Two Inquiries Reveal Two Approaches
Voicing the nation's outrage – a courageous commissioner
can hold individuals who betray the public trust to account
in clear, unequivocal language
Two Inquiries Reveal Two Approaches
Scathing Analysis, Leaden Prose
This editorial appeared in
The Toronto Star
Friday, 5 December 1997
In the past nine days, two commissions of inquiry have released reports on appalling tragedies. One bristled with righteous anger. The other was cautious and plodding.
Judge Peter Richard of Nova Scotia, who spent 5½ years investigating the Westray mine explosion, which killed 26 men, delivered a scathing analysis of the slipshod management, bureaucratic apathy, and corporate greed that led to the disaster. He identified culprits, tore into complacent government departments, and questioned the behaviour of politicians, all the way up to former premiers John Buchanan and Donald Cameron.
Judge Horace Krever of Ontario, who spent 4½ years probing the contamination of the blood supply which triggered a lethal epidemic of AIDS and hepatitis C, issued an exhaustive chronology of what went wrong written in leaden prose. He named individuals and laid out their actions in meticulous detail. But at no point did Krever say that anyone had failed the victims of the tragedy, endangered public health, or shirked his or her responsibility.
The difference in approach can be summed up in two telling quotations:
The message is basically the same. But Richard's words pack a powerful emotional punch. Krever's are prudent and passionless.
- Richard: "It is a story of incompetence, of mismanagement, of bureaucratic bungling, of deceit, of ruthlessness, of cover-up, of apathy, of expediency, and of cynical indifference."
- Krever: "When there was reasonable evidence that serious infectious diseases could be transmitted by blood, the principal actors in the blood supply system in Canada refrained from taking essential preventive measures until causation had been proved with scientific certainty."
Both were constrained by mandates that prevented them from accusing any individual of criminal misconduct. But Richard used every inch of latitude within those boundaries, describing Westray executives as "uncompromising and abusive," mine managers as "aggressive and authoritarian," and government safety inspectors as "submissive and apathetic." Krever took no such risks. The strongest phrases he used to describe key players in the blood scandal were "slow to react" and "lacking independent judgement."
Granted, an explosion in a coal mine and the contamination of a nation's blood supply are tragedies of a quite different magnitude. Richard was looking into a local catastrophe that involved a limited number of people. Krever was probing a national scandal of unknown proportions that stretched over almost a decade and involved hundreds of people. This may account for the sharper focus and clearer narrative line in Richard's report. But it does not explain the difference in tone, philosophy, and the characterization of individuals.
Part of it comes down to the personality of the author. Richard is a man who believes in the power of words. Krever prefers to make his case with encyclopedic detail. And part of it reflects a difference in objectives. Richard wanted to remind Canadians forcefully that badly run workplaces can be death traps. Krever's intent was to provide the definitive record of a public health disaster.
What can we learn from this tale of two inquiries?
Just when public patience is about to wear thin, a judge like Richard will stand up and say fearlessly: This was a preventable tragedy. Here's where the wrongdoing occurred. Here's how to make sure it never happens again.
- While it is not, and should not be, the job of public inquiries to assign criminal responsibility, a courageous commissioner can hold individuals who betray the public trust to account in clear, unequivocal language.
- Part of the purpose of an inquiry into a deadly debacle is to voice the nation's outrage and show the families of the victims that their loved ones did not die in vain. In order to do this, a commissioner needs to go beyond a mere compilation of the facts.
- Governments should set out as precisely as possible what they expect a commission to accomplish, how soon it should report, and how much it can spend. Both the Richard and Krever inquiries took too long and cost too much. By the time Krever delivered his recommendations, Ottawa and the provinces had worked out a plan to overhaul the blood collection and distribution system.
- Finally, it's too soon to bury commissions of inquiry. Although several recent ones have been plagued by legal challenges, budget overruns, missed deadlines, and internal feuding, they remain one of the best tools governments have to ferret out wrongdoing and propose reform.
Go To: Westray Scrapbook Fifty clippings about the Westray coal mine disaster
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