It turned out that 17 separate mistakes were made before anyone realized that the wrong woman was on the table.

Thankfully, Mrs. Morris was not harmed. The doctors said it was an “organizational accident,” meaning that one person could not have done it alone. Sticking tubes into the wrong person’s heart required mess-ups by many people.

One day, Mrs. Morris may be joined in the great case studies of near blunders by New York’s L train fiasco. This one took a team of people, too.

Right after the New Year, Gov. Andrew Cuomo made the startling announcement that New York City’s L subway line, whose East River tunnel was damaged by Hurricane Sandy in 2012, could remain in service while fixes were carried out.

Talk about whipsaw changes. In April, the line was to stop serving Manhattan for 15 months so the repairs could be made in the river tunnel. Its users had spent two years planning alternative routes and, in some cases, finding new places to live. They are just a fraction of the city’s subway riders, up to 300,000 people a day. But that’s more than the ridership of most mass transit systems in the country.

Losing L service for more than a year was a big, disruptive deal. But there was no way around it — or so the public had been told, over and over.

Now, it seems almost certain, that was a mistake. A team of academic engineers brought in by the governor last month devised a suite of repairs that they say would return the tunnel to a long-term safe condition with minimal closings. The academics collaborated with the government and consulting engineers who had come up with the original plan.

Their approach has been criticized in general terms by two former officials of the agency who had roles in the first plan, saying that the new one would be neither as safe nor as built to last as the original. They have identified no specific risks, and when you drill into the details, it is hard to see where the latest plan falls short.

Jerry Jannetti is a senior vice president at WSP, the consulting firm that has worked on the project since 2013 for New York City Transit, which operates the city’s subways as part of the Metropolitan Transportation Authority. If Jannetti personally owned and operated the tunnel, would he prefer his firm’s original plan, or the one that emerged last month?

“I would choose the way we are moving forward now,” Jannetti said.

Which leads us to the next question: If the planned new repairs would be as safe and durable without requiring closing the line, why didn’t anyone think of them before? Shouldn’t someone downstream of the governor have thought to bring in outside experts for a fresh look, given the disruptive stakes?

Some people are skeptical about this new plan, in fact, precisely because it was driven by Cuomo. That’s good. Without skepticism, society collapses. But this entire episode illustrates a failure to be skeptical. And it shows us the risks of ignoring what it means to fail, at scale, in a booming city that grows every month. It didn’t have to be the governor asking for a better way. But no one else did.

Until then, the new array of repairs had not been considered by the in-house engineers at the Metropolitan Transportation Authority, the WSP consultants or others involved in the project. Andy Byford, president of New York City Transit, said he was conducting an independent review of the plan and would not sign on unless he was convinced of its safety and durability. That said, he is enthusiastic about its prospects. “I own the risk,” Byford said. “I am the president, the accountable person. This is my job.”

Anyone on the MTA board could have demanded alternatives. Cuomo appoints six of the 14 voting members, and by force of personality, he has driven a number of projects, including this one — at the last minute — and pushing construction of the Second Avenue line.

You can find representatives of eight other public officials on the authority’s board, including the mayor of New York. Even more power is held by a virtually unknown committee of four, any one of whom can veto the entire capital budget. On this committee are the speaker of the state Assembly, the state Senate majority leader, the mayor and the governor.

Typically, that awesome power has not been used for actual oversight — asking questions! — but for horse trading. So one legislator hinted at a veto if political cronies were not given state judgeships. And in an infamous episode, an Assembly speaker, Sheldon Silver, demanded that a pet project be funded to a satisfactorily boondoggle-ish level, pointedly mentioning that he would soon be looking at the capital budget.

“I will expect to see the Fulton Street Transit Center fully funded, complete and at a scale that at least resembles what was repeatedly promised,” Silver wrote in 2008. He got his way. The price for fixing that one station hit $1.4 billion, more than the entire annual budget of the Chicago transit system at the time.

There are legislative oversight committees for mass transit in the City Council, the state Senate and the state Assembly. No one asked the fundamental question about finding another way.

The price of all these people being in charge is that no one owns the work.

In all walks of life — engineering, politics, transportation — there is a fine line between the earned wisdom of experience and the toxic self-regard of a credentialed rut. (That goes for journalism, too. For most of the time the L train shutdown was in the air, I was writing a column in the New York section of The Times. No one stopped me from asking questions. I just didn’t.)

The L train’s East River tunnel — “still pretty darned good at 100 years old,” Jannetti said — was built under the supervision of the master engineer Clifford Holland starting in 1916. It was part of the surge of transit construction during the first decades of the 20th century that shaped modern New York into the nation’s largest city.

New York’s mass transit system stopped expanding in 1940, and it has even shrunk since then. The city’s population has grown by about 1.5 million since 1990 and may only be choked off by frail transportation. The MTA has proved itself one of the world’s most effective garrotes.

The agency was created a half-century ago to build, among other things, the Second Avenue subway (still unfinished) and a new tunnel for the Long Island Rail Road into Grand Central (the tunnel was finished in 1989 but the connection into Grand Central is years away). In 2002, the chairman of the agency announced a series of streamlining reforms. Today, there are about 10,000 more employees and less actual service. The Regional Plan Association proposed dismantling pieces of the agency. Maybe it should go into the portfolio of the governor or the mayor. To some one, and not everyone.

Mrs. Morris landed on an operating table for a procedure that she didn’t want or need, and that no one had ordered for her. New York City wound up being prepped for a different kind of surgery that it surely did not want or need. This organizational accident took a lot more than 17 errors.