Politicization of the Non-politicizable: The Collapse of the Ice Skating Rink in Bad Reichenhall on 2 January 2006

After heavy snowfall, the skating rink of the city of Bad Reichenhall collapsed on 2 January 2006. Fifteen people, twelve children between the age of 7 and 15 and three mothers, were killed by the falling debris of the roof, 34 people were injured. Court trials came to the conclusion that the City of Bad Reichenhall, over a long period of time, had seriously neglected the maintenance of the hall despite clear indication of water ingress and related weak points in the roof structure. The Lord Mayor admitted before court to have purposefully obstructed the decision of the municipal parliament to renovate the hall since he had intended to have the hall dismantled anyway and to build a modern pastime and wellness center instead.

Evaporated Responsibility: The Collapse of the West Gate Bridge in Melbourne on 15 October 1970

On 15 October 1970, at 11:50AM, part of the West Gate Bridge in Melbourne, span 10-11 of 367 feet length, disintegrated and triggered the collapse of the bridge. Thirty-five men were killed in the disaster. The bridge was still under construction, all those killed were workers or engineers employed on the construction site. The investigation of a Royal Commission revealed a mismatch between an ambitious structural design of the bridge plus an unconventional method of erection and a fragmented, conflict-ridden construction management whose detrimental effects remained unchecked by public authorities. Regulatory powers and enforcement competence had been delegated to a QUANGO—a quasi-non-governmental organization—which diluted responsibility structures and decisively weakened the coordination and control capacity of the agency.

Introduction: Black Swans and Sinatra Inferences

Public mismanagement as a threat to life and limb is a rare and highly improbable phenomenon—the proverbial Black Swan. Bridges and buildings collapse, claiming the lives of people who had every reason to believe that governmental agencies protect their physical integrity through public oversight and maintenance. Properly analyzed, however, these unlikely events reveal causal mechanisms of a general nature, strong enough to trigger fateful mismanagement even under the restrictive conditions of professional bureaucracies and democratic government. Hence the “Sinatra Inference”: When a mechanism is powerful enough ‘to make it there’—i.e., where causal leverage is supposedly low—it is likely to ‘make it everywhere’ as soon as leverage is enlarged by weaker accountability structures, lower professional standards and lesser values than human safety.

Intended Ignorance: The Collapse of the I-35 W Mississippi River Bridge on 1 August 2007

At 6:05 PM on 1 August 2007, the I-35 W Highway Bridge crossing the Mississippi River in Minneapolis, Minnesota, collapsed due to the failure of crucial parts of the bridge’s steel truss structure. Thirteen people died in the disaster, 145 were injured. A report of United States National Transportation Safety Board (NTSB) revealed that the Minnesota Department of Transport, over a long period of time, had ignored available information about the structurally deficient status of the bridge in anticipation of ‘budget busting’ repair costs. Which resulted in a preference for less expensive patch-up measures to improve the drivability of the bridge rather than a retrofit of the fracture-critical components of the steel truss whose failure triggered the disaster of 1 August 2007.

Erosion of Professional Integrity: The Collapse of the Canterbury TV Building in Christchurch on 22 February 2011

From 4 September 2010 on, a series of earthquakes shattered New Zealand for more than one year the most devastating of which caused the Canterbury TV (CTV) building in downtown Christchurch to collapse on 22 February 2011. One hundred and fifteen people were killed. A Royal Commission found out that, in 1986, the Christchurch City Council (CCC) had granted a building permit despite concerns about structural design issues. Moreover, the authority did not insist on structural analyses of the building after the initial earthquake of 4 September 2010. Thorough investigations after the disaster of 22 February 2011 revealed that the early concerns about insufficient joints between floors and shear walls had been entirely justified since the failure of the joints, according to all likelihood, had triggered the collapse of the building.

Conclusion: Strategic Learning and Situational High Reliability

Public authorities are not high reliability organizations per se but they need to act as one as soon as safety issues are at stake. When it comes to construction and public infrastructure, however, responsibility for human safety may compete with the perceived necessity to respond to quests for accelerated licensing, fostering the local economy and general urban development, cooperative relations with contractors and consultants, compromises in local politics and similar types of legitimate expectations of clientele and the general public. Strategic learning for the sake of sustainable prevention requires to realize the responsiveness versus responsibility trade-off in the first place and to acknowledge the consequences for personal conduct in office under specific situational conditions. In the essence, it is about the strength and strengthening of professional and institutional integrity for the sake of human safety as an integral part of good governance and mindful public management.