It Should Never Happen Again

The Failure of Inquiries and Commissions to Enhance Risk Governance

Mike Lauder

• Publisher: Routledge
• Year: 2016
• Topic: Business
• eBook ISBN:
  9781317111726
• Subtopic: Business General
• Index: Business

In It Should Never Happen Again, Dr Mike Lauder questions the value of public inquiries. Every day, we hear about another inquiry being set up, or why the last one failed to deliver the hoped for outcomes. A great deal of time and taxpayers' money is spent on inquiries and even more on implementing their recommendations, but the author suggests that those conducting inquiries might be considered (by their own test) criminally negligent in the way they do so and that it is no surprise that they do not lead to the learning they should. The focus of Mike Lauder's research is the gaps between what is known, what knowledge is used by practitioners and those who judge them. He contends that the difference between the judicial perspective and that of practitioners who are judged by the inquiry process creates barriers that impede others from learning. Crucially, inquiry outcomes do not assist the leadership of organisations to improve risk governance. It Should Never Happen Again is based on research into high profile public inquiries and presidential commissions in the UK, the USA, Continental Europe, and elsewhere. Embracing issues ranging from terrorist attacks to pollution, fire and air disasters; criminal cases; banking and bribery scandals; and the state of public services, Mike Lauder contrasts the judicial perspective of those who inquire, the academic perspective of those who know and the practical perspective of those who are required to act, and offers new models for understanding risk and its governance.

1
The Complexity of Everyday Life

Introduction

“This must never happen again” is a cry often heard when someone or some group calls for an inquiry: unfortunately it, or something similar, often does but why? The desire that it “never happens again” is often accompanied by the desire “to learn from this tragedy”. However as Professor Brian Toft points out in his book Learning from Disasters1 we (organisations and society in general) continue to fail to learn from such events. Inquiries regularly lament such failures. For example, the Columbia Accident Investigation Board (CAIB) stated:

When changes are put in place, the risk of error initially increases, as old ways of doing things compete with new. Institutional memory is lost as personnel and records are moved and replaced. Changing the structure of organizations is complicated by external political and budgetary constraints, the inability of leaders to conceive of the full ramifications of their actions, the vested interests of insiders, and the failure to learn from the past.2

After citing the CAIB Haddon–Cave stated:

Changing the structure of organisations is complicated by external budgetary and political constraints, the inability of leaders to conceive the full ramifications of their actions, and the failure to learn from the past.3

A report by the Chief Medical officer (Liam Donaldson) in 2000 said:

Most distressing of all, such failures often have a familiar ring, displaying strong similarities to incidents which have occurred before and in some cases almost exactly replicating them. Many could be avoided if only the lessons of experience were properly learned.4

A report by the House of Commons, Public Administration Select Committee5 states that “preventing recurrence through learning lessons is a key success criterion for inquiries” but “that it is perhaps easier to identify lessons than to learn and act upon them”. Lord Donaldson adds that, “In one sense, ‘whistleblowing’ can be seen as evidence of a failure to learn.”6 So we can see that inquiries are held, large amounts of time and money are expended and we fail to learn and similar events happen again. This lamentable occurrence begs the question, “Why?”

Here is one example in order to set the scene for the rest of the book. On 1 June 2009, an Airbus A330-203 (registered F-GZCP) operated by Air France vanished while flying from Rio de Janeiro to Paris; its flight number was AF447. The investigation and report produced exemplified all that is good about air accident investigation. The persistence, tenacity and skills of the investigators are to be admired. This work was rounded off by a clear and comprehensive report. However the report held an uncomfortable truth. This truth was that the direction and recommendations from previous reports had had a significant role to play in this accident.

There can be no doubt about the role such accident investigations have played in making air travel safer. Many valuable lessons had been learnt over time. The technology used and the understanding of human behaviour have both been advanced by their work. However, what might be described as “the direction of travel” of this work has led the aviation industry into new areas of vulnerability. I look at two:

The first is the complexity of modern aircraft. Design has been improved, redundancies within systems have multiplied and automation has been used in order to prevent human error. The result of this trend is more complex systems where it is proving harder to spot mistakes in design, construction and maintenance prior to an accident. Some now argue that all that is occurring is that the mistakes which used to be made by the pilots are now made at the design stage. This is therefore not risk reduction but just risk transfer. Mistakes are still made that cause accidents, it is just that they now take place within a different discipline.

The second issue is pilot skills. As the systems on the aircraft, when working, can fly the plane within tighter parameters than the pilots (thereby saving fuel and money), they are used more often to fly routine sectors. In his book Antifragile, Nicholas Taleb, stressing a similar theme, quotes the US Federal Aviation Administration as saying, “Pilots often ‘abdicate too much responsibility to automated systems.’”7 This is seen to reduce a pilot’s inherent flying skills. As many of the systems are automated, the pilot becomes more akin to a system controller; the job of the pilot becomes one where they are required to arbitrate between system conflicts. To do this in real-time they will need to know the system design and weakness as well as, if not better, than the designer. The training required for their system management skills conflicts with their inherent flying skills (the proof for this lies within the ideas of “the magical number seven” and work on the viability of multi-skilling which I address later in the book). As a result there are conflicts between what system designers and operators require from modern pilots and, when the moment comes (as in AF447), the pilots were not able to comprehend and cope with the situation they face.

So who learns the lessons of flight AF447? While those directly involved will, we have to question whether these lessons will be applied to other areas of human endeavour. If they do, how will those who should learn from these events? How should those who examine these issues change the way they look at these issues in light of what we have learnt from Flight AF447? These are the types of question that I hope this book will inspire others to ask.

In this section, I start by looking at the practical problems under consideration. I then articulate the context in which this book is set and finally I will elaborate on my starting point which is within the overall concept of risk management.

LEARNING FROM THE TRAGEDIES OF LIFE

The problems at the heart of this matter are those corporate or societal failures that provoke enough vocal (or statutory) concern that it is decided that the source of the failure needs to be formally examined. These failures can come in many forms, some well known and widely reviewed and others less so. Amongst the best known and most widely researched events are:

• the Three Mile Island (1979) and the Chernobyl nuclear accident (1986);

• the chemical spill at Bhopal, India (1984);

• the destruction of the NASA Challenger (1986) and Columbia (2003) shuttle spacecraft;

• the Exxon Valdez (1989) and Deepwater Horizon (2010) oil spills;

• business failures such as Barings Bank (1995), Enron (2001), Worldcom (2002) the 2008 banking crisis;

• the 9/11 attacks on the USA in 2001.

Other equally interesting and informative, but not so widely researched, domestic and international inquiries include:

• the Laming report in 2003 into the death of a child;

• the Smith report in 2005 into the activity of a doctor who had been found guilty of killing his patients;

• the loss of the RAF Nimrod MR2 Aircraft XV230 in Afghanistan in 2006;

• the Donaghy report in 2009 into the underlying causes of fatal accidents within the UK construction industry;

• the attacks by Anders Breivik in Norway which took place in 2011.

As a result of these events and many other events that most people will have never heard of, codes of conduct and management systems have been devised as a way to enhance the effectiveness of management and prevent such events happening again. However, there are questions about whether the system that is currently in place works. For example, Unite’s Scottish Secretary, Pat Rafferty, said:

Time and time again we have been shocked by disasters such as the (tugboat) Flying Phantom and then angered by a system which has no defined structure to prevent a repeat of such an incident.8

The questions therefore become: “What is this system that fails?” and “Why does the system fail?” There is not space in this book to explore or even describe the system in place and all its intricacies. For the purpose of this book I shall give it the label of risk management which I see as embracing all the related disciplines of safety science, crisis management, business continuity, organisational resilience and high reliability to name but a few. However to call this collection “a system” is to stretch a point; I see a more accurate description as being a maelstrom. Within this maelstrom are processes which attempt to learn from the tragedies and disasters which befall us in order to prevent incidents reoccurring.

Erik Hollnagel,9 a highly respected author in this area, provides a history of accident analysis. In his text he explains how initially accidents were seen as an “act of God”, and how this evolved into a hunt for “cause and effect” linkages which, in their turn, were considered to be too limited by the underlying assumption of a “closed system”. Hollnagel’s argument is based on the concept that “open systems” are subjected to the influences (both weak and strong) of everything within their environment; this work might be seen to be part of what is referred to as a socio-technical design school of thought. Other academics10 also reject the “cause–effect” model as being too simplistic and use a system methodology in order to capture the complexity of interactions. Established authorities on management of risk11 also use a systems-type framework to provide “a structural tool to illustrate the … process, and not (as) an empirical model of how (in his case) communication is factually organised”.12 While Hollnagel and the others limit their theorising to the accident field and related subjects, I extend this logic to cover wider aspects of risk management in its most general sense. While it might not be clear from Pat Rafferty’s statement exactly what he meant by the term “system”, for the purpose of this book the idea is used in its broadest term of how things influence one another whether by design ...

Table of contents

• Cover Page
• Dedication
• Title Page
• Copyright Page
• Contents
• List of Figures
• List of Tables
• Prologue
• 1 The Complexity of Everyday Life
• 2 What Do We Know?
• 3 What Inquiry Reports Report
• 4 Quality of the Recommendations
• 5 Making Recommendations
• 6 Do We Learn?
• Annex: Recommendations Per Report
• References
• Index