Although I sent him the articles right away, I never heard back from him. A year after our meeting, I e-mailed Harald again, detailing for him the even bigger mountain of materials I had accumulated and explaining that I had been fortunate enough to speak with every major player on the project. I followed up my e-mail with a fax, a letter, and a voice mail message. A week later I spotted an e-mail reply from Harald in my inbox. As soon as I read the first sentence, I knew I didn’t need to read further. He had simply cut-and-pasted his reply348 to me from two years earlier, without adding a single word.
For years, a debate has persisted among the people who examined the diver deaths about who had been most responsible. Was it Harald, for the decisions he made in conceiving and implementing the breathing system, and for his insistence on pushing ahead despite all the warning signs? Or were the various bigger players more to blame, since they had let the project get to such a crisis point that they needed to call in Harald for the rescue mission—and then had signed off on his plan without giving it the scrutiny it desperately needed?
Plaintiffs’ attorneys John Prescott, Nina Pelletier, and Bob Norton, perhaps not surprisingly, argue that more responsibility rested with the big players, since without their failings, there would have been no Harald. On the flip side, the AG’s Joan Parker and the union’s Dan Kuhs maintain that Harald was far more to blame, because his actions were so willful. Clearly, he had not intended for Tim and Billy to die. But, they point out, he had controlled the complex breathing system that was the divers’ means of staying alive in the tunnel. He had chosen to keep critical information from other players and had disregarded the divers’ concerns.
And how about Roger Rouleau, Norwesco’s owner and Harald’s boss? Parker had kept him in her sights because he was the only one from Norwesco who had stood to gain financially from the job in any meaningful way. Ultimately, though, she concluded that Harald was far more responsible because of the way he had hoarded both information and operational control.
Three years after the diver deaths, Roger closed down Norwesco and, with a colleague, formed a new business that same year, doing the same kind of diving work but under a new name, Associated Underwater Services. In the summer of 2007, at a BP oil refinery in Washington State, a piling detached from a vibrating hammer and killed one of Roger’s employees, a Massachusetts native by the name of Christopher Primeau. OSHA levied a “serious349” safety-violation fine against Associated Underwater and several more against the general contractor. Roger told me the incident dredged up bad memories from Deer Island and contributed to his decision to leave the dive business. Primeau’s family members remain furious with him and his business partner for safety lapses they contend were inexcusable. In 2009, around the tenth anniversary350 of the deaths of Billy and Tim, Roger sold his share of the business to his partner.
In retrospect, Roger told me, he had failed to supervise Harald adequately on the Deer Island project, and failed to heed the concerns that Hoss and others had raised with him. “There were a lot of things going on that I didn’t understand fully, but I accepted the fact that Harald had his bases covered,” he said. Only after the accident did Roger come to believe something important about Harald: “He didn’t know what he was doing.” Yet Roger argues that the bulk of blame ultimately should rest with the players who were more powerful than either him or Harald. The designer, contractor, construction manager, and tunnel owner all knew about the plug problem for years but failed to deal with it, instead sloughing it off on a small diving subcontractor. (Of course, Norwesco had chosen to take on the job even though two other established dive companies had declined to bid because of safety concerns.) OSHA officials had raised no objections when Roger presented Harald’s plan to them, even though it blatantly violated the agency’s requirement for mechanical ventilation in the tunnel. Looking at it now, Roger said, one thing is clear. “We should have never been in there.”
After spending years marinating in this project and its aftermath, I now find Mary McCauley’s argument for shared responsibility to be the most persuasive. The state police detective maintains that Harald must shoulder the heaviest blame because of his reckless actions. However, she stresses that significant responsibility also rests with the project’s memo-warring big players, with Roger, and even with OSHA officials, who all became disturbingly hands-off when it was time to review the plan and supervise Harald.
Whenever a worker dies, there is a natural inclination to hunt for a huge, single failure that can be blamed. In reality, a worker’s death is usually caused by a series of small, bad decisions made by many individuals, none of which, on its own, would have been enough to produce a fatality. Disaster strikes only when all the holes in the Swiss cheese line up.
But the fact that all those holes did line up in the tunnel case forces a larger, lingering question. How could this idea of sending divers to a place as remote as the moon, asking them to entrust their lives to an improvised, untested breathing system, have ever made sense to sensible people? The answer lies in the dangerous cocktail of time, money, stubbornness, and frustration near the end of the over-budget, long-delayed job. The major players desperately needed the project to surmount its last enormous hurdle. It’s almost as if, amid all the fatigue, expense, and mutual distrust that had built up like plaque in the arteries, these players looked at Harald’s dazzling plan, then closed their eyes and hoped that it made sense. If they had kept them open, they would have had to confront the many ways in which it didn’t. They also might have hatched a better plan, like the “steel straw” vent solution that was ultimately used to get the plugs out so efficiently.
Even Dave Corkum, Kaiser’s memo-writing manager, while not walking away from his insistence that Harald’s plan seemed reasonable, acknowledged to me that as distrustful as he and everyone else had become by the end of the seemingly interminable tunnel project, he probably wanted to believe the plan was sounder than it actually was. “Was this like our fairy godmother coming in? Like manna from heaven?” he asked. “Maybe.”
The deaths of Billy and Tim had been more than just preventable. They had been more than just predicted. Given all the bad decisions—by all the players—the deaths had effectively been preordained.
Because of its untried nature, the divers’ plug-pulling mission appeared to be in a category of its own. However, when I consulted several specialists in workplace safety and organizational behavior, they found in Billy and Tim’s deaths important and widely applicable lessons for avoiding all sorts of bad outcomes on the job—and in life in general.
Injuries and deaths tend to happen late in projects, when confidence runs high and tolerance for delay dips especially low. This springs from a phenomenon known as normalization, which, in this case, allowed people to accept looser standards in the name of greater speed. The more people do something without suffering a bad outcome, the harder it becomes for them to remain aware of the risks associated with that behavior. This lesson has implications for any task involving some level of hazard, from cleaning gutters to chopping vegetables. If it was worth climbing down the ladder to move it a few feet at the beginning of the gutter job, it should be worth taking that same sensible precaution near the end.
Another important lesson: a poorly thought-out safety measure is often worse than no safety measure at all. This explains how child-safety products that careful parents once viewed as necessities—from baby walkers to bath seats—can end up leading to infant injuries and deaths. It also explains how early requirements for ironworkers to be tied off with a rope when working at high elevations unwittingly introduced serious choking hazards, a problem that continued until the requirement was upgraded to include a harness. Remember that when it came to the tunnel, the fifty-five plugs were a secondary safety measure. By failing to spell out how those plugs could be safely removed after the tunnel was finished, the tunnel designers and managers baked into the project an enormous and unnecessary risk. Like Prohibition spawning organized crime, it was a cruel case of unintended consequences. Along the same lines, all the redundancies that Harald had touted in his plan not only failed to safeguard the lives of the divers but made things worse by creating a false sense of security.
348 (Epilogue, note 2)
He had simply cut-and-pasted his reply: Harald Grob to author, November 7, 2011.
349 (Epilogue, note 3)
OSHA levied a “serious”: In December 2009 an administrative law judge vacated the serious violation and $2,500 fine against Associated Underwater Services (AUS), the successor company to Norwesco. But in February 2012 that decision was overturned and the citation reinstated. AUS paid the fine the following month, according to Patricia Drummond of the U.S. Department of Labor. Primeau’s sister Julie argues that the kind of company recklessness seen in the tunnel deaths was repeated in her brother’s death.
350 (Epilogue, note 4)
In 2009, around the tenth anniversary: After Roger Rouleau sold his interest in the company, his former business partner Kerry Donohue and Donohue’s wife took control. Rouleau, interviews by author, 2009-10; licensing records.