I told this story in my book Goal Play! Here's an abridged version
When Bill Geary took over as Commissioner of the Metropolitan District Commission (the regional parks and roadway agency for the Boston area) in 1983, he noticed an odd traffic phenomenon. About once a week, a truck that was too tall would enter one of the two main roads along the Charles River and attempt to go through the underpasses below the main bridge crossing at Massachusetts Avenue. Those underpasses had only ten feet of headroom. The truck would hit the bottom of the bridge assembly, its roof would roll up like the top of a sardine can, and it would get stuck, blocking one or both of the two lanes of traffic. Traffic would back up two miles or more. The MDC police and road crews would go to work, rescue the truck driver, deflate the tires, and tow the truck away. Meanwhile, thousands of drivers would be delayed.
He said to his staff: “What if,” he said, “we put signs up at every entrance to the river roads, at the height of the underpasses, with a pictogram warning taller trucks to stay out?”
“Commissioner,” someone replied, “Can you imagine the liability if our sign breaks a windshield and sends glass flying into the face of a truck driver?”
“Well, what if we make the signs out of rubber so they don’t break the windows?”
“But Commissioner,” someone said, “What good is a rubber sign? Truck cabs are noisy places. A trucker will just hit the sign and drive right through without even hearing that he has hit it."
“Well, then, let’s hang cow bells on each sign, so drivers will hear a noise as they approach our roadway if their vehicle is too high to go through the underpass.”
“Where will we get cow bells?” he was asked.
“I don’t know. Call a dairy farmer and ask where they get their cowbells.”
The signs were installed, cow bells and all. The frequency of crashes in the underpasses went from one per week to less than one per year. Absent Bill’s persistence and personal involvement, we would still be cleaning up those weekly truck crashes three decades later.
Now, look at the two pictures again. Do you see those lonely chains hanging down from the Soldiers Field Road entrance sign? There used to be a rubber sign (and cowbells!) there--placed carefully at the height of the Western Avenue underpass.
In contrast, now, all you have is a sign--way up high--indicating that there is a low bridge ahead. It does not tell you the height of the underpass, and by the placement of the sign, most people would assume that it is pretty high up.
Now, imagine you are an out-of-town bus driver, with a busload of noisy kids, driving at night, using your GPS to find your way to the Massachusetts Turnpike. While we can find fault with the driver if we want, I think we have to acknowledge that what happened to him could happen to anybody.
Here, as in the hospital world, the phrase, "what happened to him could happen to anybody," is usually evidence of a systemic problem, not a personal problem. The Commonwealth of Massachusetts solved the problem of bus crashes on this road 30 years ago. A lack of maintenance or will or understanding on the part of the state administration caused this problem to recur this past weekend. It was, in a sense, inevitable.
And it will happen again and again unless the state agency gets it act together.