Issues and lessons from fire inquiry tribunals

Abstract

PurposeThe purpose of the research is to identify the phases associated with the development of disasters, understand their underlying causes and learn lessons from them.Design/methodology/approachUsing a grounded theory approach, reports of the tribunal of inquiry into the three fire disasters in the country were used to analyze the data.FindingsData demonstrated that these disasters were not sudden cataclysmic events but developed in phases. Pre‐disaster period is found to consist of four phases, namely, operation, incubation period, forewarning and activation. The onset was found to be caused by active errors while the underlying causes are attributed to the latent errors. These latent errors accumulated within the organization during the incubation period. Emergency response was poor due to lack of knowledge on emergency response, inadequate safety and emergency planning and insufficient equipment. Ensuing these disasters, there were establishment of social entity, formulation of new legislations, or amendment of laws and regulations took place in the society.Research limitations/implicationsThe disaster developmental and error model proposed was based only on three major fire disasters and future studies could corroborate the model using other types of socio‐technical disasters. the vast majority of incidents could be foreseen early and could have consequently been prevented by proper application of existing experience and dissemination of learning from past events. Understanding of the development and causes of the disasters provides a tool for organizational and institutional diagnosis of vulnerability and risks.Practical implicationsBesides the negative impacts of disasters to the life and properties, they present rare windows of opportunity to learn from past mistakes, make improvements for the future and prepare to avoid future crises or minimize the impacts if they occur.Originality/valueThe paper substantiates and extends the developmental theory of disaster and systemic approach of disaster error. The hindsight gained from these negative events could be utilized by government and enterprises, particularly the safety and emergency managers, to design organizational structures that will help reduce the likelihood of disaster as a nation progresses.