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The Public Manager Magazine Article

An Eighth-Grade Science Fair Project Gone Horribly Wrong

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Mon Dec 15 2014

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Neil Swidey, Trapped Under the Sea: One Engineering Marvel, Five Men, and a Disaster Ten Miles into the Darkness (Crown Publishers, 2014)

An Eighth-Grade Science Fair Project Gone Horribly Wrong-0b30f9bddae4f17d91d6ea735c81d81a4bc511808bdfbee4ece2286e1d3aa078

Reviewed by Larry Azer

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In a story eerily reminiscent of a Richard Stillman case study, Boston Globe writer Neil Swidey effectively tells the story of a public project gone horribly wrong in his latest book Trapped Under the Sea.

After decades of dumping raw sewage into Boston Harbor, the area was called a "giant stinking cesspool" filled with "black mayonnaise" by the 1980s. As the result of a 1982 lawsuit, and with multi-thousand-dollar daily fines looming, the state finally built a state-of-the-art sewage treatment facility by the 1990s that officials hoped would display how an environmental disaster could be turned into a public triumph. Built on Deer Island, the "destination for every toilet flush in the eastern half of Massachusetts," it connected to a 10-mile-long tunnel located hundreds of feet below Boston Harbor, which allowed treated waste to flow far out to sea from the treatment plant.

Subtitled "One Engineering Marvel, Five Men, and a Disaster Ten Miles into the Darkness," the book presents years of painstaking research as a narrative, which helps the reader understand complicated engineering procedures and provides valuable in-depth back stories of the central characters.

Like the similarly timed other Boston megaproject—the "Big Dig" highway reconstruction—the Deer Island project took twice as long as planned and cost millions of additional dollars. When bad engineering decisions and clashing corporate interests endangered the project's completion, a team of commercial deep-sea divers, experienced in working in low-oxygen environments, was sent in to finish the job. Their task involved crawling up a series of 55 30-inch-wide pipes to remove a 65-pound safety plug from each shaft.

Not surprisingly, it was an extremely dangerous task that neither the divers nor their supervisors had experience with. Equipped with untested breathing apparatus, limited training time, and a lack of knowledge of both their fellow workers and the physical work environment, the effort was seemingly doomed from the start—"like an eighth-grade science fair project gone horribly wrong"—to the point where several of the divers expressed serious concerns about the work. One key team member dropped out shortly before the project began.

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As an ill-fated result of placing efficiency and profits over effectiveness and safety, all of the lighting and ventilation equipment had been removed from the tunnel, requiring the divers to carry their own air and lighting supplies. On July 21, 1999, five divers made their way into the darkness to begin their work, but disaster struck. Not all of them made it out alive when the gerry-rigged breathing equipment, designed from a device originally intended to package burritos, failed miserably.

The result of hundreds of interviews and thousands of documents collected over five years of reporting, the book describes the divers as being "used to danger ... Navy SEAL-type guys who ran toward it when everybody else was running away" and provides intriguing details of not only the divers, but also their families, friends, and project planners. Even with placing the moment of disaster in the book's prologue—"the setup for some half-baked science fiction novel"—the author is extremely effective in creating and maintaining a heightened level of suspense, where the reader knows there is nothing that can be done to prevent the impending catastrophe but is kept on the edge of his seat nonetheless.

Dysfunction Elevated Risk

Swidey writes how "dysfunction had greatly elevated the risk of a bad outcome for everyone involved" and that the "deaths had been more than just preventable ... more than just predicted; given all the bad decisions—by all the players—the deaths had effectively been preordained."

In a battle of corporate greed versus personal safety, all entities from the Massachusetts Water Resources Authority (MWRA) to the various engineering and planning firms—desperately attempt to avoid accountability for the tragedy, pointing fingers at each other in a classic case of everyone sharing some of the blame, no one shouldering the lion's share, and all parties trying to get out with the lowest possible loss of financial resources and public relations stigma.

Lessons Learned

In his epilogue, Swidey writes how the project holds lessons for the general public, "how measures that are often popular with taxpayers … can work against their interests by incentivizing risky behavior that can ultimately cost those same taxpayers dearly." Although the events at the time were overshadowed by the death of John F. Kennedy Jr.'s airplane crash, this book is an effective retelling of the avoidable tragedy that took place and provides a solid case study for future learning.

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Among the lessons to be learned from this tragedy is the cost of choosing efficiency and cost-effectiveness over values such as human life, and that doing the job the right way is preferable over doing it in the quickest, cheapest way. In an interview, Swidey said that despite the unique circumstances of this particular situation, the "forces that put this drama in motion are universal to pretty much any ambitious undertaking," such as the construction of a bridge or a complex technology launch, for example the national healthcare website.

"I tried to weave into the narrative of the book these important lessons about risk so that readers would be drawn in by the real-life characters and real-life drama, but also have lasting lessons rattling around in their mind after they put the book down," Swidey shared. "One of the most important lessons is that fatalities or other horrible outcomes usually don't happen because of one big screw-up, but instead they happen when a series of small \[decisions\]—none of which would be serious enough to cause a fatality—align in such a cruel way to produce a dangerous cascade of events. The holes in the Swiss cheese line up."

Another lesson gleaned from the book is the importance of communication across all levels and branches of the organization, especially in a complex project such as the one described in the book. "If the major players had maintained more mutual trust during the long, contentious, cost-overrun-heavy job, they would have found a way to collaborate in finding a sensible solution, advancing all their interests," said Swidey. "Instead, by the end of the job, there was no trust among the major parties, and a zero-sum, us-versus-them mentality dominated," which ultimately led to the tragedy that ensued.

Despite all of the loss experienced as a result of this disaster, both human and otherwise, the author shared an optimistic view of what happened, writing that the people at the center of the story have used it to make changes in their own lives, both personal and professional. Swidey said that one of the key decision makers told him he thinks every young engineer or project manager coming into the field should have to read Trapped Under the Sea to "open their eyes in a way that will help them make better decisions in their own careers."

While working on the project, that engineer was locked in bureaucratic battles with the contractor and other key players, and the discussion "had somehow gotten divorced from the real-life workers who would be asked to carry out their decision." After reading the book, the engineer told Swidey that "no matter how sensible a plan may look on paper, carrying it out still always falls to real workers assuming real risk."

In our current environment where police officers and firefighters are rightly portrayed as heroes, this book reminds us to also recognize other unsung public servants such as these divers, the "blue collar workers \[who\] transfer the dazzling dreams of engineers, and the promises of politicians into concrete reality." We are reminded of how seemingly smart people can make very bad choices, how safety can be ignored in the pursuit of deadlines and profits, and how worker fatalities don't result as much from a single catastrophic mistake, but rather from "a series of small, bad decisions made by many individuals."

When bad engineering decisions and clashing corporate interests endangered the project's completion, a team of commercial deep-sea divers, experienced working in low-oxygen environments, was sent in to finish the job.

Five divers made their way into the darkness to begin their work, but disaster struck. Not all of them made it out alive.

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