What Did We (Not) Learn from the Boil Water Notice

Source: 5 NBC DFW.

Richardson City Manager Don Magner read a memorandum to the City Council on December 16 titled "Boil Water Notice: Summary of Findings and Recommendations." I have three takeaways:

1. To his credit, Magner admitted that individuals on City Staff made errors in judgment on the day of the event and he disciplined four individuals.
2. Magner failed to assign blame for all of the "gaps in training and operational oversight" that contributed to the need for a BWN.
3. There is still a five hour period in the timeline that deserves more investigation.

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Further thoughts on those takeaways:

1. Magner's memo says, "Based on the facts gathered to date, I have ordered disciplinary action for four members of Public Services staff who failed to follow their training, to communicate effectively within their chain-of-command and/or to exercise good judgment in the execution of their job responsibilities."

   This is remarkable. I can't remember the City ever publicly taking responsibility for error. Such admissions, certainly from other organizations, often use the passive voice ("Errors occurred..."). In that construction, errors are something that happen "to" people instead of "by" people. Magner doesn't fall back on that common sidestepping of responsibility. So, kudos to Magner for the transparency here in assigning blame to the City. But...

2. Magner throws four city staff individuals under the bus for errors made on the day of the event, but he fails to assign any responsibility to the managers, from the City Manager on down, for errors in insuring all city staff had proper protocols in place and adequate training in those protocols. If you do a full causal analysis, this is where the root cause lies, not in anything done or not done on the day of the event.

   Magner's memo says, "We need to clearly establish protocols for ongoing training..." I would suggest the City conduct a Failure Mode and Effects Analysis (FMEA). It's a long-established practice of determining just what can go wrong and what the consequences would be if those things do go wrong. That allows an organization to prioritize preventive measures for the most consequential failures to keep them from happening in the first place. I don't want to presume the findings of an FMEA, but I saw nothing in Magner's memo that suggests such analysis is a regular part of the City's review of operations. That's a management failure.

3. Magner gives a timeline whose timestamps mostly stop at 2:14 pm, when pressure in the system was confirmed to have been restored to 35 psi. After that, there are two paragraphs of activities without exact times. One is that Public Services management staff "determined the BWN criteria had been met — meaning that a BWN was necessary." When exactly was that determined? It doesn't explicitly say.

   An action with a specific time is: "At 7:10 pm the BWN was distributed." That means, for up to five hours, from 2:14 to 7:10, for all the City knew for sure, water flowing to homes could have been contaminated. During that five hour gap, the City "held calls with RISD officials so a coordinated and orderly set of messages about the BWN could be shared with both City and RISD stakeholders." A generic set of messages warning the public not to drink the water should have been already prepared for use in such an emergency and in a computer ready to send. One call from the City to the RISD should have been enough to trigger the appropriate warning to the public immediately. That should have happened at 2:14 pm, when Public Services management staff "determined the BWN criteria had been met—meaning that a BWN was necessary."

   Instead, "At approximately 4:00 pm, discussions about the cause of the issue, and other related matters, commenced with the City Manager's office, the City Attorney, and Communications Staff, among others." Wow. That's three more hours between those 4:00 pm discussions and the 7:10 pm distribution of the BWN. The fact that the City Attorney was involved is curious. It sounds like a cover-your-ass kind of detail. If at 2:14 pm Public Services management staff "determined the BWN criteria had been met—meaning that a BWN was necessary," why is the City Attorney needed at 4:00 pm? He should have long ago signed off on those initial generic "Don't drink the water" warnings and the conditions that would trigger them being sent.

   Magner's memo made another curious point by saying that "contaminants were not believed to have been introduced into the water system." That is no excuse for the failure to act during the five hours it took to start distribution of a required BWN. It should be investigated whether that belief had anything to do with the delay.

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Those are my takeaways from the City Manager's memo. I also have some takeaways from the City Council's response to hearing the City Manager read his memo. I'll limit my takeaways to Mayor Bob Dubey's comments, as he is the leader of the City and the leader of the City Council. Let's examine the leadership he showed here.

Mayor Dubey: "Mr. Magner...great job."

Reading everything above, I have a hard time giving the City Manager an attaboy here, beyond his admission that City Staff did in fact make errors. Magner failed to go far enough up the chain in that exercise of taking responsibility and the Mayor not only lets him off the hook scot-free, he praises him — "Great job."

Mayor Dubey: "I think with the things that are in place up to this point, you followed best practices..." Was the mayor even listening? Magner admitted to "gaps in training and operational oversight." Clearly, the City was NOT following "best practices." That seems to be a term that the Mayor has a habit of bandying about in a casual way.

Mayor Dubey: "Part of our Council Goals is we want and expect that we need to be transparent. And I think you have met and exceeded that particular thing." Like I said, Magner's admission of error on the part of four City Staff was remarkably transparent. I, too, gave him kudos for this. But saying Magner "met and exceeded" the goal is going too far. Again, Magner said there were improvements needed but he did not take any responsibility for the existence of those shortcomings.

Mayor Dubey, speaking of Magner: "Your ability to communicate is stellar." Stellar it is, but not how Mayor Dubey thinks it is. Magner deflected all personal blame in this sad story and managed to get the Mayor's praise for his role. Stellar job, indeed.

Mayor Dubey: "I know it's not easy disciplining people that work within the system, but it's important that the community knows that we don't take these things lightly, and I know you didn't."

Magner did his job, disciplining when it's due. The Mayor sidestepped his own job, finding nothing wrong with the City Manager's preparation of the City for this contingency. The buck should stop somewhere but not just at the feet of the workers at the scene. It's the City Council's own responsibility to provide oversight of the City Manager. They failed, too.

"Discipline is swift,
Yet the roots lie much deeper—
Who will tend the soil?"
—h/t ChatGPT