Senior Dam Safety Program Engineer DamCrest Consulting Superior, CO
Abstract Description: The Fontenelle Dam incident was one of the largest dam incidents in U.S. history. The General Accounting Office report on the failure of Teton Dam (the largest dam failure in U.S. history) described how what happened at Fontenelle was "strikingly similar" to the failure of Teton Dam but the warnings of the Fontenelle Dam incident went unheeded. The author was the lead investigator of the human factors in the Spencer Dam Failure. He also has studied the multiple causes of major infrastructure and transportation accidents. This paper/presentation will show the many physical and non-physical factors that contributed to the Fontenelle incident including:
• Organization structure and culture [production/mission pressures, over confidence] • Complexit • Siloing/organizational secrecy (lack of sharing of information), • Erosion of safety factors over time • Financial/schedule pressures • Not learning from past events • Insufficient teamwork • Politics • Proximity • Over reliance on practices that succeeded in the past • Insularity (omission of independent review/input) • Environmental factors (weather, floods) • Luck (good and bad) • Decision making under duress with limited information • Proximity (spillway problems close to outlets can damage both for example) • Non-linear effects (a small seep quickly expanding to a major leak) • Tight and loose coupling
Many of these factors also contributed to the 1976 failure of Teton Dam (50th anniversary next year in 2026).
Learning Objectives:
To describe the diverse factors (beyond physical and individual human factors) and how they combine to contribute to dam failures and incidents.
Describe how to react to emerging dam failures and incidents and the challenges of implementing intervention to slow or stop the dam failure.
Demonstrate how small events which seem benign can combine with other events in unexpected ways and result in major dam incidents.
