Investigations into tragedies such as the Grenfell Tower fire need to look at the root causes of the incident so lessons can be learned to prevent a re-occurrence, says Lawrence Waterman.

One of the common experiences of older safety practitioners is the frustrating sense of déjà vu when reading accident investigation reports. They often immediately home in on the immediate, proximate cause, such as a worker not following the specified work procedure, and define the preventive action as re-briefing, retraining. When you concentrate on the moments before the accident, it is usual to identify something that the people about to be caught up in it could do differently to prevent it.

As has been well-argued by academics like Hollnagel in his Safety-I and Safety-II, the past and future of safety management, it is rarely the case that, if you ran the clock backwards and then forwards, you would always get to the same point, there are so many contingencies and factors at play in even everyday tasks.

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