Academic analysis of the ICE Report ‘In Plain Sight: reducing the risk of infrastructure failure’

This is the final report from Loughborough University’s commission from the Institution of Civil Engineers (ICE) to carry out an academic evaluation of the applicability and validity of the ICE’s 12 Lines of Defence model, produced for infrastructure in response to the Grenfell Tower fire. Having reviewed the main report, the interview transcripts and associated literature we consider that this adaption of Reason’s Swiss Cheese Model as a basis of the Lines of Defence is appropriate, especially as it is well recognised and understood by a wide range of stakeholders. This notwithstanding, it does have some deficiencies, and so we have proposed enhancements including an integration of post-incident analysis, appreciation for crosscutting influencers that could positively or negatively impact every line of defence, and a general risk management framework that would act as a context setting for the model and ensure that the model can be understood by non-experts, and without specific prior knowledge of the industry. The changes have been proposed in order to increase and extend the reach of the model, without compromising its recognition and effectiveness.