Responsibility all around

THE CASCADE of failures that led to the fatal ceiling collapse in the Big Dig connector tunnel one year ago was on stark display yesterday in Washington, where the National Transportation Safety Board issued its final report on the incident that killed 38-year old Milena Del Valle.

In a recitation of mismanagement that one panel member said "would make your hair stand on end," the NTSB staff described the numerous ways in which Big Dig designers and contractors didn't understand, and state authorities didn't investigate, why the anchors used to fasten the ceiling panels in the Interstate 90 connector tunnel were vulnerable to "epoxy creep." In reading the panel's findings, board chairman Mark Rosenker said repeatedly that, had the responsible parties done a better job of testing, monitoring, and inspecting the ceiling construction, the accident could have been prevented.

And who are the responsible parties? Dashing hopes for a quick resolution of the long-playing drama, the board's report revealed no single villain. Instead, the board flagged failures all along the way. There was the failure of contractors Bechtel/Parsons Brinckerhoff, design managers Gannett Fleming, and builders Modern Continental to thoroughly test and monitor the ceiling construction after they learned that some of the anchors were coming loose in 1999. The Massachusetts Turnpike Authority failed to do a single inspection of the tunnel from the day it opened to traffic in November 2003 to the day of the fatal incident more than 30 months later. And almost everyone failed to realize that the "fast set" epoxy used to anchor the bolts in the ceiling panels, made by the firm Powers Fasteners, was insufficient to bear long-term loads and wasn't holding.

Hanging over the findings was a pervasive sense of neglect and inaction from leaders on Beacon Hill -- until tragedy struck.

"I find it incredible," said panel member Kitty Higgins, "that the state played such a passive role."

The report won't draw a bright line for officials still picking their way through the thicket of pending lawsuits and financial claims. Attorney General Martha Coakley must still decide whether to pursue criminal charges in the death -- weighing the likelihood of a conviction against the need to maximize cost recovery for repairs and ongoing maintenance of the project. Transportation Secretary Bernard Cohen must still complete his promised "stem-to-stern" review of the project, necessary to restore the public confidence that surely took another hit yesterday.

Everyone knows that there are risks associated with driving in tunnels. But citizens have a right to believe that those risks are minimized by professionals doing their jobs and caring about them. And, that nearly $15 billion in taxpayers' money would have bought a decent measure of oversight.

Correction: This editorial misquoted National Transportation Safety Board member Debbie Hersman. She described some problems reported by the board as "enough to set your hair on fire."