Are Inquiries fit for purpose?

Does the Grenfell Tower tragedy reveal a need for an inquiry into inquiries?

The COVID19 era demands that we review and prioritise everything according to its societal value and this includes close examination of the instruments and processes of governance and management which are the principal root causes of organisational underperformance and failure. It is timely and legitimate for society to seek better, quicker, and cheaper improvement processes and question why we are still ritualistically conducting cycles of costly protracted official inquiries that deliver essentially the same recommendations regarding effective prospect and risk governance and management. E.g. when was the last inquiry that did not say there was a problem with the culture. We do not need protracted and costly judge led inquiries to keep rediscovering already existing expert knowledge and avoidably continually re-exposing those tragically involved depriving them of much needed closure. Governments of whatever persuasion just need to ensure the existing expert knowledge is systematically and competently applied everywhere it is relevant.

The UK Grenfell Tower tragic fire , which is now three years past, had many familiar root causes like other tragic events that have punctuated our history. Our understanding of major hazard governance and management is now highly advanced following many years of analysis of major loss events. The development and accumulation of such knowledge has been painful, and it would no doubt be a societal sin to fail to apply it wherever it can safeguard human life and other assets. The Grenfell Tower inquiry is unlikely to add to this knowledge apart from acting as another example of governance and management failing to implement that knowledge. Most of our major hazard industries in the United Kingdom now rigorously and systematically apply this expert knowledge within fit for purpose regulatory and licensing arrangements, but somehow general major hazard infrastructure capable of killing large numbers of people in a single event and/or destroying valuable infrastructure and has escaped effective risk control.

Given the tardiness of the Grenfell Tower Inquiry to complete its investigations and deliver a report, which even then is likely to restate the timeless wisdom of effective risk governance and management, it is right to ask whether ‘an independent enquiry into inquiries’ is needed examining their poor performance? This would identify not only the root causes of underperforming post event inquiries and investigations but the motivations for initiating them in the first place. After decades of official independent judge led inquiries, can they be more than just a political expedient to kick issues into the long grass? What stakeholder benefits, if any, can accrue and does the process of realisation compared with alternative improvement processes represent stakeholder value for money? It should also look at the uniqueness and relevance of the recommendations – has there ever been an enquiry that did not list the culture as being a root cause. Afterall, the reasons for organisational failure and accident causation are now very well understood.

The protracted conduct of the Grenfell tower fire enquiry surely compounds the initial shame that circumstances were tolerated allowing it to happen. Why was not investigating the root causes of the event and preventing re-occurrence made the top priority and why couldn't the enquiry have been split into pre-event and post-event sub enquiries and conducted concurrently? When will we acknowledge that inquiries and investigations are projects and need competent project management skills and the application of project risk principles? Would it be better if professionals other than judges led enquiries into major loss events with broader competences to expedite improvement, preventive actions, and societal learning? This would not preclude legal and other experts from participating in the inquiry processes.

From the first sight of the flames traversing up the side of the Grenfell Tower viewed on our televisions in real-time, it was obvious that a major hazard event was taking place, many people appeared to be in great danger, and something had seriously failed for it to be happening. Since the fire occurred over three years ago, there has been considerable debate and dialogue about preventing a reoccurrence of the tragedy with many well-intentioned suggestions and others serving narrower interests. However, if we accept that the creation and maintenance of infrastructure capable of killing large numbers of people in a single event is a major hazard industry, all that is needed is to simply acknowledge it and manage it like any other major hazard industry. We simply need to transfer the proven knowledge, expertise, and regulatory methodologies from the established major hazard industries. This includes fully integrated management systems without boundaries , proportionate infrastructure hazard classification, the graded application of risk control, the establishment of approved expert peer reviewed safety cases, where appropriate ‘defence-in-depth’, and life-cycle responsibility and accountability etc. Governance and management should be conducted utilizing a fully integrated management system complying with a universal management system standard such as MSS1000 integrating prospect and risk management . All this could be encapsulated in a single simple inquiry recommendation without further delay.

The additional costs of proper regulation and licensing should be factored into planning decisions, just as we do in other major hazard endeavours. This helps ensure that the needs, expectations, and aspirations of stakeholders are equitably satisfied while making the best use of resources – the foundation principle of integrated management . This point in human history demands that we achieve more using less resource by sharply focusing on what delivers the most value. Those who by desire or of necessity make their homes or work or participate in leisure pursuits in major hazard infrastructure deserve no less.

Those interested in joined-up thinking approaches to governance, management and problem solving may care to:

• Visit www.integratedmanagement.info
• Join the Integrated Management Community LinkedIn Group
• Download the free Universal Management System Standard MSS 1000