The first part of the inquiry is to establish what happened, with a detailed timeline, how the response was organised and deployed, and the outcomes of dutyholders’ decisions and actions. The second part will explore the “why” questions.
We have had significant disasters in the past and as Winston Churchill is reputed to have said, we should “never let a good crisis go to waste”. Learning the lessons and adopting preventive measures is part of the memorial to those who lost their lives and their families.
But we must avoid the restrictions of OSH law before the Health and Safety at Work Act 1974, when every small failure quantified in statistics resulted in highly specific, narrow regulations. The law mandated the disinfection of imported camel skins to prevent anthrax outbreaks, then a separate statutory instrument to disinfect imported goat skins. There is a similar problem of scope when major inquiries’ findings and recommendations are limited to ships leaving port, systems on oil rigs, rail maintenance programmes, and so on.
There is a problem of scope when major inquiries’ findings and actions are limited to the ships leaving port, systems on oil rigs and rail maintenance programmes
Moore-Bick asserts correctly that there is an immediate need to establish what lessons we can learn to prevent re-occurrence and to safeguard those who live and work in high-rise buildings. But as Roger Bibbings, former director of OSH policy at RoSPA, points out, the work of phase two in uncovering root causes is crucial in protecting people from preventable tragedies of other sorts. Weaknesses in organisational safety culture and disdain for those at risk may affect other organisations and could express themselves in other disastrous ways.
Those seeking justice from the Grenfell Tower inquiry want to know what caused the fire to develop and the adequacy or otherwise of emergency action taken. But again we should listen to their voices – ignored by Kensington and Chelsea council and its tenant management organisation before the fire – calling for a root cause examination in equal forensic detail of why the pathways to disaster were not foreseen and blocked. The inquiry should not allow the mass of detail it will uncover to obscure the most significant failures, both technical and organisational.
The inquiries into major safety failures, including Aberfan, Hillsborough, Piper Alpha, Bradford City, King’s Cross, Ladbroke Grove and Southall, have shown repeatedly how tragedies involving multiple losses of life could easily have been prevented.
As a result we have a better legal framework and better systems for managing parts of our world, but the reports’ narrow focus means that new areas of risk are ignored and the next disaster is awaited, to be followed by its own inquiry. This time, let the Grenfell Tower inquiry set down a marker by detailing not just a pattern for improved fire safety in tower blocks but the development of a more effective culture of public safety, a culture no longer shackled by the ideology of deregulation or fatally weakened by a disdain for the views of those exposed to risks to their safety, health and wellbeing.