Ethics Series: Did you sleep well?

Article by Dame Judith Hackitt FIChemE

Speaking the truth when others don’t want to hear has to be part of our DNA as engineers, says Dame Judith Hackitt

BACK in April 2013, just weeks before I became IChemE President I attended and gave a presentation at the Hazards Asia Pacific Conference in Kuala Lumpur. One of my fellow speakers at that conference was John Bresland, former Chair of the US Chemical Safety Board. The key message of his speech on that day has stayed with me. It wasn’t about learning lessons – although he talked about that a lot. What I remember was John telling us all that “leadership often comes down to making a choice between making decisions that are expedient and what people want to hear versus making decisions that may be career limiting in the short term but which will enable you to live with yourself and sleep easy knowing you’ve done the right thing.”

Less than 24 hours after hearing that memorable insight, I found myself standing in the lobby of the hotel, alongside John, watching a TV screen showing the horrific explosion which had occurred at an ammonium nitrate facility in West, Texas that very day. Perhaps unsurprisingly, a few short weeks later my Presidential address featured the history of the tragic catalogue of ammonium nitrate incidents and a theme I would keep returning to in the years that followed – there are no new accidents – just different people making the same mistakes because they haven’t learned.

For me, being able to live with yourself and the decisions you have taken, lies at the heart of responsible ethical leadership. I believe our profession has come a very long way in recent years in seeing the importance of its role in delivering solutions for society’s benefit. I had the privilege of being involved in some of the early work done by the Engineering Council and the Royal Academy of Engineering in developing a statement of Ethical Principles for all Engineers. I can remember feeling at the time that we as chemical engineers seemed to have a greater awareness of ethics than some other branches of engineering. That’s not to say I felt we were on the moral high ground and knew all the answers. It was much more that we had learned some very hard lessons in our branch of engineering through tragedies like Bhopal, Flixborough, Piper Alpha and many other explosions, leaks, and fires which had led to loss of life or environmental damage. Perhaps we had been forced to face up to the need for us to act responsibly and ethically earlier than others. It is certainly the case that we were among the first to be subject to regulatory regimes which made us think about what harm could occur and how we should mitigate the risks.

Wanted: Protestors demanded the arrest of Warren Anderson, CEO of Union Carbide, following the fatal Bhopal disaster

Regulation and self-regulation

You would probably expect the former Chair of the UK Health and Safety Executive (HSE) to stress the importance of regulation in driving the right (good) behaviours, but I am also acutely aware of the limitations of regulation. This dates back to long before my HSE days. Regulation provides a framework that should encourage good behaviour, penalise those who behave badly, and deliver good outcomes for everyone. Prescriptive rules-based regimes do not encourage responsible behaviour and often leads to gaming of the rules. That is true of health and safety regulation but also equally true for environmental regimes (think about Volkswagen and emissions) and road traffic regulation (speed limits are limits ie maximums – but they require us all to behave responsibly and drive appropriately for prevailing conditions such as rain, snow and fog – that’s the self-regulation part).

Today, when we talk about health and safety leadership and culture, many people refer to a maturity scale where achieving compliance with regulation is one of the lowest levels of performance. Real safety leadership comes from a deep-seated and passionate belief that everyone who comes to work in any role has the right to go home at the end of every working day unharmed by their work. For many of us, as chemical engineers in high hazard industries, that same passion extends to believing that those who live around us and who use our products must also reap the benefits whilst not being harmed or put at risk. Motivations really do matter – doing it because someone tells you what’s right and you feel obligated to comply to avoid punishment is very different from doing the right thing because you know it is right and you want to act responsibly and with integrity.

We as chemical engineers seemed to have a greater awareness of ethics than some other branches of engineering... perhaps we had been forced to face up to the need for us to act responsibly and ethically earlier than others

Michael Sohn/AP/Shutterstock
Emissions scandal: Martin Winterkorn (front right) former CEO of Volkswagen arrives for questioning in the German parliament

Doing the right thing

It is perhaps prescient that one early ethical dilemma I recall from my career was related to health and safety.

It was back in the 1990s when I was Operations Director of a pigments production facility. We had recently completed a project to install a new dry blending and milling facility and were experiencing teething problems during commissioning, with parts of the equipment blocking up. An incident occurred which resulted in the blending operator receiving severe, but not life-threatening, facial injuries. It could have been much worse.

We reported the incident to the Health and Safety Executive but also launched an internal investigation which I decided to lead myself, given the seriousness of the incident. It emerged that the operator’s injuries had been caused by using a scaffold pole to try to clear blockages in the blending drum whilst the drum was still rotating. The pole had become stuck and whipped round hitting the operator in the face. But what also became clear during the investigation was that this practice had been going on for some days and some supervisors and the commissioning engineer were aware that it was happening.

I wrote up my report on the investigation and sent it to my Managing Director. I then received a call to meet him. He asked me to “think very carefully” about the wording of my report and asked if I was aware that by admitting that someone knew about the poor practice before the incident, it would be very likely that we would be found guilty in any prosecution brought by HSE. The pressure was clear but I didn’t have to think for very long. The report went out in my name unchanged. The company was duly taken to court by HSE where we pleaded guilty to the offence – and rightly so.

I am not going to pretend that it was an easy decision to take. It wasn’t. I certainly felt under pressure to take a different course of action but I also do still remember that “think very carefully” coming back into my mind vividly when John Bresland talked about being able to live with yourself rather than giving in to what people want to hear.

When I was Chair of HSE I talked a lot about the need for real leadership and commitment and the need for personal integrity. I also struggled a lot at that time with those who tried to rationalise away why it “wasn’t their fault” that something bad had happened, even when they were clearly responsible. I never referred to my own story during that time, but for me, my commitment to doing the right thing was rooted in personal experience.

Thabo Jaiyesimi /
PA Images / Alamy Stock Photo
Grenfell: Judith Hackitt chaired a review of building regulations in the wake of the tragedy

Grenfell truths

Almost five years ago, and after I had left HSE, I again came into very close contact with the subject of ethics on both a professional and personal level. Having spent close to a decade championing the importance of both people and process safety and the need for strong leadership I encountered a shocking culture when I undertook the independent review of Building Safety and Fire Regulations in the wake of the Grenfell Tower tragedy in the UK.

As a reminder, my brief – from the then Secretary of State – was to conduct a review into the regulatory system, not to review what happened at Grenfell specifically. (That is the subject of a Public Inquiry which is ongoing and which repeatedly provides further shocking examples of unethical behaviour on a weekly basis). In the first few weeks after the tragic fire it became clear that poor practices in the design and construction of high-rise buildings were much more widespread and also that many residents and others had raised concerns about numerous buildings but their concerns had not been listened to.

The way in which I undertook the review owes a lot to my training as a chemical engineer. I needed to understand how the regulatory system was supposed to work and then find out what was happening in real life to understand what had gone wrong. I mapped out the regulatory system – in essence a process flow diagram – and it was very complicated. I then asked people if that was how it worked, and at every point I kept hearing how people bypassed or manipulated the system, gamed the rules – I called it a race to the bottom.

I met a lot of people who felt really bad about what had happened – many of them professionals who felt bad because they knew long before Grenfell that the system was broken and that bad practice was rife but they didn’t speak up. Those who did speak up felt that they’d “done their best” but nobody was listening. This raises a really crucial leadership question – is it enough to raise concerns if nothing is done about it? When a tragedy occurs, as it did at Grenfell, believe me, the people I spoke to who had not been heard found it harder to live with themselves than some of those who chose the “it was somebody else’s problem” (head in the sand) approach.

As the weeks of my review went by I was repeatedly struck by the lack of connection to and sense of responsibility for the final outcome – and by that I mean the intended outcome of delivering safe homes for people to live in. That lack of connection to purpose meant no one felt morally or ethically responsible and pointed the finger of blame at everyone else.

My final report recommended fundamental change to the regulatory system, which in turn needs to drive a massive culture shift and change behaviours within all parts of the industry. I was clear in my request to Government not to cherry pick from the 53 recommendations but to deliver systemic change by implementing them in full. I am pleased to say that the new regulatory framework is well advanced and the Building Safety Bill is well advanced in its passage through Parliament. We are going to see two new regulatory bodies here in the UK – the Building Safety Regulator and a new Construction Products Safety Regulator.

The way in which I undertook the review owes a lot to my training as a chemical engineer. I needed to understand how the regulatory system was supposed to work and then find out what was happening in real life to understand what had gone wrong

There has also been significant movement in culture and a handful of people standing up to lead the way forward. These are the true leaders – the ones who are doing the right thing because they know they should have been doing it before – they have learned the lessons and are putting things right. I suspect these leaders have done a lot of heart searching after Grenfell and want to regain trust for themselves, their companies and their profession. They know that to do this they have to follow ethical principles and show that they care about achieving the right outcomes for society whatever their role in the system. There is still a long way to go to deliver the culture change in full across the whole sector but with leadership from within the sector and a good regulatory framework I am confident we will get there.

One of the sadnesses for me in conducting the Building Safety review was the discovery of just how much of the knowledge which is core to our discipline and which has been embedded in us as chemical engineers for years by Trevor Kletz, John Bresland and others is not familiar to other engineering disciplines. That is not to say that I think we have the monopoly on good practice but rather that it points to a failure to share our knowledge more broadly and perhaps also to seek out where we can learn from others. Strong ethical leadership includes humility and being able to admit what you don’t know and when you need to seek help and inspiration.

It never occurred to me to turn down the invitation to conduct the independent review. I felt a strong sense of wanting to understand how such a tragedy could have occurred and to do what I could to make things better. But there was no shortage of “advice” to not take it on. Despite the progress we are making, there have been challenging times for me as a leader. None more so than on the day when my final report was published and was met with very mixed reviews. I was under huge pressure from many stakeholders throughout the review to “ban cladding” because that would fix the problem. It was abundantly clear to me then that the problem was much bigger than that. With the passage of time – and as others have learned more about the scale of the problem and the revelations from the Public Inquiry have shocked more and more – there is widespread acceptance of the need for culture change and a very different regime. But at the time – back in 2018 - that was not what many people wanted to hear. They wanted a simple, quick fix – and I was unable to offer that.

Ethical leadership, speaking truth when others don’t want to hear, can often be very hard but it has to be part of our DNA as engineers. Our role is to deliver solutions which benefit society, to act in the public good and to act with honesty and integrity. That’s how we live with the weight of responsibilities which we carry, how we live with ourselves and how we derive huge satisfaction from what we do for others. If we know we have done that we can sleep well.

This article is part of a series on engineering ethics. For more articles, visit the series hub at:

Article by Dame Judith Hackitt FIChemE

Chair of Enginuity and a Board member at the High Value Manufacturing Catapult and at HS2; she chaired the Independent Review of Building Regulations and Fire Safety following the Grenfell Tower fire; and was previously President of IChemE, and Chair of the Health & Safety Executive (HSE)

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