Digging beyond a nuts-and-bolts cause

LAST MONTH Milena Del Valle died when a giant ceiling panel in the Interstate 90 connector of the Central Artery/Tunnel project fell on her car. Her tragic death brings to mind other tragedies involving large technological systems, and the lessons they teach.

In 1986 the space shuttle Challenger disaster killed all seven crew members, and in 2003 the shuttle Columbia catastrophe killed seven as well. Boston's Central Artery and the space shuttles would appear to have little in common. But in fact they are close kin: Both are large, complex systems.

Such systems have spread through the industrial world in recent decades. Accident prone, they endanger operators, passengers, and bystanders. Accidents increase as the systems encounter challenging and changing circumstances. Overloads cause blackouts in electric light and power systems; traffic overwhelms highway networks, causing jams and collisions; fly-by-wire control systems send erroneous signals, and planes crash; and hackers intervene to make computer systems collapse.

Yet we depend on large, complex systems, including the Central Artery/Tunnel. Who in the end would want to go back to the overhead ``Green Snake" snarling traffic and slicing the North End off from downtown? Who would remove the handsome vista of the Leonard P. Zakim Bunker Hill Bridge across the Charles River? Who does not look forward to imaginative use of the freed-up acres in the heart of Boston?

The challenge, then, is to find out why the tunnel project is flawed. Other cities will need to know why this environmentally sensitive system that points the way to the future stumbled so badly.

Exhaustive investigations and reports followed the space shuttle disasters. The tunnel project failures require the same. The presidential Rogers Commission investigated the Challenger disaster, and the Columbia Accident Investigation Board dealt with the Columbia one. The tunnel project failures merit similar hearings. Otherwise, the public and the authorities will depend on superficial analyses.

In the interim, a review of the findings and recommendations of those prior panels offers insights into the root causes of the Boston problems. Both the commission and the board emphasized organizational, or management, inadequacies as well as technical failures.

In the tunnel tragedy's wake, exclusive focus on the ceiling panels is too simple and misleading. Physicist Richard Feynman, a Nobel Prize-winning member of the Rogers Commission, moved the public's attention away from technical failures and to organizational ones. He stressed that management's estimate of the possibility of space vehicle failure was 1 in 100,000, while engineers estimated 1 in 100. Feynman asked, ``What is the cause of management's fantastic faith in the machinery?" He added, ``Reality must take precedence over public relations, for nature cannot be fooled." A high-level manager on the tunnel project chided engineers who, in effect, wanted to build a gold-plated Mercedes. He wanted them to build a solid, affordable economy car. Now we long for the engineers' Mercedes.

The Columbia board determined that physical and organizational issues played a major role in that failure. Managers had allowed the shuttle to continue to fly with known problems that were eventually catastrophic. NASA's organizational culture had failed.

Boston's tunnel project was an organizational nightmare. Responsibility was dispersed throughout the system. Peter Zuk, a former tunnel project director, lamented that not enough decision makers were going home at night with stomachaches. The Massachusetts Department of Public Works, in theory, had ultimate responsibility for overall management, but it was understaffed and inexperienced, so Bechtel/Parsons Brinckerhoff wound up taking a decisive role. Under state law, however, the overseeing firm could do conceptual and preliminary design, but not final design and construction, which it could only schedule and coordinate.

Several years ago, a reporter told me that she sensed that Bostonians' feelings about the Central Artery/Tunnel had changed since the handsome silhouette of the Zakim Bridge rose above the Charles. I found this plausible and began to wonder if, decades from now, the local project may symbolize Boston as the Golden Gate Bridge does San Francisco. It, too, has had its problems. Eleven men were killed from falls during construction, and the bridge is notorious as a site for suicides.

Responsible retrospective will, in time, reveal the causes of the local project's failures, and then other cities can learn from its flawed, yet still heroic, history.

Thomas Hughes is a University of Pennsylvania emeritus professor and an MIT visiting professor. His book ``Rescuing Prometheus" has a chapter on the Boston project.