The main value of the joint report by the Health and Social Care and Science and Technology Committees, though, is in demonstrating precisely how the public inquiry should not proceed. There may be therapeutic value in airing grievances but this does not help us understand what has happened.
Over the past 50 years, social scientists have learnt how organizations fail. There is a substantial body of work on construction failures, nuclear accidents, and, most notably, the 1986 explosion of the Challenger space shuttle.
You would not know any of this work existed if you read the report. But it provides an essential foundation for the inquiry.
The core finding is that the world is full of accidents waiting to happen. This is the natural state of things. Mostly, these events do not occur because humans build prevention into their daily actions.
But some risks are so novel or have such serious implications that we should go further. We need systematic ways of identifying gaps in our knowledge, filling them, and then thinking about how to improvise in the face of new challenges.
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