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One of the Worst Engineering Disasters of the 20th Century

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The St. Francis Dam was designed and built by Mulholland, the man who brought water to Los Angeles. Unfortunately, the dam failed with great loss of life. Why? And, there is a dam designed exactly the same way, still in Los Angeles.

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One of the Worst Engineering Disasters of the 20th Century

  1. 1. “The only ones I envy about this whole thing are the ones who are dead.” William Mulholland, Chief Engineer, Water Department, Los Angeles .
  2. 2. The Rule of Seven: Every catastrophe has 7 events. Six Cascade Events leading to the final event, the Catastrophe. At least one of the Cascade Events involves human error. Thus most catastrophes can be avoided.
  3. 3. Two and a half minutes before midnight on 12 March 1928, the St. Francis Dam failed, sending a surge of water and debris that killed an estimated six hundred people on its journey before finally pouring into the Pacific Ocean.
  4. 4. 1877: William Mulholland arrives in Los Angeles 1878: Mulholland begins work as a ditch tender 1886: Mulholland becomes superintendent of Los Angeles Water Company 1908-1913: Mulholland supervises the building of the Los Angeles Aqueduct 1924: Water Wars begin August 1924: Construction of the St. Francis Dam begins 1926: Dam is completed 1 March 1926: Water begins to fill the reservoir 12 March 1928: 10:30 am: The Dam Keeper notes a new leak. Alerts Mulholland. Mulholland inspects and feels there is no immediate danger 11:57:30 pm: The dam fails 5:30 am: The water finally reaches the Pacific Ocean
  5. 5. Lack of Formal Training & Education. William Mulholland went from being a ditch digger to the superintendent of the Los Angeles Water Department. Along the way, he gained great practical experience in developing water projects, but never received formal training as an engineer. He designed & built the Los Angeles Aqueduct, still in use today. His honorary doctorate from UC-Berkeley read: “He broke the rocks and brought the river to the thirsty land.”
  6. 6. Lesson: Education & Training Are Key in Technical Design and Building.
  7. 7. Bad choice of location, which was suspected but not acted on and exemption from regulation. Mulholland had surveyed the area in 1911 and noted a schist. Los Angeles was exempt from California’s dam-safety law. Mulholland rarely sought the opinions of other engineers on projects.
  8. 8. LESSON: Nature always wins. Oversight is needed in any large, complex construction project.
  9. 9. A Histor of Failure and Ego. In1918, there was a partial collapse of the Calaveras Dam near San Francisco, which Mulholland had supervised. This required reconstruction. A visiting engineer wrote that Mulholland’s work was sloppy and his construction techniques slipshod and crude. He also claimed Mulholland was so conceited that he believed himself immune from criticism. The engineer was ignored.
  10. 10. LESSON: The flip side of burning ambition is the danger of hubris. Mulholland was a shining example of the American dream– a person who pulled himself up on his own merit and hard work. But as such, he was not a ‘team player’. When it works, one is a genius, such as the Aqueduct. When it doesn’t . . . .
  11. 11. The California Water Wars. The Aqueduct was an engineering marvel, but for the farmers and ranchers in the valley from which the water was being drained, it was destroying their land and livelihood. Mulholland’s speech on the opening of the Auqeduct was five words: “There it is. Take it.” The Aqueduct was dynamited several times. This left the St. Francis Dam reservoir as the only northern source of water for the city; causing it to be over-filled several times, stressing the structure.
  12. 12. LESSON: Care must be taken when external factors influence engineering decisions. Crack appeared in the dam each time it was refilled, but Mulholland thought that was a normal part of the dam’s operation.
  13. 13. The Design was Flawed. The Mulholland Dam was the first designed like this. While the St. Francis was being built, Mulholland constantly made adjustments to the plan, increasing its capacity. A visiting engineer criticized the placement and design of the dam. He wrote “This dam, if kept full for any length of time . . . will unquestionably fail.” Mulholland viewed this report as politcal, part of the Water Wars.
  14. 14. Lesson: Ignoring Warnings is a Staple of Catastrophe.
  15. 15. Constant Instability Wasn’t Addressed. As soon as the reservoir started to fill, cracks appeared in the dam. There was also seepage. Mulholland said this was normal. A similar dam failed in Pennsylvania in 1911, killing 78 people. An engineer who reviewed that case, consulted with Mulholland but was ignored. The day before the dam failed, the dam keeper noted a muddy leak and called Mulholland. He drove up from Los Angeles, inspected the dam, and pronounced it safe. The dam keeper and others who lived below it joked about it, telling each other: “See you later if the dam don’t break.”
  16. 16. LESSON: Sunk Cost and We Don’t See What We Don’t Want To See; we are unwilling to accept potential failure when we’ve invested too much in something.
  17. 17. The Dam Fails. Mulholland went back to Los Angeles and the dam keeper went back to his house, just below the dam, thus becoming the first to die with his family when the dam broke. The collapse was sudden and complete. All that was left was center section. 12.4 billions gallons of water headed down the San Francisquito Canyon. One piece of concrete, weighing 10,000 tons, was found a mile below the dam site.
  18. 18. LESSON: Leaving the construction of such a significant project to one man was foolhardy. The Mulholland Dam was then surveyed and the water level lowered and an earthen dike place behind it, which exists to this day. California passed a new dam safety law. Mulholland took full responsibility. It is rumored that in the last years of his life, he pulled all this teeth out, one by one, with pliers as atonement. “If there was an error in human judgment, I was the human. I won’t try to fasten it on anyone else.”
  19. 19. 1. Have a Special Ops preparation mindset 2. Focus by utilizing both big picture & detail thinkers 3. Conduct Special Forces Area Studies 4. Use the Special Forces CARVER formula 5. Have a “10th man” 6. Conduct After Action Reviews 7. Write and USE Standing Operating Procedures (SOPs)
  20. 20. Shit Doesn’t Just Happen: The Gift of Failure Free Excerpts
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