For the COVID-19 Era, a United States Disaster Investigation Board

By Glenn Corbett, Scott Gabriel Knowles

Every morning, when we scroll through the day’s infuriating COVID-19 news, we take some solace knowing that the United States Disaster Investigation Board is collecting documents, data, and testimony now, so that the next Congress can aggressively reform the nation’s national disaster response capacity, preventing another virus—or some other black swan event—from walloping us in exactly the same way.

And then we remember, of course, that the nation doesn’t have a Disaster Investigation Board. And because of that, we have no guarantee that the crucial lessons of COVID-19 will be learned in time to shorten the pandemic or to prevent the next one. Perhaps more demoralizing, we will not have the sort of above-the-fray analysis needed to force political accountability and cultivate the political will to avoid future crises.

Although the current disaster is new (literally a novel coronavirus), the United States has many precedents for investigating and determining basic accountability for disasters, with varying success. And recently, there has been no shortage of calls to reanimate the inquiries of disasters past, with all their shortcomings.

We have no guarantee that the crucial lessons of COVID-19 will be learned in time to shorten the pandemic or to prevent the next one.

Former New Jersey governor and 9/11 Commission cochair Thomas Kean has called for a COVID-19 investigation modeled after the one he led. The 9/11 Commission, for all its apparent popularity today, was slow, underfunded, and criticized in its time for the Bush administration’s delays and conflicts of interest. In addition, it was composed of politicians, not subject matter experts, and that prevented the investigation from asking the sort of probing questions that were needed. Many of those questions remain unanswered today.

Likewise, Craig Fugate, a former administrator of the Federal Emergency Management Agency, has called for an investigative commission to start right away. In a recent op-ed in the Washington Post, Fugate and his coauthor emphasized the need for speed because “information and personal observations needed for effective after-action assessments are best collected while they are fresh.” We agree, in part because the “fog of disaster” does create situations where precious information is lost, crucial interviews are never performed—and in this case key parties may become sick or even die in the middle of the pandemic response.

Another model that is sometimes mentioned is that of the congressional committees that investigated Hurricane Katrina, which ultimately produced some useful information and some limited accountability. But political posturing led to unnecessary delays and rushed conclusions. It is notable that it was not Congress, but Levees.org (a private nonprofit organization) that exposed the failures of New Orleans’s levees, rather than the storm, as the cause of many of the fatalities in the city.

We do not believe these past mechanisms are up to the task of investigating COVID-19. If we wait for the normal gears of government-disaster-forensics to turn, we will likely end up with a feel-sorta-bad report in which first responders and the medical community are patted on the back, agencies such as the Department of Health and Human Services are scolded for not being better prepared, and that’s it—there will be no accountability for key failures.

Fugate and Kean aren’t wrong in calling for an investigation, but speed and confusion and the usual political wrangling are not the only concerns here. Conducting an inquiry into COVID-19 given the nation’s current political polarization will be incredibly difficult, if not impossible. Long before the pandemic dominated the news, trust was at a low ebb, and to assume now that the Trump administration will make a good faith effort to examine its own shortcomings is beyond naïve.

To meet the challenges of this era, we have to set aside 9/11 and Katrina thinking. What we need is a way to investigate disasters—not only this one but those of the future—that has bipartisan credibility, and is always ready to spring into action. We need COVID-19 era thinking.

The Disaster Investigation Board that we propose does not need to be imagined out of thin air: the model already exists in the Chemical Safety Board (CSB) and the National Transportation Safety Board (NTSB). These federal agencies are bipartisan, term-limited, staffed by scientific experts, and largely independent from the political winds of the day. They enjoy wide public confidence and international respect.

Despite the relatively small size of both the NTSB and the CSB, their reports and recommendations have been numerous and spot on. Back in 2017, elements of the chemical industry itself called for full funding of the CSB when it was proposed to be zero-budgeted by the Trump administration. Improvements in airline safety and prevention of chemical plant explosions can be tied to the numerous investigations conducted by these agencies.

What we need is a way to investigate disasters—not only this one but those of the future—that has bipartisan credibility, and is always ready to spring into action. We need COVID-19 era thinking.

And these boards’ recommendations for improvements aren’t just “technical” in nature. For example, when the CSB investigated the explosion of a fertilizer warehouse in the town of West, Texas, in 2013, its findings identified a range of diverse problems in such areas as emergency response, limited regulations on proper storage of the materials, occupational safety and health, and land use planning. The findings were directed at federal, state, and local governments as well as the private sector.

A Disaster Investigation Board would also be capable of launching a broad and deep investigation, led by experts from disparate disciplines who are capable of ensuring that all the different issues evident in a disaster would be investigated. These experts would come from various fields of science, technology, engineering, and mathematics, as well as from the social sciences and public health. Any disaster investigation worth conducting must pack the analytical capacity to match the complexity of the disaster under review. Indeed, the investigators must not only determine what went wrong but also frame technical and policy solutions so that they can be acted on by regulators and elected officials.

As the COVID-19 pandemic is making obvious, any modern disaster under expert scrutiny reveals compound, overlapping, and complex sociotechnical phenomena that are too often decontextualized, and oversimplified. This pandemic, however, is not solely a “natural disaster”—it reveals a deep history of risk toleration, and the full interconnectedness of natural, technical, and social systems. Identifying the multiple and many-layered factors that drove the disaster requires taking stock of all the contributing circumstances. For example, postdisaster investigations of COVID-19 must examine not only the failure of government to provide tests and ventilators but also the structural racism that appears to be driving disparate rates of cases and deaths among people of color. A partial investigation will miss the full societal impact of the pandemic. We will have likewise missed a crucial opportunity to formulate meaningful, equitable, postdisaster reforms.

Establishing a Disaster Investigation Board capable of recognizing this fact of disaster complexity will get the United States out of the trap of using narrow analytical approaches to understand what went wrong at different stages before, during, and after a disaster. And it will put the nation on the path toward truly learning from these events.

Postdisaster investigations of COVID-19 must examine not only the failure of government to provide tests and ventilators but also the structural racism that appears to be driving disparate rates of cases and deaths among people of color.

For all these reasons, how we formulate a Disaster Investigation Board will be of great importance. It must be led by a nonpartisan expert and should have embedded staff scientists in the Department of Health and Human Services and the Federal Emergency Management Agency, and it should have subpoena powers to obtain documents and testimony, and the power to impose criminal penalties for those who hide, destroy, or delay the truth. It would confer with private-sector entities, including university laboratories and commercial firms, in order to gain the greatest insight into the crucial problems exposed in a disaster. But it would be free from allegiance to any agency, any industry, or any party ideology; through this independence it would draw strength.

In nondisaster times (if we ever have those again), the Disaster Investigation Board could retain a small staff, but when disaster strikes it would call on networks of scientists and other subject experts who are vetted and ready to serve. Keeping a lean permanent team will demonstrate a consciousness that what is not needed is one more bureaucratic solution—those clearly have not worked.

Establishing a Disaster Investigation Board will allow us to break free of the history of postdisaster investigations that have (like disaster relief bills) allowed Congress to come together and show seriousness and concern in moments of national need, before moving on without addressing the underlying hazards in American society that produce disasters.

Of course, former vice president Joe Biden should make this demand part of his presidential campaign. But we believe much of the will to create an investigation board will come from pressure outside Washington, from the governors who have suffered in the absence of federal leadership, and from the American people who expect better of a system of scientific research that they’ve invested in for decades.

The end point for today’s disaster is not clear. But the nation cannot afford to wait for a blue ribbon commission or trust the president to empower experts after the fact. We need a permanent Disaster Investigation Board, and we need it now.