Errors of judgment and public safety

File this one under understatement of the year:

Responding to criticism from lawmakers and other officials, Transportation Secretary Jeffrey B. Mullan said he should have consulted with the governor’s office and gone public earlier. Instead, the Department of Transportation did not inform Governor Deval Patrick until Tuesday, after inspectors had already discovered corrosion affecting a few hundred of the 23,000 lights that illuminate the O’Neill and other Big Dig tunnels.

Ah…yeah. Where to start?

First of all, public safety should be the top concern for the DOT. There is absolutely no reason – none – to withhold information from the public that forces them to blindly accept what may amount to a lethal risk. I sympathize with the desire not to start a panic – but, honestly, the worst thing that would happen would be a lot of people would suddenly take alternate routes (and that would be plenty bad enough).

Secondly, this issue with corrosion is unacceptable. “A few hundred” light fixtures showing corrosion is not a simple problem. It is a systematic problem, either with engineering, manufacturing, or with the actual installation/maintenance of the lights (I’m leaning towards the latter). Corrosion doesn’t just happen. It takes exactly the right conditions and materials to be present.

Third, this is pretty poor reporting. Tucked away at the very end is this bit of vital information:

The state on Wednesday sent a letter to the company detailing what it called “two serious problems with your tunnel lighting” fixtures – the loss of paint that has exposed the aluminum to the elements, and the specific corrosion where the aluminum comes in contact with the steel clips.

Here’s a clue to any amateur chemist: “where aluminum comes in contact with the steel clips.” That almost screams galvanic corrosion. Basically, you take two dissimilar metals, immerse them in an electrolyte, and electrons flow from one metal to the other – which results in the physical destruction of the “sacrificial” metal one atom at a time (in this case, the aluminum clips, in contact with steel braces, coated with moisture and salts/oil from the road). In this case, that means that the aluminum will simply disappear.

This points heavily to a failure of maintenance. I can’t believe that a single light-bulb has not been replaced. Part of replacing those bulbs should be a spot inspection for pitting – the hallmark of galvanic corrosion. Failure to do so constitutes, in my mind, a total failure of responsibility to the public to maintain a safe environment.

The failure is from the top of the heap down to the deckplate level. It may not rise to the level of criminality, but it certainly constitutes dereliction of duty. This is not an accident from out of nowhere, it is a foreseeable and preventable incident.  

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13 Comments . Leave a comment below.
  1. $quot;Though it be honest, it is never good to bring bad news.$quot; --William Shakespeare

    "Always have a solution to any problem you bring to the boss." Two sayings that filter a lot of situations in any bureaucracy. Neither help in dealing with realities.

    How bad can it get? Next comes the "cat on the roof syndrome."  

  2. This is not going to turn out well...

    Surprisingly, it seems that his job is safe for now.  

    See ya in a couple of months or next year, it's going to be something else.  Concealing information and acting on your own is usually not a one time offense.

  3. Welcome to......(cue scary voice)...MASSDOT!!!

    Why talk about the 'boss'?  There IS none.  As I said on RMG, this is a 'concrete' example of how the transportation and infrastructure of MA will continue its spiral.

    Deval Patrick chose in his Transportation 'Reform' Bill to place ALL transportation agencies under a management system that apes the old Mass Turnpike system.  The Gov appoints the board one by one, and then they are autonomous.  Sort of like the Supreme Court, only with a fixed five year term.

    Mullen is under NO technical obligation to notify the Governor of any problem.  MassDOT is autonomous.  In fact, now that it's off-budget, you can't even withhold appropriation to bring them into line any more!  If anyone remembers how Mitt tried to fire Matt and couldn't until somebody was killed - that's how much authority Patrick has over Mullen.  And Patrick did this to himself - and all future Governors.

  4. i don't get the blowback

    Obviously, it's bad that there's a problem.  It always is.  I think that the diarist is wrong about blaming maintenance -- this is a materials problem.  They didn't have to choose materials that would corrode, but they did anyway.  To me, hat means either the wrong material was spec'd or installed.

    Secondly, why can't you believe that the light bulbs weren't replaced?  They last a while, and it costs quite a bit of money to change them, so why change them if they're still working?

    Thirdly, we just don't have the money to inspect everything, all the time.  Prior to the first breakage, there was no reason to expect that this would be a problem.  Now that there is an identified problem, they've done the inspections.  They determined the cause of the problem, inspected the others, etc.

    This strikes me as an emotional response to a process problem.  Public safety costs money, and investing it emotionally doesn't minimize risk.

    • It's bad ...

      when Mullan kept this away from the Governor's office for 5 weeks.  It's pretty simple.

      Then you add all the activity on top of it, inspecting 23,000 fixtures, sending samples to labs, having state engineers work with the fixture company.  This didn't turn the light on in his head that maybe he should have contacted Patrick?  

      Maybe the public should know?

      This is ugly.  

    • I appreciate the response

      But I didn't blame the maintenance. I said specifically that it was either engineered wrong (though I find that HIGHLY unlikely) or it was installed wrong (as simple as putting the wrong kind of washer on) or it wasn't maintained properly.

      It is impossible, however, to get away from the maintenance having some responsibility. You are right that those bulbs are designed to last a long time, and I don't advocate changing them until they are out - but I'm sure that at least ONE of those has been changed. And typical maintenance requirements are that you don't just plop in a bulb and ignore the rest - just like the guy checks your brake lights when he changes your oil.

      Finally, there is plenty of money to do inspections. You just schedule it so that several things happen at once. This is what I had to do when I was a work center supervisor in the Navy and had to maintain records of maintenance on everything on-board that used electricity.

      I have absolutely no emotion invested in either the Tunnel or anything that's happened to it. But I do know how to maintain electrical equipment, and meet a budget, and maintain safety as a primary goal. And if I, who have not had to deal with galvanic corrosion for thirty years, can remember a problem with I see "aluminum" and "iron" together, then I don't think it's asking too much that SOMEONE involved in maintaining the Tunnel understand it as well.  

      • While I'm alarmed...

        ... that this is a systemic issue and needs immediate addressing, I'm not alarmed that the Governor and the public didn't know right away.  At some point, a fixture fell.  It was heavy and it's a good thing nobody got hurt, but until you gather more evidence this is probably a maintenance event.  I expect stuff to break - it's why we have a maintenance and inspection budgets.  Until there is investigation, its a single event that could be systemic or could be isolated.  So I'd try to answer that question first before letting everyone panic or jump to conclusions.  Until it's shown to be a large issue why would we want it to get a large public attention?  Does every "could be this or could be that" need reporting?  I don't need to be made aware of every maintenance event that happens in the state that could have hurt people but didn't.  And I don't need a Governor willing to spend significant time chasing those shadows to distraction.  It also invites slow-news-day bad reporting.

        • Could be a slow day

          But a first point, it isn't the Governor that's directly responsible. There is a Department of Transportation for a reason.

          A second point is that, while we probably don't need to know the results of every maintenance action, it is very rare when a light fixture falls from the ceiling of a tunnel. In fact, I don't remember ever hearing of another light fixture that simply fell from the roof of a transportation tunnel.

          A third point is that the particular history of the Big Dig has to be considered. Things falling from the ceiling have a tragic history there. "Wait for something really bad" isn't an operative plan.

          Think of it this way - if the next light fixture that fell killed your family, would you think, "They should have given us warning!" or would you think, "It is perfectly understandable why they never told us about this problem?"

          • $quot;There is a Department of Transportation for a reason.$quot;

            Really?  And what would that be?

            This is a new developement.  Gov. Patrick actively withdrew his authority over MassHighway, RMV, Mass Aeronautical, etc. in HIS BILL that was named 'reform'.  You speak as if this were the situation forever, and it's really in its first (fiscal) year.

            So why DID the Governor deliberately divest himself of repsonsibilty and autority, given the crackerjack track record of these agencies in responding to the public?

            • You're asking for a very long answer

              The short answer to why is there a DOT is: To depoliticize the infrastructure system so it can respond to need rather than to direct political pressure. And it doesn't matter if it has been this way for one day or one year or one hundred years. It doesn't even matter if the DOT is independent or if it reports directly to the Governor. It is still responsible for the maintenance of transportation infrastructure and that includes keeping the public safe - and if it can't do that, then it should at least keep the public informed about the risks of using transportation infrastructure.

      • Good Point, Thurman

        the dissimilar metals in an electrical fixture that is susceptible to a salt atmosphere certainly deserves special attention.  Merely moving the clips won't do.  

    • I wonder what $quot;should$quot; have happened

      Should they really have announced that "A light fixture corroded and fell.  There may be a safety problem.  Or not.  We won't know for another three weeks while we conduct inspections. So, for now, we don't know anything and can't confirm anything, so feel free to speculate wildly for the next month, and then insist that your speculations are true even after we actually figure out if a problem exists."?

  5. Where was the press?

    I wonder if often too-cozy relationships between the press and government officials played a role in allowing this to remain buried for six weeks. Did our local journalistic community really not know about this, or did they choose to sit on it to "protect" their sources? Neither choice bodes well for good governance and a well-informed public.

    Are there any reporters today who sit by scanners, tuned to radio communications of maintenance departments, fire departments, police departments, and so on? No cubs who hang around bars frequented by supervisors, receptionists, interns? I find it hard to believe that this wasn't a very hot topic among workers and staffers starting a day or so after it happened. I have the crazy idea that uncovering and publishing hot topics like this is the primary mission of an independent press.

    I note, with interest, that this story didn't "break" until Jeffrey Mullan issued a press release and made a statement. While I'm glad that Eric Moskowitz dutifully attended Mr. Mullan's briefing, and filed his description of that briefing on time, is that what passes for "reporting" today?

    I believe the government officials of all political persuasion should be "held accountable". I am also convinced that an active, often-adversarial, and aggressive fourth estate must play a lead role in accomplishing that. I expect public officials like Mr. Mullan to attempt to "manage" such events — that's why we need an adversarial press.

    I think our local press blew this story.

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Fri 19 Dec 9:20 AM