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.

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.

Go To:   Westray Scrapbook Fifty clippings about the Westray coal mine disaster
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