Systemic and Underlying Causes of the 1965 Fontenelle Dam Incident: A Manmade Disaster Theory Perspective

Post-event investigation and research into the physical factors and mechanisms of how dam failures and incidents occur have long been used to improve the technical and program practices of dam engineering. Since 2017, the inclusion of a human factors team member on the investigation teams of the Oroville Dam spillway incident, the Spencer Dam Failure, and the Edenville/Sanford Dam failures offers insights into the underlying human factors of why these events occurred. 

This paper applies causal theories of other non-dam manmade disasters such as airplane crashes, mine disasters, space shuttle explosions, bridge failures, and nuclear accidents to the U.S. Bureau of Reclamation’s (Reclamation) Fontenelle Dam incident of 1965. It is a narrow, case-specific view on the question: does causal analysis of other non-dam disasters offer new perspectives on why dam failures and incidents occur? 

The author examined manmade disaster theory that has developed since the 1970s by social scientists B. Turner, C. Perrow, D. Vaughn, and S. Dekker. The theory expands individual human factors to include the groups and organizations that design, construct, operate, maintain, and regulate high energy systems. The author also reviewed several notable non-dam disaster case studies. He researched the culture, leadership, administration, and engineering practices of Reclamation in the 1965 era using oral histories and other primary sources. 

This paper reveals that the following manmade disaster theories are consistent with the Fontenelle Dam incident: 

• Success can cause reliance on standard methods, a production focus, and narrowing of safety margins over a long period. 

• Organization administration, leadership, and culture affect decision making at all levels. 

• Organizational decisions may be made that do not prioritize safety. 

• Group separation and lack of communication can contribute to failure. 

• Unstable systems are at risk from minor events which cascade into increasingly large effects (non-linear response) due to complexity, coupling, and proximity (one adjacent component affects another). 

The paper begins with multiple organizational, group, and individual human factors which led to the construction of a fragile dam which nearly failed on first filling of the reservoir (physical factors). 

Review of manmade disaster theory as applied to the Fontenelle Dam incident of 1965 offers new and deeper insight into why the event occurred. Applying lessons from other manmade disasters to dam safety program and technical practices could result in a reduction of the underlying systemic factors (individual/group/organizational) and the resulting physical factors that give rise to dam failures and incidents.