compassion. On the other hand, those affected by the fire, especially those who have lost everything – including loved ones – feel quite rightly that the exercise must be one that delivers what they see as “justice”.
Of course, truth is always a pre-requisite for justice. An enormously powerful team has been established at great expense to get at the truth. (Would that only some of these public resources had been devoted to fire prevention!) Those seeking justice will want that team not only to examine and piece together a clear and objective account of the mechanisms that caused the fire to develop as it did and the adequacy or otherwise of emergency action taken, but to examine in equal detail why these pathways to disaster were not foreseen and blocked off before they could lead to the tragedy that unfolded on June 14.
The danger is that in examining a very large volume of evidence, a whole catalogue of errors of various kinds will be uncovered. Accidents, both large and small, are rarely simple and investigations usually uncover many causes. Nevertheless, it will be quite unacceptable, not just to the Grenfell survivors but also to the wider community, if Sir Martin does not in the end seek to attribute exactly which failures, both technical and organisational, were the most significant.
Ever since Aberfan, more than half a century ago, inquiries have shown again and again how tragedies involving multiple losses of life could so easily have been avoided. Changes have followed in many spheres like better road, rail, maritime, aviation and workplace safety and these have definitely saved lives.
And yet because disaster inquiries, however diligent, are often too narrow in focus, later preventable tragedies which have had the same or similar root causes have continued to occur. Let us hope that ultimately Sir Martin has in his sights, not just better high-rise fire safety but the aim of creating a more effective culture of public safety in the UK, if not internationally too.
Roger Bibbings MBE, RoSPA partnership consultant
Posted: 9/15/2017 3:01:21 PM