Root Causes Analyses of the Oroville Dam Gated Spillway Failures and Other Developments

We have performed forensic Root Causes Analyses of the Oroville Dam Gated Spillway failures and other associated developments as unfunded (approximately 3,000 pro-bono hours) volunteers of the University of California at Berkeley (UCB) Center for Catastrophic Risk Management (CCRM) Oroville Dam Advisory Group (ODAG). We initiated this work on January 27, 2017. The results contained in this report have been developed based on the currently available public document and information sources cited at the end of this report, included in the Preliminary Root Causes Analysis of the Failures of the Oroville Dam Gated Spillway report dated April 17, 2017, and in the Legislative Oversight Report: Oroville Dam report dated May 11, 2017.  This report documents our analyses of the Root Causes of the initial failure of the Gated Spillway. Appendix A of this report provides summaries of the procedures and processes we used to perform the Root Causes analyses, background on the components that comprise Engineered Systems, and background on the Human and Organizational Factor malfunctions (errors) responsible for failures of Engineered Systems. Appendix B provides details of our analyses of the Physical and Organizational Root Causes of the initial failure of the Gated Spillway.

The opinions expressed in this Report are ours alone. The opinions expressed herein are a fair and accurate summary of our opinions, based upon our experience, education, training, and expertise.