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William Mulholland and the St. Francis Dam Disaster


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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 . . . .

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William Mulholland and the St. Francis Dam Disaster

  1. 1. What Caused the Greatest Engineering Disaster of the 20th Century?
  2. 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. 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. 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
  5. 5. 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
  6. 6. 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
  7. 7. 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
  8. 8. Lesson: Education & Training Are Key in Technical Design and Building.
  9. 9. 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
  10. 10. LESSON: Nature always wins. Oversight is needed in any large, complex construction project.
  11. 11. 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
  12. 12. 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 . . . .
  13. 13. 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. Cascade 4
  14. 14. 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.
  15. 15. 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
  16. 16. Lesson: Ignoring Warnings is a Staple of Catastrophe.
  17. 17. 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
  18. 18. 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.
  19. 19. 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 dam site. Final Event
  20. 20. 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
  21. 21. Final Event
  22. 22. 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
  23. 23. Seven Ways to Prevent Catastrophes 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)
  24. 24. 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 preparation. 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 Summary
  25. 25. More Free Information I constantly update free, downloadable slideshows like this on my web site for preparation and survival and other topics. Also, I conduct Area Study workshops for those interested in properly preparing for their specific circumstances.
  26. 26. The guide on the left is the complete preparation and survival guide. The one on the right is a pocket-size manual with just the survival portion. Useful in your Grab- n-Go bag, car and kitchen drawer. SURVIVAL GUIDES
  27. 27. New York Times bestselling author, is a graduate of West Point and former Green Beret. He’s had over 80 books published, including the #1 bestselling series Green Berets, Time Patrol, Area 51, and Atlantis. He’s sold over 5 million books. He was born in the Bronx and has traveled the world. He’s lived on an island off the east coast, an island off the west coast, in the Rocky Mountains, the Smoky Mountains and other places, including time in East Asia studying martial arts. He was an instructor and course developer/writer for years at the JFK Special Warfare Center and School which trains Green Berets and also runs the SERE school: Survival, Evasion, Resistance and Escape.