Wednesday Morning Rant

As the details about the disastrous Maui fire continue to unfold, many people are left wondering how the hell a foul-up this spectacular is possible. How did everything go so wrong at every level of the response? Why did Maui have to wait for water authorization? Why were the emergency sirens not activated? Why was traffic allegedly blocked from leaving on the only good road out? Assuming that all of what we've heard is true, how did so much go wrong?

I think that the sad conclusion is that, in reality, nothing went wrong. Not officially. Everyone likely followed every guideline, rule, regulation and requirement. Procedural compliance was probably quite good. What apparently nobody did, however, was the single most important thing: think. The environment in which they operate has been designed to eliminate the need to think and ensure compliance instead.

The purpose of the rules laid down in such great volume for so long a time is to obviate thinking. You don't need to think if there's a rule to cover whatever it is you need to do. Follow the rules, comply with the procedures, adhere to the regulations and you will achieve your goal or at least be shielded from any poor consequences. Nobody is to blame, because the rules were followed. The rules are there to act as a substitute for thinking. Robotic adherence to the rules - and striving to have a rule for all things - is awfully bad in situations that even slightly deviate from the context envisioned by the rulemakers.

The water situation in the Maui fire response is, I think, an unfortunately spot-on example. Why did the local authority on Maui call Honolulu for permission? Because the rules said it needed to. Why did Honolulu allegedly keep Maui waiting for five hours? They were busy, I'm sure. And the rules permitted it. Why didn't the local incident commander or similar grab the water guy by the lapels and tell him to get the damned water flowing or else, and pick up the pieces later? That would be against the rules. Why didn't they use the emergency sirens? No rule for that, not for a fire. The rules are for tsunami warnings. No rule, no action. Everyone apparently followed the rules. If the rumors that kids were sent home from school into the path of the blaze because of high winds or that firefighters left the scene before the fire was fully quelled are true, there were probably rules for that, too.

Maui isn't the only example. The Flint, MI municipal water disaster is another. Flint wanted to change the water source to reduce costs. Both water sources were safe. The chemistry was a bit different between the two sources, but both were fine and complied with safety and quality standards. All of the regulations were satisfied. All the rules were met. But nobody thought about it. They were ticking boxes, not thinking about whether the difference in acidity would cause built-up scale in the pipes to release and expose the water supply to lead. There was no rule for that, and disaster followed.

The world is a complicated place and it is impossible to have a rule - or set of rules, or set of sets of rules ad infinitum - that will cover all conditions. But bureaucracy runs on rules and metes out reprisals for breaking them - even if breaking a rule or deciding not to proceed despite the rules saying you can would be the single best thing to do. Rule-following is in the organizational DNA at all levels, and it has made thought redundant.

And box-ticking is a poor substitute for thinking.

posted by Joe Mannix at 11:00 AM

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