Three quotations appeared, apparently by coincidence, in the
Times on the day that the Police Commander at the Hillsborough football
disaster was reported as cleared of manslaughter:
“I would like to know who is
responsible for my father’s death because someone is.” Christine Burke, from the public gallery
after the judgement by Mr Justice Openshaw.
“Name the greatest of all the
inventors. Accident.” Mark Twain.
Never attribute to malice that
which can be adequately explained by stupidity or incompetence. Hanlon’s razor.
Mr Duckenfield’s defence argued that he had done “what he
was expected to do in difficult circumstances.”
I conducted two major Boards of Inquiry into aircraft
accidents; one in which there were no survivors to tell their side of the story
and the second in which political considerations, eventually, trumped reason
and fairness. In both cases I had to
negotiate the fine line set out in my terms of reference: distinguishing the determination
of the cause with apportioning blame, if any.
Determination of the cause relies on pure logic and a
painstaking process of analysis of the facts.
There can be no conjecture – either something happened as a result of
something or it didn’t. When we come to
apportioning blame subjectivity inevitably arises and it follows that one man’s
interpretation could be open to challenge from another. Did a human act or
omission either cause the accident or made the consequences of the accident
more severe? In identifying a human act
or omission was it reasonable to have expected the individual to have acted otherwise
(according to the standards and criteria of the time)? Difficult territory indeed and probably the
subject of ongoing disagreement, regardless of the judgement.
My wife suffered the trauma of losing her first husband in an
aircraft accident, the 48th anniversary of which is shortly to
arise. Historians might examine that Board
of Inquiry and, even by applying the standards of the time, conclude that the
tragic events arose through more than misfortune with hubris and stupidity to
the fore. Joan has the same suspicions
but, long ago, decided that nothing in the future could change the past and got
on with her life accordingly. I am most grateful.