On June 5, 1976, workers were called to the Teton Dam on the Teton River in Idaho to attempt to repair a leak. Workers in bulldozers narrowly avoided being sucked into the dam with their equipment, and watched helplessly as the dam was breached. It would kill 14 people and cause nearly hundreds of millions of dollars in property and environmental damage. To examine what went wrong, we can perform a visual root cause analysis, or Cause Map.
The Cause Mapping process begins by determining the impacts to an organization’s goals. From the perspective of the government, specifically the Bureau of Reclamation, the safety goal is impacted because of the 14 deaths. The environmental goal is impacted due to the severe impact the dam failure and subsequent flooding had on the ecosystem of the area. The customer service goal was impacted due to the evacuation of three towns. The production goal is impacted due to the abandonment of the dam – at a cost of approximately $50 million. Additionally, property damage of at least $400 million (some estimates are much higher) is an impact to the property goal. (There were also substantial claims related to the loss of property and livelihood from impacts to industries, particularly fishing.)
Once we have determined the impacts to the goals, we begin with an impacted goal, such as the safety goal, and ask “Why” questions to determine the cause-and-effect relationships that led to the impacted goals (also known as “problems”.) In the case of the Teton Dam failure, people were killed due to a massive wave of water released from the dam (which was filled to capacity) when it failed. The dam failure was also the cause of severe damage to the dam, which was never rebuilt, leading to the impacted production goal.
The failure of the dam was found to be caused by erosion and inadequate strength. Due to the less than ideal geological conditions of the site (which was picked because there were no “good” sites available), unequal stress distribution and inadequate fill material (which was used from the site) led to reduced strength. Susceptible materials and seepage from leaks in the embankment, caused by joints that were not resistant to water pressure due to inadequate testing, and inadequate protection from water due to an over-reliance on an ineffective curtain intended to stop flow, led to the erosion.
Many geologists had predicted problems with the dam before it was built. Specifically, in his book “Normal Accidents”, Charles Perrow states “The Bureau ignored its own data that rocks in the area were full of fissures, and in addition they filled the dam too fast . . . All it takes to bring a dam down is one crack, if that crack wets the soil within the interior portions of the dam, turning it into a quagmire.”
Although tragic, and expensive, the failure of the Teton Dam did lead to many reforms in the Bureau of Reclamation, who is responsible for dam safety. Detailed geological studies performed in order to determine the causes of the dam failure also provided additional insight to the strength provided by various types of earth, erosion and seepage.
{ 0 comments }
