He started out as a ditch digger in Los Angeles. Designed the Aqueduct that is still used. With no formal education he designed dams and waterways. The St. Francis Dam was a crowning achievement until . . . .

1. What Caused the Greatest
Engineering Disaster of the 20th
Century?

2. “The only ones I envy about
this whole thing are the ones
who are dead.” William
Mulholland, Chief Engineer,
Water Department, Los Angeles
.
The St. Francis Dam Collapse.
The Second Greatest Loss of Life in
California History after the San Francisco
Earthquake.

3. 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.
Anatomy of Catastrophe

4. 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.
THE FACTS

6. 1877: William Mulholland arrives in Los Angeles
1878: Mulholland begins work as a ditch tender
1886: Mulholland becomes superintendent of LA 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
THE TIMELINE

7. 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, carrying bodies and
debris, finally reaches the Pacific Ocean
THE TIMELINE

8. 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.”
Cascade 1

9. Lesson: Education & Training Are Key in Technical
Design and Building.

10. 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.
Cascade 2

11. LESSON: Nature always wins. Oversight is needed in
any large, complex construction project.

12. A History of Failure and Ego.
In 1918 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.
Cascade 3

13. 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 . . . .

14. 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 at the
opening of the Aqueduct 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.
Cascade 4

15. LESSON: Care must be taken when external factors
influence engineering decisions. Cracks appeared in the
dam each time it was refilled, but Mulholland thought that
was a normal part of the dam’s operation.

16. The Design was Flawed.
The Mulholland Dam (still in existence in Los
Angeles) 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 political, part of the Water Wars.
Cascade 5

17. Lesson: Ignoring Warnings is a Staple of
Catastrophe.

18. 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 who drove up from Los
Angeles, inspected the dam, and pronounced it safe. The
dam keeper and others who lived below, joked about it,
telling each other: “See you later if the dam don’t
break.”
Cascade 6

19. 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.

20. 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 the center section.
12.4 billion 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.
Final Event

21. BTW, an identical dam still exists in Los Angeles.
Location on next slide.
However, the water level was reduced and large
amounts of dirt were brought in and dumped
alongside it, strengthening it.
Final Event

22. Final Event

23. LESSON: Leaving the construction of such a
significant project to one man was foolhardy.
The Mulholland Dam was then surveyed. The
water level was 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.”
Final Event

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www.bobmayer.com