The anatomy of a disaster

Reading case studies in public policy is like watching a good thriller.  You see each decision lead down the path to disaster.  You know the disaster is coming, you see the many places where the disaster could be avoided but the characters, often for the right reason, just keep making the wrong decisions.  You just keep watching the story unfold, both helpless and fascinated.

I’ve watched the horror of the Flint water supply since April, and it did not take long to realize the residents of Flint are living through a public policy case study.  This week’s anniversary reminds me of a specific public policy case study in the lead up to the loss of the space shuttle Challenger.

The Flint water situation and the Challenger disaster is essentially the same problem manifest in two separate ways.  In both cases, the people with the authority to proceed were doing the jobs they were tasked with doing, which was not the same as fulfilling the mission of their respective organizations.

It appears that in both cases, people died as a result.

The mechanical problem that brought down Challenger was an O ring that was brittle at low temperatures.  It was a known problem, and expensive to fix correctly.  The less expensive solution to not launch in cold weather.  Despite the known risk, the launch proceeded.

The cold weather made the O ring between two sections of the solid booster rocket brittle.  The ring failed, creating what amounted to a rocket powered blow torch aimed directly at a large fuel tank.  The tank then ruptured and ignited.  The ship and crew were lost.

The political problem that brought down Challenger was that people running NASA were tasked with a priority above the good management of the organization.

Space travel was becoming routine.  NASA needed to encourage a new generation of STEM students to bring the United States into the future.  NASA was going to launch a schoolteacher into space, and the President was going to tell the world about it that night in the State of the Union.  The job of NASA was to provide the timely launch of an inspiring figure into space.

The engineers who know the risks tried to halt the launch, but lacked the authority to do so.  Those with the authority had the job of putting a teacher in space before the State of the Union.  They could not do that while still heading the engineers concerns.  The launch proceeded resulting in the disaster.

The mechanical problem with flint water supply is that treated water from Lake Huron was replaced with corrosive water from the Flint River.  The corrosion ate away at the lead pipes, causing the lead to leach into the water supply, poising the residents of Flint.  Additionally, the corrosive environment lead to a drop in the disinfectant qualities of chlorine, winch may be a contributing factor the spike in legionnaires disease from which 10 people have died.

The political problem that poisoned Flint’s water supply  was that people who were running Flint were tasked with a priority above the good management of the organization.

The city of Flint was in serious financial trouble, to the point where the State took over.  During a period of just over 4 years, the State appointed a series of 5 emergency managers with extraordinary powers to govern.  By and large, these powers are unchecked, and there is little local oversight.  The managers had one job, and that is to get the city’s finances in order.  The functioning of the city was secondary to that goal.  An old back-up plan to use water from the Flint river from was dusted off and implemented as a cost saving measure, but without the full engineering knowledge or institutional memory of a functioning city government, it was not implemented completely.  The highly corrosive water from the Flint river was not treated with an anti-corrosive agent before being fed into the water supply.

There was a rising chorus of people and institutions raising the alarm about the condition of Flint’s water supply.  Residents were complaining about the water, independent tests were finding the water not safe to use, and Ford switched away from Flint water to protect its plant from damage.  However, the people who were raising the alarm lacked the authority to fix or mitigate the problem.

Those with the authority had the sole job of putting Flint’s financial house in order, and did not feel they could do that while heading the concerns about Flint’s water.  They stayed the course, resulting in the disaster.

We don’t know yet how extensive the lead poising truly is, but it could pose a major public health challenge for decades.  We don’t know that the deaths from Legionnaires’ disease are directly attributable to the lead reducing the effectiveness of chlorine, but there is certainly a correlation worth further study.  We don’t yet know the cost of repair to the water system but estimates exceed hundreds of millions, and possibly more than a billion, dollars.

Both in Flint and at NASA those who we were paying to manage the respective organizations were doing exactly what we were paying them to do.  The problem in both cases is that we were not paying the managers to do the right thing, we were paying them to do the politically expedient thing.  In both cases doing what they were paid to do resulted in disaster.