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 . . . .
Cockpit Resource Management (CRM) was begun in 1979 as a result of a NASA workshop. One of the key elements was to make sure that co-pilots would be more responsive to warning/advising the pilot. In the case of Air France Flight 447, they didn’t even get to that stage, with two co-pilots, both of whom tried to control the plane. Instead of working together, they actually worked against each other.The situation got worse when the Captain entered the cockpit, with neither co-pilot filling him in on the sequence of events and vital readings which might have allowed the Captain to quickly assess the situation.
One minute 38 seconds
William Mulholland and the St. Francis Dam Disaster
What Caused the Greatest
Engineering Disaster of the 20th
“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
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
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.
1877: William Mulholland arrives in Los Angeles
1878: Mulholland begins work as a ditch tender
1886: Mulholland becomes superintendent of LA Water
1908-1913: Mulholland supervises the building of the Los
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, carrying bodies and
debris, finally reaches the Pacific Ocean
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
His honorary doctorate from UC-Berkeley read: “He
broke the rocks and brought the river to the thirsty
Lesson: Education & Training Are Key in Technical
Design and Building.
Bad choice of location, which was suspected
but not acted on, and exemption from
Mulholland had surveyed the area in 1911 and
noted a schist.
Los Angeles was exempt from California’s dam-
Mulholland rarely sought the opinions of other
engineers on projects.
LESSON: Nature always wins. Oversight is needed in
any large, complex construction project.
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
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
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 . . . .
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 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.
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.
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.
Lesson: Ignoring Warnings is a Staple of
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
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.
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 billions gallons of water headed down the San
Francisquito Canyon. One piece of concrete,
weighing 10,000 tons, was found a mile below the
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.
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.”
Seven Ways to Prevent Catastrophes
1. Have a Special Ops preparation mindset
2. Focus by utilizing both big picture & detail
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
Are you interested in a presentation about various catastrophes
and how the cascade events could have been prevented?
Events covered range from human-machine interface, to
leadership, to communication, cost-cutting, engineering, group
think, perseverance, systematic failure, and more?
Catastrophes are cascade events culminating in disastrous
chaos. War is chaos. Special Forces is the most elite unit trained
for a variety of combat situations.
What makes Special Forces elite is our mindset and
Are you interested in a presentation on how to use Special
Forces tactics, techniques and mental attitude to help your
organization anticipate and prevent potential catastrophes?
Please email firstname.lastname@example.org
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New York Times bestselling author, is a graduate of West
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He was an instructor and course developer/writer for years
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Survival, Evasion, Resistance and Escape.