A powerful address by former HSE chair Judith Hackitt in November – at a meeting of the Institution of Engineers in Scotland – offered what seemed a much-needed airing of the difficulties that prevent the learning of lessons from accidents, and a vision for how these can be overcome
Moral courage is not a core topic in the education of engineers, but those who heard Judith Hackitt speak on “Safety Leadership – a moral and ethical imperative” in Glasgow on 19 November may well be lamenting the omission.
Her speech pinpointed some of the reasons why, in her view, lessons are not learned from accidents. And this explains why the statement “there are no new accidents” continues to be true.
On the surface there seem to be prosaic reasons for this, including the fact that there can be long periods without accidents, when nothing much seems to happen. Then, there’s the tendency for corporate memory to be lost all too easily. Lawyers can be an obstacle too, when details can’t be shared publicly because of legal privilege.
“There are many many reasons why that [kind of] learning, that should be going on in our profession, doesn’t happen,” she said, and this is true even when it comes to understanding what exactly happened leading up to an accident – “the ‘what’”, as she summarised it. This kind of detail is obviously important, but there’s a grander prize in view, she seemed to be suggesting, by probing a bit deeper. “The better and more important lessons come from understanding ‘why’ incidents occur.” And this takes a lot longer to establish.
Rapid disassembly
Buncefield in 2010 – “the biggest peacetime explosion in the UK” – is considered to have happened because a level gauge failed, resulting in the overflow of an oil storage tank and the distribution of flammable vapour in the surrounding area. This accounts accurately enough for the “what” aspect. But why it happened – “an even more interesting story,” she said – had to do with poor communication and a lack of clarity in the various lines of responsibility that had a bearing on the handling of the material.
Because of difficulties reading the level gauge on a tank, and poor communication between di erent people, an operator had ended up using an alarm clock from home to time the transfers, and this had become the means of ensuring the tank did not overflow (and you can guess what happened next).
So, the reason why the accident happened, she said, was “management failure”, including “failure to notice the pressure the operators were under”, “turning a blind eye” to various uno icial practices, and failure to provide the requisite communication and oversight.
These sorts of lessons “are far more broadly applicable than the what,” she said, and offer insights that can be applied by people in all walks of life.
Ultimately, it comes down to leadership, and the need for people to recognize their responsibilities, and take proactive steps to ensure safety.
Learning hard lessons
Leadership, ethics and moral courage perhaps elude crisp definition. In Judith’s account it was about “being able to live with yourself”, a phrase that recurred throughout the night.
While engaged in a project in the past to formulate a statement of ethical principles for engineers, she recalled feeling that her fellow chemical engineers “seemed to have a better grasp of this subject than other engineers.”
This wasn’t because they were better, but was more about the hard lesons they had learned through tragedies like Bhopal, Flixborough and Piper Alpha – and a great many other incidents where leaks or fires have incurred loss of life or environmental damage.
She believed regulation was important. There are ways of designing a regulatory regime so that it encourages moral and ethical behaviour. But it’s also possible to come up with one that doesn’t, and even one which is open to being gamed to nefarious advantage – the VW emissions scandal is an example.
Moral and ethical behaviour can’t be encoded within a set of rules. This is true of road traffic regulations, where “the assumption is that we will all behave responsibly and drive appropriately for the prevailing conditions”. This motivation sits alongside “the rules we all learn by heart”, but it seemed to be a secret sauce that’s necessary for regulation to achieve its aim.
What had become increasingly clear to her, she explained, was that the more prescriptive the regulation, the less likely it was to produce a culture where people want to do the right thing.
Doing the right thing
A defining incident in early career seemed to have set Judith’s trajectory, in the form of an ethical dilemma faced while operations director at a pigment production facility in the 1990s. An incident occurred involving an operator who had attempted to unblock a machine using a scaffolding pole, and the resulting accident had caused “severe but not life-threatening facial injuries”.
Judith had volunteered to lead the investigation. When it came to light that the practice in question had been ongoing for some time, and that supervisors had turned a blind eye, she came under intense pressure to consider the wisdom of submitting an honest report, forces against which she seems to have refused to capitulate. As a result, the company was taken to court by the HSE and prosecuted. “I’m not going to pretend that was easy, by any means,” she said. Her testimony certainly gave a strong impression that – decades after the event – she was truly thankful for having told the truth.
Speaking truth to power is a big challenge for people in positions of responsibility. She cited recent examples like the Post Office scandal, decisions taken during Covid, and occasions when bad news needs to be delivered on the costs or schedules of infrastructure projects.
Culture shock: Grenfell
Facing down a great deal of opposition seems to be an item in her skillset, though her address was at times touchingly honest about the difficulties. These seemed particularly apparent following her appointment to lead a review of the building safety and fire regulations that had been in place during the 2017 Grenfell fire (distinct from the public enquiry report, of which more later).
It was clear to her, in the first few weeks after the fire, she said, “that poor practices in the design and construction of high-rise buildings were much more widespread than just one tower block in London.”
Maybe deepening the tragedy was the fact that many residents and others had raised concerns, but had not been listened to. Her methods seemed to eschew legal-document analysis in favour of the engineer’s approach. “I mapped out the regulatory system… In essence, it was a process-flow diagram… and it was pretty complicated.”
Then she asked people if this was how it worked in practice, noting that “at every point, I heard about how people bypassed or manipulated the system, and gamed the rules.”
She had met lots of people who seemed to feel bad about what had happened, many of whom were professionals who had realized the system was broken.
Some had tried to raise the alarm but not been heard. These people “found it harder to live with themselves”, she said, than those who had simply washed their hands of any blame.
One problem her review identifies is the tendency of people working in the built environment to see their part “out of context from the whole”, and not directly related to the outcome (which in this case might be “to deliver safe homes for people to live in”, as she put it). So someone working on a particular aspect of the design or construction of a building, or a capability like “fire stopping”, will lose sight of the bigger picture.
“That lack of connection to purpose really does underline why people do not feel morally and ethically responsible,” she said. And this allows them to point the finger at someone else. People seeking to blame others, she said, had been a bugbear when she chaired HSE, prior to her work on Grenfell. “It worries me greatly, the tendency today, for many people to seek to blame someone else and move on, rather than stopping, and considering honestly what they could have done, or might have done differently.” No-one learns from such a mindset, she said.
The need for a massive culture change in the sector is now widely accepted, but in 2018, the pressure was on to produce a quick fix. “People didn’t want to hear that ‘this is a complex system that needs to be fixed in its entirety’”. These had been “very challenging times”, not least when the report was published, “and I was met with some very mixed reviews”.
Concrete learnings
Her final report produced 52 recommendations, and insisted these be taken as a whole (not cherry picked) to provide a complete regulatory framework, a means to produce fundamental change. The new framework is now enshrined in The Building Safety Act. Under development are two sets of regulations, for Building Safety, and Construction Products, respectively. “Both have huge challenges ahead,” she said, but she was encouraged by the progress being made with the Building Safety regulations in particular.
Presumably this addressed some of the “how” aspects of Grenfell. The “what” has been distilled by Sir Martin Moore-Bick’s 1,700-page report, published in September, presenting the findings of the six-year public inquiry. Failures included (in Judith’s list): “systematic dishonesty”, “complicit behaviour by those who should have been acting as regulators”, “incompetence”, and “the folly of deregulation”. There had been “blurring of the lines between responsibility and oversight” (calling people “customers” rather than “duty holders”, etc).
“It shames us all,” she concluded, and it “should be the clarion call to look deeply at ourselves”. Even those not working in the built environment have an opportunity “to learn some very hard lessons”. Her own prescription for ethical leadership included “act in the public good”, “carry the weight of our responsibility” and “take pride in knowing we are doing the right thing”.
One simple formula I took away – from a night that was mostly about avoiding simple formulas and box-ticking – was that regulation is good if it encourages ethical behaviour, is focused on the desired outcomes, and constantly strives for improvement.
- The presentation “Safety Leadership – a moral and ethical imperative” was given by Dame Judith Hackett in Glasgow on 19 November, an event organized by the Institution of Engineers in Scotland (IES). You can watch the full video below.
