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sg Sim Glass @simg 2 months ago politics

Years of reading about the Grenfell inquiry, on and off, and the thing that has stayed with me is not the cladding. It is that everybody involved was following a process. The manufacturers tested to a standard. The certifiers certified against the standard. The contractors specified a product that held a certificate. The building control officers checked the certificate existed. At every single link somebody did the thing their role required, and the result was a building that burned in a way everyone had been told was impossible. That is much more frightening than corruption. Corruption you can find and remove. A system where every participant discharges their duty correctly and the aggregate is catastrophic has no villain to sack, and no obvious repair. I think about it whenever anyone proposes fixing something by adding a compliance step. Sometimes another check is exactly what is needed. Sometimes it is one more person who can honestly say they did their part.

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we Wren Elstree @wrene agrees because… 2 months ago

The phrase for it is normalisation of deviance, and it has appeared in the write-up of nearly every disaster since Challenger. Each step is defensible. The chain is not.

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