Armchair RCA: Nightmare in the Museum

A Root Cause Analysis of the problem is so important to prevent these issues from happening again. But unfortunately I’ve seen a lot of cultural paternalism and blame-the-curators going on in this case. Not only is this not helpful, it will not prevent the next Nightmare in the Museum.

This week news came out of Egypt that made museum professionals across the world cry out in a simultaneous scream of anguish. King Tutankhamun’s burial mask, one of the most famous Egyptian artifacts ever discovered, was permanently damaged when its beard fell off and was then hastily re-attached using epoxy, resulting in a repair job that is neither discrete nor conservationally sound.  According to reports, museum staff were attempting to change lighting used in the display case which contained the mask, when the beard detached from the King’s chin.  No one is quite sure of whether it was knocked off, whether someone was holding the mask improperly and the mask broke under pressure, or whether the beard was purposefully removed because it was loose.  After this already horrible event, museum staff used epoxy to glue the beard back into place.  The resulting re-attachment was very poorly done, as you can see from the photo below.

Photo courtesy of USA Today (Photo: Mohamed El-Shahed, AFP/Getty Images)

Photo courtesy of USA Today
(Photo: Mohamed El-Shahed, AFP/Getty Images)

Not only was the repair job obvious, but the staff who used the epoxy apparently used too much of it. As anyone who has graduated kindergarten knows, if you use too much glue trying to attach anything, the glue will squish out around the area of the object you are trying to attach.  When this happened to you in school, you could simply wipe the excess glue away.  But with epoxy, it is not that simple.  It dries too quickly.  So what did the museum team do at this point?  They reportedly tried to chisel the excess epoxy off of the mask!  It was around this point when every museum professional on the planet let loose a collective scream of horror that could probably be heard on the International Space Station. The museum world has been in an uproar over this news.  For those who aren’t trained in basic collections care or standard museum protocol, the question may be “Why is this a big deal?”  Allow me to explain using two conservation rules why this is a big deal and what went wrong in this particular case:

  1. The first and most important rule in any conservation or object repair activity is First Do No Harm.  This is the driving force behind any conservation activity.  You don’t want to do anything to the object which will cause further damage (In this case, both the decision to use epoxy AND the decision to try to chisel off excess were violations of this rule).
  2. Related to rule #1 is the following: Do Nothing that Cannot be Undone.  If you are doing repair work to any object, standard protocol requires that you use methods and materials that are reversible.  Remember that museums exist to preserve these objects in perpetuity.  If you find out that the adhesive you are using will eat through the object’s surface, even if the repair work was done 50 years ago, you need to be able to un-do the repair to prevent further damage to the object.  Though at least one expert has now said that it is possible to reverse the botched repair, the use of a permanent adhesive (which is what epoxy is considered) is a direct violation of this rule.

Any way you slice it, this event represents a giant error in the treatment of this priceless artifact.  However, it is also an error that was entirely preventable.  Allow me to indulge in a bit of armchair Root Cause Analysis. As I see it, the botched repair of the mask is more indicative of a toxic culture within the museum which houses the artifact.  Any error is not the result of one person or even a group of people, and getting rid of those people will not prevent errors like this from happening again.  Note: I am in no way absolving those involved of responsibility for this event…they have their share of the blame as well. In order to prevent another catastrophe like this, the museum needs to take a hard look at itself and address systemic and work culture issues which contributed to the error.  There are several factors they may want to consider in their internal investigation:

  1. Management Style – It is clear that the management style being used at this museum is not conducive to the prevention of errors such as this.  How do I know this?  There are two pieces of evidence that are telling.  First is that the museum staff involved has insisted on anonymity before they speak, fearing backlash if they were to speak openly.  If your employees feel they need to go the whistleblower route and cannot openly address any issues, it is not an environment where employees can bring forward observations which may prevent these errors from recurring.  Until employees can feel comfortable bringing up areas of concern and practices that they may question, errors like this will continue to be made. The second piece of evidence to prove this point is the fact that there are multiple versions of how the events transpired. When three different curators at the museum give three different versions of events, it’s a clear sign that there are issues between the staff themselves, but also between the staff and the management.
  2. Lack of Education – This is where the curatorial staff involved in the repair work get to shoulder a portion of the blame.  In all of the versions of the events, the curatorial staff all admit that they were ordered to repair the damage ASAP so that the mask could go back on display.  An order like this can only be made by someone who is ignorant of basic conservation and curatorial standards and ethics.  Conservation work is slow and expensive for a reason (the whole do no harm and make it reversible rules mean that every repair is treated on a case-by-case basis by experts who take their time establishing a plan which will both conserve/repair the object and not damage it).  Given this order, the curatorial staff should have educated the person that this was not an acceptable or ethical solution; as a curator you are the ambassador and representative of the objects you care for, and you should advocate for them.  The fact that they did not is another indicator of the toxic management style which is clearly in place, but also where they shoulder a portion of the blame for the damage.
  3. Lack of Resources – Most museums don’t have the luxury of having expert conservationists on staff, ready and waiting to perform their miracles on any object in the museum’s collections.  But I am guessing that cost might have played into the decision for the curatorial staff to attempt a repair themselves.  Curators and anyone who studies museum sciences generally have basic knowledge of object cleaning and preservation methods, but they are not professional conservators in most cases.  Is it expensive to either bring in locally or send the mask out for professional repair by skilled and trained professionals?  Yes it is.  But it is important to remember that cheap is not cheap.  If resources were the concern, the museum should have reached out to other organizations and professional conservationists for help; I am very sure that arrangements could have been made to get the mask repaired in the correct manner without decimating the museum’s finances.
  4. Communication/Work Culture – I’m not referring to the culture of the people involved in this case; I am referring to the culture of the workplace.  Overall, this episode demonstrates that the culture with the museum is very poor.  The curatorial staff did not feel safe bringing up the issue to their superiors.  Those at the top had unrealistic expectations about what could be done by staff at their facility and emphasized only getting the mask back on display rather than repairing the damage in a safe and reversible manner to preserve the mask.  No one is taking accountability for what happened, and those involved are only speaking under the condition of anonymity for fear of reprisals.  Communication in any organization needs to flow from all directions, not just from the top down.

In the end, there are likely many places where this error could have been stopped in its tracks.  For example, if the mask was improperly handled and that’s what caused the beard to break off, then clearly education on proper object handling could have prevented it.  If management at the museum had not insisted on a quick fix for the beard, proper time, techniques, supplies and expertise could have been obtained to repair the mask in a more appropriate manner.  If the curatorial staff felt safe enough to advocate for proper care for the object, the repair could have been done in the proper manner.  If any one of these issues were addressed, this error may not have occurred.  That is why doing a Root Cause Analysis of the problem is so important to prevent these issues from happening again.  But unfortunately I’ve seen a lot of cultural paternalism (they clearly don’t know how to care for their stuff, so they should send it to those who can!) and blame-the-curators going on in this case. Not only is this not helpful, it will not prevent the next Nightmare in the Museum.

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