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Agenda

Cleaning Up Messes

Affordable Care Act

On October 21, 2013, President Barack Obama entered the Rose Garden and spent nearly an hour apologizing to the American people for the launch of HealthCare.gov. The insurance website designed by the federal government to allow consumers to purchase health insurance policies as mandated by the Affordable Care Act (ACA), aka Obamacare, was broken. "The website," President Obama said, "is not working the way it should."

The website launch had quickly become a train wreck and threatened to upend the ACA, one of President Obama’s crowning accomplishments. In response, the government engaged some of the world’s finest information technology experts to fix the system and restore confidence. The new team quickly established a plan for solving the mess.

Fixing Problems

Experts are often called in to clean up other people's messes. It should be an honor to be entrusted with such a task. In the case of the HealthCare.gov issues, the measures the IT experts took are instructive to all experts who are called upon to fix other people’s problems. Here are some tips for what SMEs should do in this situation.

1. Identify the Problem
Identify the true problems independent of politics, preferences, finger-pointing, and emotion. What is the actual problem, and more important, what precisely constitutes resolution of the problem?
2. Identify the Obstacles
Identify the obstacles to resolution. There will always be barriers to fixing a problem. The expert must be empowered to perform the work required. If the necessary actions cannot be taken, then the problem will not be solved.
3. Engage the Right People
Include the people who understand the problem and want to fix it. An expert can rarely walk into a critical problem when tension is high and solve the problem without the contribution of those who have been involved from the beginning.
4. Avoid Blame
Finger-pointing was plentiful in the days immediately after the launch of HealthCare.gov. Republicans blamed the Democrats, government bureaucrats blamed the contractors, and so on. Ultimately, the people who solved the problem ignored the blame game and focused on the problems and solutions, not any incompetence or malevolence.
5. Don't Jump to Conclusions
Even if you think you know what is wrong and how to solve it, don’t embrace a solution until all other possibilities are eliminated.
6. Seek Knowledge, not Rank
Involve people with knowledge, not rank. Just because a person appears at the top of the organization or sits in a corner office does not mean they know what is wrong. Cubicles hold solutions just as readily as offices do.
7. Focus
Triage the immediate problems and resolve them first. Organize all remaining issues and prioritize them for resolution.

Whether you love or hate Obamacare, the fact is the website launch was resolved. The right people came together and fixed the problems that ailed the initial launch. Enrollments went from twenty-six thousand to nearly one million in one month.

The Disaster at Lac Megantic

First impressions matter, and they matter a lot.

  • On July 6, 2013 a train with 73 freight cars derailed at Lac-Megantic, Quebec, Canada
  • The train was left parked on the tracks 7 miles away. When the parking brakes failed the unmanned train began rolling down the 1.2% grade
  • At 1:15am local time the train entered the town at 65 mph. (The speed limit on the curve at Lac Megantic is 10 mph)
  • Most the cars contained crude oil. When the train derailed approximately six millions liters of crude oil exploded
  • 47 people died in the blaze
  • 30 buildings were destroyed, 36 more eventually demolished due to contamination

More Disasters

Over the centuries experts have made some colossal errors. Here are just a few that stand out.

Beirut Ammonium Nitrate Explosion

On 4 August 2020 a large amount of ammonium nitrate stored at the Port of Beirut in the capital city of Lebanon exploded, causing at least 218 deaths, 7,000 injuries, and US$15 billion in property damage. The blast left 300,000 people homeless. The chemical material had been stored in a warehouse without proper safety measures for the previous six years after it was confiscated by the Lebanese authorities from the abandoned ship MV Rhosus. The blast shook the entire country of Lebanon. It was felt in Turkey, Syria, Palestine, and Israel, and heard more than 150 miles away. It was detected by the United States Geological Survey as a seismic event of magnitude 3.3, and is considered one of the most powerful artificial non-nuclear explosions in history.

Great Chinese Famine

Trofim Lysenko was a Russian agriculture researcher who worked as the Director of the USSR Institute of Genetics during the Stalin era. In the 1950s Chinese agricultural policy makers followed Lysenko's dogma regarding food production. Based upon Lysenko's theories, China adopted new farming policies which banned private farming and changed farming processes. At the same time, China experienced draught conditions in much of the country. Food production dropped dramatically. As a result, between 1958 and 1962 as many as 36 million Chinese citizens starved to death. Trofim Lysenko was considered an expert in genetics and food production yet he was responsible for the starvation of tens of millions on multiple continents.

Bhopal Pesticide Disaster

The Bhopal disaster was caused by a gas leak on the night of 2–3 December 1984 at pesticide plant in Bhopal, India. Over 550,000 people were injured when exposed to methyl isocyanate gas. The highly toxic substance made its way into and around the small towns located near the plant. Approximately 4,000 people died. Warren Andersen was the CEO of Union Carbide at the time of the incident. He was charged with manslaughter by Indian authorities, declined to appear in Indian court hearings, and was declared a fugitive from justice. Until his death in 2014, Anderson denies any personal wrongdoing.

Iraq Withdrawal and Weapons of Mass Destruction

America's involvement in Iraq is bookended by two intelligence disasters. In 2002, during the Bush administration, US intelligence believed that Iraq possessed weapons of mass destruction, more than ten tons of uranium, and that they could build nuclear weapons within three years. This misleading information led to the United States' ill advised decision to initiate the second gulf war. Fast forward to 2021, during the Biden administration, US intelligence believed that democratically elected leadership would maintain the country's security for a prolonged period. The rapid transition of power to Taliban forces left thousands of Iraqis displaced and vulnerable.

Fire on Apollo 1

In 1963 Joseph Shea was assigned to manage the design and construction of the Apollo space craft. Three years later the crew of Apollo 1 expressed concern about the amount of flammable material inside the oxygen rich cabin. In response, Shea ordered the removal of the materials from the craft but five months later the material remained. On January 27, 1967, during a launch simulation, the materials caught fire. Due to faulty design, the crew was unable to open the cabin's door, resulting in the death of all three crew members.

Gettysburg

General James Longstreet knew that the Battle of Gettysburg would end poorly for his Confederate Army. He told his commanding officer, General Robert E. Lee, that their forces would fail to over power the Union forces. "No fifteen thousand men ever arrayed for battle can take [the Union] position," he told Lee. Nevertheless, General Lee commanded the attack across a mile of open terrain. In just three days, half of Longstreet's forces would be dead or wounded.

Bloodletting

Removing blood from patients as treatment for nearly any malady was embraced for nearly 3,000 years. The precise origin of the practice are not certain, but one doctor significantly influenced its prevalence. Galen of Pergamum lived in 200 AD and was the most renowned physician of his time. His prolific writings embraced and reinforced the practice of bloodletting. His works were translated and studied throughout the middle ages. It was not until the 19th century that the practice was finally rejected at scale.

Fidenae Stadium Collapse

The wooden amphitheater of Fidenae, in ancient Greece, was constructed in 27 AD by the entrepreneur Atilius. After a temporary ban on gladiator games was lifted, tens of thousands of spectators flocked to the stadium to witness the earliest events. Filled beyond capacity, the stadium collapsed killing or injuring more than 20,000 people. The Roman Senate responded to the disaster with new building codes and inspections. Atilius was banished.

Chernobyl Nuclear Disaster

Anatoly Stepanovich Dyatlov was the deputy chief engineer at the Chernobyl Nuclear Plant for 13 years before the fateful day of April 26, 1986. Contrary to the advice of at least two subordinates, he ordered the continuation of the ill fated nuclear experiment which melted down reactor #4 and caused the death of thousands of people, the forced relocation of 350,000, and the contamination of living quarters of 5,000,000. As the primary cause of the world's worst nuclear disaster, a Soviet court sentenced Dyatlov to 10 years in prison.

Halifax Shipping Disaster

Aimé Le Médec was the captain of the SS Mont-Blanc cargo vessel. On Dec 6, 1917 the ship was fully loaded with explosives in route to France. While entering the Halifax harbor, the ship collided with the outgoing vessel, SS Imo. As a result of the collision the Mont-Blanc caught fire which ignited the explosive cargo on board. The resulting blast was the largest man-made explosion to that date in history. A 1,100 pound section of the ship's anchor was thrown 2.5 miles inland. 2,000 people were killed and nearly 10,000 injured. The ship's captain was assigned blame for not taking actions that could have averted the catastrophe.

Countrywide Financial Disaster

Angelo Mozilo has become the poster child of the greed and scandal that rocked the financial industry in the subprime mortgage crisis. As co-founder of Countrywide, he engaged in aggresive lending practices and derivative selling. The company grew to become the largest mortgage lender in America. Mozilo obtained backing and favor in Washington D.C. through zero interest 'loans' to political officials. He is one of few financial industry executives who faced criminal charges in connection with the financial crisis. In 2010 he agreed to pay settlement and industry bans rather than go to trial.

Space Shuttle Challenger

The Space Shuttle Challenger disaster occurred on January 28, 1986, when the craft broke apart 73 seconds into its flight, killing all seven crew members aboard. The disaster was caused by the failure of the two redundant O-ring seals in a joint in the shuttle's right solid rocket booster. Record-low temperatures at the time of the launch reduced the elasticity of the rubber O-rings, reducing their ability to seal the joints. The broken seals caused a breach in the joint shortly after liftoff, which allowed pressurized gas from within the solid rocket booster to burn through the wall to the adjacent external fuel tank.

Vajont Dam Disaster

The Vajont Dam is located in northern Italy. At 262 meters (860 feet) tall, it is one of the tallest dams in the world. It was built between 1957 and 1960 for electricity production. On 9 October 1963, during initial filling, a landslide displaced 50 million cubic meters of water. The resulting tsunami overtopped the dam by 250 meters (820 feet) bringing massive flooding and destruction to the towns above and below the reservoir. Between 1,900 and 2,500 people perished.
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