It will take months of hearing statements, studying legal documents, and analysing the evidence before the lessons of Grenfell are understood. However, some of the instinctive reactions to Grenfell illustrate a human tendency we must be aware of when looking at accidents in our own workplaces. When someone is hurt, or even when equipment is damaged, our human instinct is to look for someone to blame. It is unlikely our workplaces would have events on the scale of Grenfell, but consider an accident typical in manufacturing. Imagine a worker loses a finger in some machinery. A common first reaction is to blame the worker for having her hand in the wrong place. But the worker was told by her supervisor that he’d switch the machine off so that she could lift the guard and unblock the machine. So it was the supervisor’s fault for failing to isolate the machine properly? But the supervisor was following a written procedure for isolation, which didn’t mention the need to lock out the power to avoid inadvertent switch-on. Who wrote the procedure then? It must be their fault. The consultant who wrote the procedure wasn’t allowed any time to talk to staff or study the machinery, but was given the original manuals which described an interlock, so it should have been impossible for the machine to start up with the guard up. Who do we blame now? Did someone give the consultant the wrong manual? Had someone decided on some modifications to override the interlocks to improve efficiency? Whose fault was that – the person who suggested the changes, the one who implemented them, or the management placing pressure on the workforce to get more done?
If such an apparently simple case can end up with such complexity, how much more complicated will the Grenfell enquiry be? The press has been ready to blame the contractors who installed the cladding panels. But if the contract was accurate about the materials being used will the blame fall on the procurement process at the council? Or, considering the pressure on hard-pressed councils to save council taxpayers’ money, should we blame central government for cuts to council funding? Since no one group of legal experts, construction specialists, or fire professionals can agree on what the regulations require to demonstrate “limited combustibility” will the blame be placed on those who wrote or approved the regulations? Or on those who place pressure on civil servants to make sure regulations don’t apply “unnecessary” burdens of red tape on businesses. The approach of offering multiple alternative routes to compliance was supposed to encourage innovation, but will those who produced the related building regulation document (known as Approved Document B) that referred out to over 90 other documents now be criticised for not proposing one simple approach?
Hindsight should not be used to blame people for actions that occurred at some point in a chain of events preceding an accident – actions for which they might have been rewarded before, such as saving money, or making a process quicker. We should consider the decisions made in the context of the information available to people at the time. In our manufacturing example the important question is not “looking back, who do we blame?” but “looking forward, what can we learn to prevent future harm?” In the machine guarding case, the answers are well understood and revolve around standard health and safety management systems. The solutions to Grenfell will be more complex and take longer to determine, but I hope the inquiry doesn’t focus on who to blame for past decisions, and instead asks questions that focus on improving the future.