"It Should Never Happen Again" …
but sorry, it will!

Mike Lauder
Alto42 - Risk Performance Management Specialists

Let us try to understand why.

Whenever I hear someone uttering the phrase 'it should never happen again' (or some derivative of that phrase), I have to wonder about the nature of that person. After the work that I have done on organisational failure, I am left wondering whether that person is naive, pathologically optimistic (to put in another way, is suffering from a surfeit of optimism bias) or venal. To ensure that something never happens again we would have to produce a perfect system. None of my working experience tells me that this comes anywhere near being a realistic possibility. While I can understand why, in desperation, someone may hope for this to be the case, I cannot understand why the more rational parts of society would allow such an illusion to exist. Having said that, I have to acknowledge that I too, held this view in the past.

My doctorate focused on what was known about how disasters and other crises emerge. This was driven by the idea that if we were aware of their causes, we could prevent the next one.

This proved to be a flawed concept for two reasons.


  • The first flaw in my thinking was that most failures are due to the complexity of the systems in which they occur. They are often caused by several minor failures interacting in unexpected ways.


This work has led me to the view that I was looking at the issue through a faulty lens. I had been using what I have now come to know as the Perfect World paradigm. In essence, this way of seeing the world removes much of its inherent complexity. I therefore saw the need to try to develop a different way of seeing: one that embraced rather then rejected complexity. I have named this perspective Normal Chaos. How these two views co-exist I explain here.

My Aim


The aim of this website is to document my learning so that I can share it with others. In the past this would have been done by producing a book. As I have found, this is a lot of work and, as the author, the reward does not balance with the effort. I have found that using a website is now a better way of communicating my ideas with my collaborators and other interested people.

What do I get out of it?

I get two things from curating this site. The first is that the discipline of publishing in a public forum makes me think more carefully about what I say. The second is that, I hope, it will stimulate interesting conversations with like-minded people.

The website reflects my understanding at the time that I publish. I think that while some of my ideas may be useful to others, others will be flawed. I therefore invite anyone who feels that they have something to offer (such as corrections to what I have said) are most welcome to contact me via my "contact me" page.

Dr Mike Lauder


Website Structure

I have divided the website into three sections.

The first section "Risk Governance" describes tools that I have found useful when thinking about how we might manage risk and crisis. This section is meant to be useful to practitioners.

The second "Complexity Research" explores how I went about making sense of complex situations (such as everyday life). Much of the research into complexity uses quantitative methods (maths) to make sense of complexity. This is not how many people see the world. Therefore, my work focuses on ways of supporting a more intuitive way of seeing the world and making sense of it. This section may be of interest to those people who like to think about how we think.

The third Organisational Learning uses my analysis of Public Inquiries to show how their findings may be fundamentally flawed and to propose a new way of looking at this subject. I focus on learning operational lessons rather than legal or social ones. The subjects that I am following at present are the debate on the Grenfell Fire, the Manchester Arena bombing and the Government's handling of COVID19. This section may be of interest to those people who are concerned with why we fail to learn from the past: in particular why public inquiries fail to prevent similar events reoccurring.





'It Should Never Happen Again': Mike's first book is available from Gower Publishing.  

Details can be found on the publications page.

It should never happen again - book by Mike Lauder

'In Pursuit of Foresight': 

Mike's second book is also available from Gower Publishing.

Details can be found on the publications page.


My Focus on Catalytic Frameworks

Before you go any further, I feel it is important that I set out my approach to research as this will put what follows into context.  My approach is driven by the acceptance that we live and work in a complex world.


This complexity means that it can be very difficult to make sense of the world around us. As a consequence it also means that routines that have worked in the past may not work the next time they are applied. This is often due to some minor variation in the prevailing circumstances.

For practitioners, complexity means that they will, almost always, have to make decisions in less than ideal circumstances. Inevitably the circumstances surrounding the decision will be clouded with uncertainty. However much of the academic literature on how to manage such situations focuses on the removal of that uncertainty: I did not find this approach very helpful. I looked for another direction.


That direction was provided by John S Reed in his speech to the Academy of Management as their ‘Executive of the Year, 1999’. He stated:

We (as managers) have to do two things: we decide what to do, and we try to make it happen. If you boil down all of the practice of business, it is the combination of those two things and the interaction between them that defines the world in which we live.

He went on to suggest that:

All… research can do is inform us. It certainly does not give us answers.

From this I asked myself that if we researchers do not provide answers, how can we help? Of course, the answer came from Sir Winston Churchill.

After the fall of Singapore, Churchill is reported as having said: “I ought to have known… I ought to have asked”. More recently, in 2010, Lord Browne (when head of BP) is quoted in a newspaper as saying 'I wish someone had been brave enough to say "we need to ask disagreeable questions"'. I therefore looked to focus my research on helping practitioners ask better questions. However, before going down this route, I first checked whether there was any support for this approach already within the academic literature. I found that there was.

Karl Weick agrees that there is utility in academic work that “provokes” discussion (it ‘gets us talking, digging, comparing, refining, and focusing on the right question’). Peng and Dess also state that scholarship ‘can help managers frame issues, ask the right questions, and question their underlying assumptions’. Keith Grint promotes the idea of managers being 'investigators' (hunting for the truth) rather than 'experts" (knowing the right answer).


I have therefore set the purpose of my research as being to provide “good questions” that provoke animated risk discourse. The issue then became one of how to do this. Within academia there is a wide range of models and frameworks; these are used to describe how a system works or they are designed to predict what will happen within a system. Neither of these suited my purpose. I needed something that provokes questions in the way described by Weick. I therefore now refer to the frameworks and models that I produce as being Catalytic Frameworks. I see these as being ways of promoting foresight.

I am aware that there are many different ways of looking at any single problem and many different ways to solve that same problem. With this in mind, I therefore expect (and hope) that people reading these pages will question what I say for this is my purpose. I hope that what my work does is to provide a framework for the discussion that enables diverse groups to reach levels of cross-understanding sufficient to achieve their goal and to avoid the many pitfalls en route. While the advantage of having a diverse range of opinions (providing requisite variety) is that it is one way of avoiding groupthink, the downside is that it is hard for the group to align their mental models of any situation.  I believe that this approach can help.

If you have any ideas how we might do better, please let me know. 

As of 27 Nov 21

In the last month I have reshaped my website and it is now in its new configuration.

I have reconfigured my framework for the analysis of recommendations to provide a more repeatable and robust methodology.

I have added my analysis of the "independent review of the UK response to the 2009 influenza pandemic" produced by Deirdre Hine published in July 2010. This report is important because it sets the scene for the UK Government's 2011 Pandemic Strategy.

I have re-analysed the recommendations produced in the Sixth Report of the Health and Social Care Committee and Third Report of the Science and Technology Committee of Session 2021–22 – Part 2 Assessment: "Coronavirus: lessons learned to date" produced on 12 Oct 21. The result of this work is that I have changed about 20% of the categorisation of recommendations.

I have started my analysis of the Francis Report into the Mid Staffordshire NHS Trust. My analysis of his 2010 report can be found here


On 27 Nov 21 I reconstructed my methodology for analysing recommendations. I reversed the order of the steps to be taken. I now recommend that you first deconstruct each recommendation (Part 1) and then categorise them (Part 2). I am now in the process of updating the illustrations on this site to conform to this new methodology. However, as I may have missed some, please check whether the page you are looking at has been updated (that is, dated after 27 Nov 21).


Last Update; 27 Nov 21