Over twenty years ago, my colleagues and I organized a forum on disasters related to information and communication technologies (ICT), where lives may have depended on the safe and effective operation of computer systems (Dutton et al 1994; Peltu et al 1996). As I, along with many many others, try to sort through the facts and timeline of decisions leading to the Flint Water Crisis, I was reminded of one powerful lesson learned from our study of ICT disasters.
Namely, there is a tendency of organizations and their leadership to get on a decision-making escalator. As they make a decision, such as shifting the source of water to the Flint River, organizations are in some ways stepping onto a metaphorical escalator. The further they ride the escalator, the more difficult is the psychological and practical problems of jumping off, even when they consider it a bad decision. This is not an excuse for persisting on the wrong track, but it is a lesson that might be exemplified by the Flint River Crisis.
Of course, another theme that emerged from our discussions of ICT disasters was the degree that each disaster we studied was over-determined. That is, there was seldom one specific, determining reason behind any particular disaster. Most often, disasters occurred as a result of a large number of mistakes, including failures to follow good practice and use common sense, such as trialing a change before going live.
I agree with many who argue for a focus on solving the water problems in Flint, rather than dwelling on the reasons for the disaster. However, study of such crises and failures to get off the escalator can help avoid similar disasters in other cities across the US that are also financially stressed, and dependent on old infrastructure.
References
Dutton, W., MacKenzie, D., Shapiro, S., and Peltu, M. (1994), Computer Power and Human Limits: Learning from IT and Telecommunication Disasters, PICT Policy Research Paper 33, Uxbridge, UK: Brunel University, Programme on Information and Communication Technologies.
Peltu, M., MacKenzie, D., Shapiro, S., and Dutton, W. H. (1996), ‘Computer Power and Human Limits,’ in Dutton. W. H. (ed.), Information and Communication Technologies – Visions and Realities, Oxford and New York: Oxford University Press, 177-195.