430 Reasons Why Engineering Ethics Matters: A Case Study of the Saint Francis Dam Collapse

The St. Francis Dam was designed by William Mulholland in 1924 to create a reservoir near Los Angeles, California. Mulholland was the general manager and chief engineer of the Los Angeles Department of Water and Power, then called the Bureau of Water Supply. There he designed and managed the production of many public works including the Los Angeles Aqueduct and the Mulholland Dam, which served as the template for the St. Francis Dam (Rogers 1992).

Off to a Leaky Start

From the beginning of the project, like most of its kind at the time, the dam was plagued by small cracks that would allow leakage of relatively small amounts of water. In 1928, following reports of worsening cracks and leaks in the dam, Mulholland and an assistant inspected the dam and found it safe for continued service. That night, the dam failed, releasing a wave that tore through the Santa Clara Valley, destroying everything in its path (Stansell 2014).

The collapse highlighted an ethical dilemma in which the designer of the dam was also the head of the government department in charge of its construction and determining its safety once operational.

The collapse highlighted an ethical dilemma in which the designer of the dam was also the head of the government department in charge of its construction and determining its safety once operational. This singularity of leadership represented a conflict of interest and ultimately led to the disaster.

Nothing To See Here

The National Society of Professional Engineers' “Code of Ethics for Engineers” states in Section III, subsection 4-e that “engineers shall not solicit or accept a contract from a governmental body on which a principal or officer of their organization serves as a member.” However, in the 1920s, the American Association of Engineers Code of Conduct did not contain this same language (Luegnebiehl and Davis 1992). As cracks began to be noticed by the dam’s keeper, Tony Harnischfeger, Mulholland was the expert on call to make the inspection based on his position as head designer and chief engineer of the Bureau (Rogers 1992). On several inspections it was reported that Mulholland stated that it was the driest dam he had ever seen and that the cracks were nothing of concern (Outland 2002, Stansell 2014, Rogers 1992).

A Growing Concern

These cracks grew and multiplied over the two years of the dam’s operation. A specific anomaly at the base of the dam alarmed the keeper with signs of erosion due to the dirty nature of the water that was coming from the leak (Rogers 1992). Mulholland and his assistant, Harvey Van Norman, inspected the dam again due to this report, and recommended that some corrective measures be taken but that even these cracks were not urgent enough to drain the reservoir (Outland 2002, Coroner’s Inquest 1928).

The men left, deeming the area safe. Less than twelve hours later... the dam collapsed, destroying the entire 54-mile valley and spreading debris all the way to the Mexican border.

After spending another two hours inspecting other leaks, the men left, deeming the area safe. Less than twelve hours later, at 11:58pm on March 12, 1928, the dam collapsed, destroying the entire 54-mile valley and spreading debris all the way to the Mexican border (Stansell 2014).

Requiem for a Dam

In the course of the investigation that followed the failure, it was determined that the substrate that made up this hill and the western foundation of the dam had become saturated by the reservoir and lost its rock-like quality, eventually causing the collapse. This investigation was conducted without any evidence other than geological and engineering considerations, and the officials published that the failure “was not caused by the type of structure or its construction, or any seismic disturbance in the area, but by the saturation and subsequent disintegration of the hill and defective foundations of the dam” (Outland 2002). It should be noted that at this same time the Hoover Dam’s construction was being debated in Congress. Conclusions that blamed the disaster on the landscape and construction rather than the idea of dams themselves would have been considered politically favorable at the time.

During the months prior to the disaster, there were reports from locals that the western side of the dam’s foundation and the entire hill beside it were visibly wet, and streams of water running down the sides of the dam were alarming visitors and travelers (Outland 2002).

Inspection galleries, pressure grouting, drainage wells and deep cut-off walls could have been used to prevent or delay the disaster, but neither Mulholland, Van Norman, nor any of the dam keepers instituted any of these measures.

A few of the experts involved in the investigation mentioned that although the collapse was probably inevitable, water could have been kept from reaching the foundation. Inspection galleries, pressure grouting, drainage wells and deep cut-off walls could have been used to prevent or delay the disaster, but neither Mulholland, Van Norman, nor any of the dam keepers instituted any of these measures (Rogers 1992).

Mulholland Gets a Golden Parachute

William Mulholland was a hero of sorts in the Los Angeles and Southern California region, having brought gravity powered water to the city with his system of aqueducts in the early 1920s. His prestige and power grew with each completed project as he became more of a government official and less of an engineer. A coroner’s inquest was held after the state investigations. In disagreement with that report, the selection of the location for the dam and of using only augmented variations of his original Mulholland Dam design were cited as the reasons for the disaster (Coroner’s Inquest 1928). This was despite Mulholland’s testimony where he reiterated that the cracks and leakage were all normal for a dam of the size of St. Francis. Not surprisingly, the inquest found Mulholland not guilty of any criminal negligence but did publicly blame him for the destruction.

No one was ever criminally charged in connection with the deaths that resulted from the dam collapse and flood.

He remained the director until December of 1928, when he withdrew from society. He still drew a salary from the department as its chief consultant for many years while it was run by Harvey Van Norman, previously his assistant, and the man with him at the St. Francis Dam the day of its collapse. So, while many see this event as having ended his career, Mulholland lived comfortably until his death in 1935 (Nunis 1995). No one was ever criminally charged in connection with the deaths that resulted from the dam collapse and flood.

430 Reasons Why Engineering Ethics Matters

The St. Francis Dam collapse uncovered a serious flaw in the way dams and other projects were planned, executed, and inspected in California in the early twentieth century. Ambitious speculators and fame seekers were unfortunately able to play with municipal lands, funds, and labor in hastily approved, poorly planned projects with deadly consequences. Although it was determined that the ground beneath it was at fault, once cracks began to show signs of soil deterioration the reservoir should have been drained. Because of the inflexible and career-minded leadership of William Mulholland and his associates, more than 430 people lost their lives in a tragedy that could have been prevented.

Works Cited

Rogers, J. David. Reassessment of the St. Francis Dam Failure. Star Publishing, 1992. A thesis submitted in Public Archaeology. “Memorialization and Memory of Southern California's St. Francis Dam Disaster of 1928: Stansell 2014.” SCVHistory.com, scvhistory.com/scvhistory/stansell2014.htm.

Outland, Charles F. Man-Made Disaster: The Story of St. Francis Dam: Its Place in Southern California’s Water System, Its Failure, and the Tragedy in the Santa Clara River Valley, March 12 and 13, 1928. A.H. Clark Co., 2002.

“Code of Ethics.” Code of Ethics | National Society of Professional Engineers, www.nspe.org/resources/ethics/code-ethics.

Luegnebiehl, Heinz C, and Michael Davis. “ENGINEERING CODES OF ETHICS: ANALYSIS AND APPLICATIONS.” Publications, Illinois Institute of Technology, 10 July 1992, ethics.iit.edu/publication/CODE--Exxon%20Module.pdf.

Coroner's Inquest. Los Angeles County Department of Coroner, "Transcript of Testimony and Verdict of the Coroner's Jury In the Inquest Over Victims of St. Francis Dam Disaster: Book 26902; 1928.

Nunis, Doyce B., and Charles N. Johnson. The St. Francis Dam Disaster Revisited. Historical Society of Southern California, 1995.

About the Author

Tom Griffin is a Mechatronics Engineer in Georgia, a graduate of the Southern Polytechnic College of Engineering and Engineering Technology at Kennesaw State University, a member of IFAC and IEEE, and an advocate for engineering ethics, root-cause analysis, predictive maintenance, and enhanced safety through automation. When he's not developing and providing CEOs and engineers with IIOT solutions that keep factories and citizens safe and productive, you can find him 3-D printing, assembling, and programming robots. In a past life, he also worked in the automotive industry, keeping motorists safely moving forward.

If you would like to contact Tom, he would love to hear from you. Email him at [email protected]. You can also follow him on LinkedIn where he posts about the latest in industrial automation research and product developments, the surprisingly colorful history of automation, and more.