Introduction: Other people's disasters are reminders to re-examine your own practices and your hubris. Most disasters are unsurprising surprises: They are the result of an extended series of ignored warnings, omissions and mistakes--the cumulative effect of lots of little things. Given enough chances, the disaster was going to happen--what was uncertain was exactly when. One of the constants is that people and organizations become increasingly desensitized to the risks as they get away with mistakes, shortcuts... Too often close-calls don't provoke action to stave off the disaster, but have the opposite effect of making the eventual disaster worse because they undermine and discredit important safety measures. The two Space Shuttle disasters are commonly used as examples.(foot#1) The RMS Titanic disaster provides another interesting example. Some analyses of the historical record claim that the inadequate number of lifeboat did not result from a desire to reduce costs or clutter, but rather was the result of the passenger ship industry having dismissed the risk of a large ship sinking quickly. Lifeboats were seen as being needed only to ferry passengers to other ships that had come to the rescue, and that those lifeboats would have time to make multiple trips, and would be supplemented by lifeboats from those other ships.(foot#2)
The current public health disaster in Flint Michigan--lead and other pollutants in the drinking water--is a good example of the class of disasters one sees in governments and other bureaucratic organizations. If you follow Palo Alto governance and have read a summary of what transpired in Flint, your response will be that you have repeatedly seen the same categories of actions here. While you will read claims that what happened was the result of Flint's citizenry being predominantly poor and Black, that demographic is likely only a proxy for the ability of the citizenry to fight back and of the government's awareness of that ("Correlation does not (necessarily) imply causation"). There is a long history of drinking water disasters inflicted on a range of communities.(foot#3) In the general case of the citizenry getting steamrolled by narrow special interests, such as developers, I have friends in affluent communities similar to Palo Alto where they turn out in force at meetings that are nothing more than pro forma events where the officials make only a transparent pretense of listening to the public. In contrast, I have friends living in cities with more modest income levels where stable organizations (civic, social, religious,...) seem to be what allows their citizenry to have a voice.
Hanlon's Razor (many minor variations): "Never attribute to malice what can be adequately explained by incompetence/stupidity." to which I would add "(depraved) indifference".
I'm going to use only the details of other disasters relevant to my points. There are many online summaries of what happened in Flint, with new details arising almost daily. The best concise version I have seen so far being Flint's water crisis reveals government failures at every level by Lenny Bernstein and Brady Dennis in the Health & Science section of The Washington Post dated 2016-01-24.
The fundamental basis of the disaster was the appointment of emergency managers by the State of Michigan to takeover the running of the city government. This management was not accountable to the citizenry, and was primarily focused on finances. The technical basis of the disaster was the decision switch the city from the City of Detroit's water supply to taking water from the highly polluted Flint River. The reportage indicates that the emergency managers were focused on the savings, and gave little consideration to the true costs of the change. A similar dynamic can be seen in the Challenger Disaster: The managers (NASA and the contractor) were so focused on the politics of staying on schedule that they wouldn't/couldn't consider the costs of failure, even though their engineers were strongly and insistently warning them of the risks. You find the same phenomenon in commercial enterprises: "Ship the (unready) product on schedule--we can fix the problems later." This is especially prevalent in high-tech and especially in Silicon Valley: If the product or company fails because of this, those responsible for the (unforced) error simply move on, portraying it on their resumes as valuable experience. And this attitude--of "we can fix it later"--oozes over into our local politics.
The next contributor to the disaster involved government regulation. Flint's emergency manager is trying to deflect blame for what happened by claiming that their water treatment followed government regulations--not true, but we will get to that later. This category of regulation was initially established as minimum practices for the common cases. This was in part to protect the public and in part to create a "level playing field" for businesses, that is, to make it more difficult for businesses to gain competitive advantages by engaging in fraudulent, unsafe and other shady business practices.(foot#4) However, lawyers are trained to pervert the best of intentions, and soon corporate lawyers were arguing that the regulations represented the maximum that should be expected of their client, and that the responsibility for shortcomings lay with the regulators.(foot#5) The success of such arguments were a factor in leading to more detailed regulations, which are then labeled "over-regulation". You will see the hypocrisy of a business or industry group arguing against regulations by saying that regulations interfere with them using their expertise and judgment, and then turning around and arguing that they shouldn't be expected to apply expertise and judgment but rather only adhere to the regulations.
Regarding regulations as the maximum that can be expected has the dangerous side-effect of licensing an attitude that some regulations can be easily ignored. In Flint, the polluted water plus the treatment for the biological pollutants made the water highly corrosive, resulting in the biggest known problem: lead poisoning of those drinking it. The excuse that the Flint managers gave for not adding the required anti-corrosion treatment is that that they didn't believe that the regulations required it. The cost of that treatment has been reported as $100 per day, or roughly $100K over the three years that they anticipated using Flint River water. The result is an estimated $100M in damage to the city's water mains alone (a factor of 1000). The damage to human health is incalculable.
The regulatory problems extended into enforcement. First, there were people in the various regulatory body who knew that there were serious problems, but, to put it bluntly, decided that "getting along" was more important than "getting it right".(foot#6) They saw that others were dangerously not following crucial procedures, but they themselves were so committed to following procedure for intra- and inter-agency interactions that they effectively did nothing. Here in Palo Alto, the City Council has recently been increasingly willing to ask pointed questions of the City Manager and Staff and to reject recommendations. This is a welcome change from the mid-2000s when there were multiple Council members who were very deferential to the City Manager, including explicitly announcing from the dais that they didn't understand the issue and were simply going to vote for the City Manager's recommendation.
The second category of enforcement failures was testing that was incompetent, deceptive and even fraudulent, for example, biasing the sample selection to produce passing values. This was not just a few rogue employees. Part way through the testing, they were told that they were at risk of failing--a no-no because it is often perceived as instructions to manipulate the test to get a passing grade. There were officials who internally warned that the testing methodology would mask the problem. And the deficiencies in the testing were simple enough and on such a scale that it is difficult to believe that upper management would not have recognized it once the public raised serious concerns.
Palo Alto City Hall has a long history of avoiding enforcement of its ordinances.(foot#7) For example, current Assistant Director of Planning Jonathan Lait has noted that for Palo Alto to have the same number of code enforcement officers per capita as his previous city, we would need to have 6 instead of only 2 (he has been hoping to bring that up to 3). Palo Alto's deficiency is not the result of historical patterns or a needs-based assessment, but resulted from a series of political decisions over the past decade to have fewer enforcement officers. The cynical wag could characterize this as "A policy of not following its policies."
In addition to resistance to enforcement, City Hall often works to warp ordinances to the benefit of developers and at the expense of the public (for example, trying to change the definition of "building envelope" for the old University Arts building). The corrosive effect of this can be seen in the moratorium on PC zoning (Planned Community): Although PC zoning has potential legitimate uses, its actual history is one of flagrant abuse. People won't support change when they have been trained to expect that the promises made to them won't be honored--the whole point of having ordinances is that they represent an agreement among the competing interests about what is allowed, and that it will be enforced. Note: It is an encouraging development that City Hall is actually enforcing penalties for the empty grocery store at Edgewood Plaza.
The citizenry of Flint was not passive--far from it. They went to meetings to raise their concerns. They did their own testing. And it wasn't just the citizenry that saw the water as dangerous: General Motors stopped using Flint water because it was corroding their machinery. But the appointed officials dismissed all this. Only when it became a major media story did those officials begin to treat it as a real problem. This is reminiscent of the PBB poisoning scandal in Michigan in the mid-1970s (I was living there).(foot#8) The problems with public input has been a repeated topic of this blog (see the index below). Many citizens have been frustrated attempting to correct facts and analyses being proffered by City Hall, its consultants, and favored advocacy groups. One of the high honors is to be dismissed as one of "The Usual Suspects" (sarcasm).
I expect that the Flint disaster will continue to be in the news for quite some time. As you read the stories, think beyond the specifics of that particular situation. Use it as a "There but for the grace of God go I." Use it as a reminder that many disasters result from the confluence of many festering small problems that mutually reinforced each other and cascaded out of control. The RMS Titanic disaster is often treated as simply a matter of hubris--treating "unsinkable" as meaning "invulnerable"--but if you look at the slew of reforms that follow, what you see are "Could have, should have" measures.
1. Space Shuttle Challenger Disaster was recently in the news because of its 30-year anniversary (January 28).
Space Shuttle Columbia Disaster, 2003.
2. One elaboration of this analysis was presented in an opinion piece re-published in the Wall Street Journal (tiered subscription) of 2012-04-13 entitled The Real Reason for the Tragedy of the Titanic.
Note: The name of the author "Chris Berg" made me suspicious (close to "iceberg"). Although I couldn't find the article on the website of the supposed original publisher (Australian Broadcasting Corp), there are other articles there by an author of that name.
3. Examples: Fracking polluting the drinking water supply to the extent that one could set what was coming out of the tap on fire (subject of the documentary Gasland). Or the events in Hinkley CA that made Erin Brockovich famous (and subject of a Julia Roberts movie).
4. Although the Pure Food and Drug Act of 1906 and its successors are typically portrayed as consumer protection, they had substantial backing from various businesses. For example, the big meat packing companies saw it opening up foreign markets that had been closed to US imports because of a history of dangerous product (unsanitary butchering, diseased animals,...). It also broadened domestic markets for smaller meat packers: The USDA inspection stamp eliminated the need to carefully research the reputation of the packer you were buying from. Aside: In recent years, there has been substantial backsliding--more "trust", less "verify"--with increasingly consumers getting sick or dying being the alert that a particular company was not trustworthy.
5. The Wall Street Journal opinion piece on the Titanic in the earlier footnote is an example of this argument (that the regulators were to blame for not having stiffer requirements). What it ignores is that the widely accepted analysis that the Titanic would not have sunk if it had been going only a little slower, in which case the number of lifeboats would have been adequate. However, even at the slower speed, the Titanic would have sustained massive damage--other ships near the Titanic had assessed the risk and decided to stop until the next morning. Were the regulators to blame for failing to factor in that a captain would behave in such a reckless manner?
6. It wasn't just lead poisoning that was ignored, but other problems, such as Legionnaires' disease.
7. I became sensitized to the problem of non-enforcement in the 1990s as a member of my neighborhood association board. There was a bar (now gone) that generated lots of criminal activities. Some were visible as patterns, but some were easily linked to the bar itself, such as fights and brawls that spilled out onto El Camino. In working with the PA Police Dept, we were told that there was drug-dealing going on in the bar's basement. Similarly for the pay phone that the bar had had installed on the sidewalk--a phone that was illegal both because it was on public property and because it obstructed the sidewalk. Getting the bar's liquor license revoked would have been effective, but City Hall was repeatedly slow in taking the steps needed. And when ownership was transferred between members of a tight-knit family, City Hall allowed this to be treated not as a sham transaction, but as a whole new ownership team that would eliminate the past bad behavior. It took years of pressure from a well-organized neighborhood association to get City Hall to finally clamp down on a business that was abetting criminal behavior, if not profiting from it.
8. PBB was used as a fire retardant on seeds for planting but got mislabeled as livestock feed supplement: Reportedly, the factory ran out of bags for PBB so they took pre-labeled bags from the other production line. The State government rejected warnings and complaints from a range of farmers about widespread sickness among their cows, chickens... The State's explanation was that there was a sudden, widespread outbreak of gross incompetence among highly experienced and successful farmers, many on farms that had been in their families for generations. Because of the State's failure to act, PBB became widespread in the food supply, with dairy milk being the highest profile problem. When the situation could no longer be denied, the State recommended that infants not be breast fed or given fresh milk. Although the health effects of PBB on humans had not be studied, there was substantial worry because of its similarity to PCB (Polychlorinated Biphenyl) which was known to cause various serious problems. Also, the farm animals that received large doses had died in a variety of horrible ways.
For the political junkies: This provided an example that there was a time and place where large numbers of voters would cross party lines because of positions on issues or competence. The then-governor of Michigan was a moderate Republican, William Milliken, and he lost substantial support in the Republican-dominated rural areas. Some were upset with how long the State had ignored the problem, suppressed information, and treated farmers badly. Others were upset that he hadn't done more to suppress consumer concerns about the situation (private profits over public health). The cumulative effect was that he looked certain to be defeated for re-election (in 1978). But then an Irish Catholic clique in the leadership of the Democratic Party decided to stage a coup against the Party, repudiating multiple planks in its platform. There was a widespread revolt among Democrats. In Detroit, Black politicians and pastors were very visible in supporting the Republican governor, not just endorsing him, but introducing and standing next to him at events. The resistance in the liberal suburbs was not as publicly visible but just as strong. Consequently, the Republican got re-elected. It was truly amazing how many precincts state-wide had the vote for governor be the opposite of the dominant party for the other candidates on the ballot.
An abbreviated index by topic and chronologically is available.
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