​In this section I will explore why we seem to fail to learn from the past. While public Inquiries and "lessons learnt" sessions are common, and while the public appeal for it (whatever 'it' is) to "never happen again", it does. The easy answer to why they do is to put these repeated failures down to the stupidity or negligence of those involved. However, we have to ask whether there is something deeper going on.

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Before this can be established the multiple purposes of inquiry each creating their own dynamics.  Some of these are:

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• The need to determine what happened and why.

• The need to give victims a voice (to let them be heard).

• The need to hold the system to account.

• The need to learn from this event.

• The conceptualisation that the Inquiry team had of their task and their analytical method.

• The accuracy with which witnesses could recount their actions and intentions on the night.

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On top of the internal dynamics are the external dynamics. While, in a perfect world, these should not influence the cause of the inquiry, in reality they are likely to have considerable effect. These may have included:

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• Lobbying by victim support groups.

• Lobbying by those likely to be held to account.

• Politicians for their own purposes.

• The press for its own purposes.

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These dynamics create an attractor that steers the Inquiry in an overall direction. What has to be questioned is the priority (energy) given to the desire to find the root cause behind the way those involved acted. One of the major dynamics of contemporary inquiries is the desire of victims to “see justice”.

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Of these purposes, my research focuses on whether Public Inquiries are a suitable vehicle to extract operational lessons and to provide useful recommendations about how the system might be improved. To this end, I am examining whether we might be able to judge the likelihood of recommendations achieving this goal.

 

My research to date suggest two factors work against us learn from the past; these are the very nature of the public inquiry and politics (both with a 'P' and a 'p'). These provide the themes for my research

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The theme running through all my work has been to seek ways to prevent organisational failure. Two key issues have emerged. The first concerns the complexity of everyday life; I examine this issue under the banner of "Normal Chaos". The second issue is our seeming inability to learn, at the organisational level, from previous experience. This failure leads to the often heard cry of "This should never happen again" or variants thereof. I will focus on this subject under the banner of "organisational learning".

 

As with all such fields of study, organisational learning contains many schools of thought. To me, the main focus of this field is on how the lessons from the past become embedded within an organisation.  Here the assumption is that we know what needs to be taught and it is this process of embedding the lessons that needs to be optimised. This is not my area of interest. My area of interest is how we extract lessons from past operations and turn them into an effective failure prevention tool - in particular those that enhance foresight and prevent the erroneous use of hindsight. My prototypical methodology for such work comes from air accident investigation practice which gives me hope that such organisational learning is possible.

 

As an example of such a tool, I would offer the one that I developed for use by an organisation's risk and audit committees. This can form a conversation around how many organisations' risk management processes had identified the threat posed by the likes of COVID19 and, if not, why not?  To address this question, I produced a discussion document which was designed to stimulate that debate.  As with most of my work in this area, the model is based is Barry Turner's Disaster Incubation Theory. [Why I chose this model is covered in some detail in my book "In Pursuit of Foresight".]

 

For the purpose of this work, the organisations that I focus on are public bodies. This is because it is these that are of most  interest to the general public. It is also important to note that I am not suggesting that there is not any learning taking place in such organisations for this would be wrong. One of my key assumptions is that, as individuals  and organisations, we aspire to learn from our past experience. I believe that, at an individual level we learn and develop on a daily basis. However, at an organisational level, we are less successful. I justify this statement within the context of the rest of my work which examines why organisations fail. In the opening pages of my book "It should never happen again" (published in 2013), I listed a series of statements from previous inquiries expressing regret that some organisation had failed to learn some pertinent lesson from the past.

 

This regret continues. Recently, in his Phase 1 Report (Published October 2019) on the Grenfell Tower Fire, Sir Martin Moore-Bick stated his regret that the London Fire Brigade had failed to learn the lesson from the 2013 coroner's report following the 2009 Lakanal House fire in Southwark, South London. At the start of the Manchester Arena Inquiry in September 2020, Andrew Roussos, whose  daughter was the attack's youngest victim, told the public inquiry that lessons  “should have been learned and in place” after 9/11 and subsequent bombings in London (7 July 2005). The effectiveness of the UK Government's response to the COVID19 pandemic has shown that, as a nation, the UK has failed to learn all the key lessons from previous pandemics despite being rank second for preparedness in the Global Health Security Index published in October 2019.

 

So why did organisations "fail to learn"? Alternatively, do these failures raise a larger question about the process of learning? Might we draw the conclusion from these repeated failures that the process for learning from such events is itself flawed? Are our expectations of what can be learnt, also fundamentally flawed? It is this issue, along with the harm it can do to society, that I want to discuss in the blog that follows. At this point I would wish to emphasise that it is the process that I am examining. Where I use examples it is only to illustrate my point. I do not wish for these to be seen as an attack on any individual nor that I would wish to advocate for any particular alternative conclusions to be drawn. All I am attempting to do is to suggest that the process as currently practiced may be leading us to draw false lessons.