Long before Luger Nodar Kumaritashvili of the Republic of Georgia crashed and died on a training run there, Vancouver’s Whistler Sliding Centre, now the site of the Olympics luge, bobsled and skeleton competitions, had been the target of complaints, warnings and controversy regarding its safety. After the first international training event at Whistler in November 2008, the president of the luge governing body openly expressed worries over the speed of the track. Since then, there have been sufficient accidents on the track, not only in the luge, but also bobsled and skeleton races, that the fatal accident there could not fairly be called “a surprise.” Just a day before the Georgian was killed, United States luger Mark Grimmette was quoted as being concerned about the course’s speed, saying, “I think we’re probably getting close, too close, to the edge.” Later the same day, a Romanian luge racer was knocked unconscious during his training run. The frequency of crashes during the training runs last week were far above the norm.
Nevertheless, Olympic and luge officials chose not to make changes to the course that would limit the speeds in excess of 90 miles per hour that luge, bobsled and skeleton competitors were reaching, speeds beyond what they were used to, or had trained to handle.
The joint statement from the luge federation and the Vancouver Organizing Committee following Kumaritashvili’s death after he was flung off the course into an unpadded metal pole announced that “there was no indication that the accident was caused by deficiencies in the track.” The accident, the statement suggested, all Kumaritashvili’s fault, because he “did not compensate properly to make correct entrance into Curve 16.” This conclusion came without the assistance of any investigation.
When the luge runs resumed, the ice on the track had been re-contoured to keep sleds toward the center of the track. A new, high wooden wall stood just beyond the curve where Kumaritashvili had been thrown off the track and died. Exposed metal beams just before the finish line now had protective padding. Finally, the men’s starting position was had been relocated to a lower position, a change that would slow maximum speeds by about five or six m.p.h.
Not that the track was dangerous before, you understand.
This sequence of actions leading up to and following the Winter Olympics luge tragedy is an especially pure example of the classic progression of irresponsibility, carelessness, dishonesty, lack of integrity and avoidance of accountability that infects bureaucracies everywhere. The terrorist attacks of 2001, the mortgage meltdown, Toyota’s implosion, the Madoff scheme, baseball’s steroid scandals, the current scientific blunders surrounding climate change research and too many other fiascos to mention in industry, entertainment, sports, science,the arts, politics, international affairs and every other human activity follow this pattern.
Just in case you can’t already recite it from memory, it goes like this:
• There is a known weakness in a system and a looming danger.
• Credible individuals issue warnings.
• Those in charge ignore them, because 1) it is easier to do nothing, 2) the flawed conditions have compensating benefits, 3) they are afraid to take responsibility, 4) nothing bad has happened yet, so by definition the Cassandras are just alarmists, or 5) the leaders and managers are incompetent.
• The predicted disaster occurs.
• The leaders of the organization responsible deflect all blame, and assign it elsewhere, saying that there was no way they could have predicted what has happened.
• The organization then makes all the changes, repairs and systemic improvements that could have prevented the disaster that already happened, all of which they could have, and should have, done before it occurred.
• The organization and its leadership loses a substantial amount of its credibility and public trust, perhaps permanently.
All right, you can’t change human nature. Hindsight is always acute, and the tendency to let problems continue until ignoring them is no longer an option seems to be hard-wired into most of us…
“…That tire looks a little bald, but we can probably drive on it a little longer. Yeah, that water heater is way past its expected life span, but it can last another year. I’m feeling pretty good; no need to have that scheduled physical right now…”
We can lecture, curse, demand, and rant about leaders, executives and managers procrastinating or focusing on short-term rather than longer-term problems, and we will be absolutely right, but most of us exhibit the same self-destructive traits ourselves. When the U.S. infrastructure starts to fall apart soon—-and it will—with bridges collapsing weekly, streets flooding after hundred-year-old water main pipes burst, and sewer system break-downs turning our Northeastern cities into 19th Century London, all because our politicians couldn’t find the courage to raise the tax money to keep it functioning, we will have a right to be furious. But we should also be furious at ourselves for not painting our homes and keeping the gutters clear. As Pogo said, “Yep, son, we have met the enemy, and he is us.”
The failure of accountability, however, is a different matter, and it is inexcusable. There will be some who will blame lawyers, arguing that admitting blame is tantamount to handing over a huge check for damages, but I don’t accept that. If you are responsible for being negligent and something horrible happens, the only ethical option is to accept responsibility and accountability immediately. This is the only response that begins to rebuild trust. The luge officials claiming that their deadly track was safe was the equivalent of Janet Napolitano saying that “the system worked” after the Underwear Bomber failed to blow up a plane he never should have been able to board in the first place. Her response was dishonest, an avoidance of accountability, and obviously so. So was the response of the Olympic officials.Their subsequent changes to the track proved it.
And yet… they still refuse to be honest and accountable. Incredibly, the New York Times reported that the officials insisted that the changes to the track were not made for safety reasons, but rather to soothe the emotional state of the athletes following Kumaritashvili’s death.
They refuse to learn. We refuse to learn.
Everybody refuses to learn.