Failure Analysis Report for the Dept of Water Resources was released.
It soundly condemns the DWR for systemic management and planning failures. Also, the selected primary designer back in the original design phase was a new-hire. He had never designed spillways before, and his work was not challenged nor adequately reviewed. Basically, the spillway had never failed before because it had never been used before.
There were many opportunities to intervene and prevent the incident, but the overall system of interconnected factors operated in a way that these opportunities were missed. Numerous human, organizational, and industry factors led to the physical factors not being recognized and properly addressed, and to the decision-making during the incident. The following are some of the key factors which are specific to DWR:
• The dam safety culture and program within DWR, although maturing rapidly and on the right path, was still relatively immature at the time of the incident and has been too reliant on regulators and the regulatory process.
• Like many other large dam owners, DWR has been somewhat overconfident and complacent regarding the integrity of its civil infrastructure and has tended to emphasize shorter-term operational considerations. Combined with cost pressures, this resulted in
strained internal relationships and inadequate priority for dam safety.
• DWR has been a somewhat insular organization, which inhibited accessing industry knowledge and developing needed technical expertise.
• DWR’s ability to build the appropriate size, composition, and expertise of its technical staff involved in dam engineering and safety has been limited by bureaucratic constraints.