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Risk Governance Management Specialists

It Should Never Happen Again …

but sorry, it will!


Let us try to understand why.

Welcome to my blog


We fail to learn from the past and we wonder why. This purpose of this blog is to exchange ideas on what needs to change if we are not just to repeat our past mistakes.


I have been researching this subject for over ten years. In my first book, published in 2013, I explored the type and quality of recommendations made by public inquiries.  What became clear is the gap between the aspiration of the various recommendations and the likelihood that they will achieve their aims. Since that time, I have been examining what needs to be done if we are to learn from our practical experience.


At the time I started this blog the calls for society to learn where focused on the Sir Martin Moore-Bick's inquiry into Grenfell Tower fire, Sir John Saunders' inquiry into the Manchester Arena bombing and the COVID19 pandemic. I will use these cases to illustrate my arguments.


As the COVID19 crisis developed, I considered it to offer a valuable case study as it was developing in real time. This enabled the roles of foresight and hindsight within the learning process to be examined. Aware of the limits of my own expertise, I approached Professor Nigel Lightfoot CBE for his expertise in public health matters:   Nigel is a former Director of Emergency Response at the Health Protection Agency and now has his own private company where he continues to focus on emergency preparedness, crisis management and  the CBRN terrorism threat.

Submission to House of Commons Select Committees (Dec 20)

By alto42, Dec 14 2020 11:37AM

In November (2020) the Health and Social Care Committee and Science and Technology Committee announced that they were holding a joint inquiry into lessons to be learned from the response to the coronavirus pandemic so far.

The Committees stated that they would jointly conduct evidence gathering sessions examining the impact and effectiveness of action taken by government and the advice it had received. They listed eight topics that they intended to examine. One of these was the ’UK’s prior preparedness for a pandemic’. As the subjects of learning from crisis and preparedness for crisis are central to the research that Nigel and I are conducting, we decided to make a submission. (The full submission, that had to be brief, can be found here.)

We are concerned that this committee will repeat the mistakes made by other such inquiries and that they will fail to take on board lessons readily available to them from the past. Our proposition is that, if our theory of failure is valid, then we will see evidence of the following behaviours:

… We will see basic elements of crisis management and other issues (already well understood by subject specialists) taken as being new learning. This would support the proposition that the learning point was not new and that the organisation had already failed to learn from the past. The question then becomes, why should they learn the lesson this time?

… We will see little effort to understand the system as a whole and to understand how the various elements (components) interact: that is, little effort to map the interdependencies between those elements that are a key feature of these complex systems.

… We will see single point errors identified and solutions offered: that is to say, the implicit assumption will be that the process can be perfected by finding remedies that have caused it to be imperfect.

… we will see better learning around tangible technical issues that we will around less tangible social (management) issues.

… We will see hindsight and foresight conflated and therefore a poor appreciation of the quality of the information available to decision-makers. The perfect world paradigm assumed perfect knowledge whereas normal chaos assumes imperfect knowledge. To learn from the past we must learn to cope, as best we can, with imperfect knowledge.

… We will see poor appreciation of the implications for future crises of the information provided by the witnesses.

… We will see evidence of politics and blame culture that is known (and well documented) to be detrimental to the process of learning.

Over the period of these committees holding their hearing and making their report, we will be reviewing the evidence and the final analysis to see whether it supports or invalidates our propositions.

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