On April 15, three-year-old Jacob Smith left the side of his mother, who had traveled from New York to act in an American Repertory Theatre production. The pair were descending a staircase leading from the main lobby to the basement of the 25 year-old Carpenter Center for the Visual Arts. The toddler ducked between a nearly three-foot-wide gap in the stair railing and fell one story to the concrete floor.

The child was not critically injured--he was treated and released from a hospital the same day for a broken wrist, fractured skull, and head and facial injuries--and the University paid for all medical expenses. But the accident left Carpenter staff angry and spurred the University to reexamine its campus safety procedures.

The incident is a classic example of the hazards of a labyrinthine bureaucracy. The danger was known, reported by a state inspector, and ignored. Red tape encumbered state, city and Harvard offices--all were aware of the threat, yet all were confused about who had official responsibility. So none took the initiative.

Internationally famous architect LeCorbusier built the center. And center affiliate Michael A. Callahan left it--taking an unpaid leave of absence to protest the failure to repair the rails.

Callahan, supervisor of Film Studios and electrical engineer, wrote an explanatory letter to his students: "I've known the place was unsafe for 11 years...I talked to people, they agreed it was unsafe, but after all, if the building met code when it was built, and it's now a registered national landmark, doing anything would despoil the work of the Master. Not to mention cost a lot of money."

State documents reveal that a state inspector on unrelated business was examining the Carpenter Center in October 1985 when he found the widely-spaced stairway rails "in gross violation of our present code." According to current code, stair railings may not be separated by more than six inches.

However, because the state transferred authority for code enforcement to city governments in 1973, the state inspector, Arthur Ritacco, was powerless to issue a citation and instead had to turn the matter over to Cambridge inspectional services.

Ritacco then, in letters to city officials and administrators at the Carpenter Center and the Faculty of Arts and Sciences (FAS), "strongly recommended" immediate corrective action on the Center's railings. He urged this move although building owners usually do not have to comply with changes in state codes after original construction or major renovation.

But confusion surrounding building codes effective when the Carpenter Center was built in 1963--10 years before cities assumed regulatory duties from the state--forced Cambridge inspectional services to ask Ritacco's state office for documents determining whether the Center was in compliance at the time it was built.

But for an unknown reason the matter was dropped that fall, and Ritacco never responded. The Cambridge inspector was later dismissed for unrelated reasons. Cambridge inspectional services is also under investigation for possible violations in its inspection procedures.

Clogged Cogs

Meanwhile, the cogs of the Harvard bureaucracy were equally hesitant to turn. Carpenter Center officials who received Ritacco's notice in 1985 said the problem "did not lie with us" because structural maintenance problems were designated to other University agencies; staff said they forwarded the notice to Facilities Maintenance at the time. However, earlier this year Carpenter officials did authorize placement of chicken-wire mesh around the site of the April accident when a tour group of small children visited the center.

The FAS official whom Ritacco had written, Eugene J. Arcand, director of facility finances, said he did not recall the letter or the details of the situation. No action was taken by the University until the accident.

At the time of the accident, an official with the Harvard Planning Office said the events seemed to resemble a "caricature of bureaucracy."

FAS Associate Dean for Physical Resources Philip J. Parsons, who took office in summer 1986 after the correspondence had ended, said he assumed someone in his department "knew about the center" and the railing problem. "I've asked people to try and find out" what happened, he said.

"There's got to be a clear place where there's somebody who knows or feels it's his responsibility. That's something that is not clear in this situation," said Parsons.

He said he instructed building superintendents after the accident to "by all means follow procedure, but be alert beyond that."

Repairing the Hazard

The railing gap which caused the entire problem was simply patched up this spring. Workmen installed stiff wire grids on all the railings around the building the week after the accident at a cost of approximately $10,000, according to Parsons.

A committee of Parsons, Carpenter officials, professors, and architects met this month to design a permanent solution for the wide Carpenter railings, Parsons said. The committee commissioned Boston architectural firm Wallace Floyd Associates to design changes, which may include scrapping the current railings and constructing safer ones, or adding permanent covers to the existing railings.

But repairs for the accident stretched beyond the Carpenter Center railing, as Harvard aimed to sort out its bureaucratic jumble and prevent such a mix-up in the future.

Following the accident, Harvard sped up plans to check campus buildings for danger zones. Now superintendents will be encouraged to inspect their own buildings on a regular basis, using a standard checklists of hazards and acting under the FAS coordination. Although Harvard Insurance Office director Annemarie Thomas said she considered last December creating such a program, she and Parsons said the Carpenter accident hastened their efforts.

Harvard's insurance brokers are now compiling safety checklists for five buildings representative of the types of buildings FAS operates--classroom, lab and studio, office, museum and library facilities, Thomas said. Depending on the success of the FAS pilot program, Thomas said, a similar inspection program may be adopted for all Harvard buildings, which number more than 500.