Page - 1526 - in Book of Full Papers - Symposium Hydro Engineering

4. THE EVIDENCE THAT SOFT RISKS AFFECT DAMS? In the recent report on the Oroville dam spillway failure, there are a number of references to problems at the human level, including complacency, bureaucracy and an inadequate safety culture. For instance the report notes:  the California Department of Water Resources, was “significantly overconfident and complacent about the integrity of its State Water Project civil infrastructure, including dams.”  “insular organization which inhibited accessing industry knowledge and developing needed technical expertise.”  an “insular organization which inhibited accessing industry knowledge and developing needed technical expertise.” Within the department, the engineering division clashed with the operations and maintenance staff, resulting in a “lack of mutual respect,” it found. Andrew Brazier reports that upon reviewing the prevalence of Human Error in the US forces: “Further to this, 20% of defects are missed by inspectors who are specifically looking for them and the U.S. Strategic Air Command claim that 16% of all critical events are made worse by human intervention. 5. APPLYING SOFT RISK LESSONS TO THE PROTECTION OF DAMS The application of systems and procedures aimed to reduce soft risks, requires commitment from the top. Without an understanding of the issues raised there will be little chance of addressing them. The values inherent in the proposals herein must be communicated from the top and demonstrated by main board actions. Once the main board is united, they need to get the safety culture right. In general, this needs:  A single, responsible person at the top for dam safety issues.  A balanced board, both for skills and gender.  The avoidance of incentives for the lack of recorded incidents and accidents, since this encourages non-disclosure. Rather the encouragement and celebration of opportunities to learn from experience.  The non-punishment of mistakes.  The encouragement of an open, honest and respectful dialogue between work colleagues without dependence on where they are placed in the organization hierarchy. It is important that incidents can be investigated and reported upon without putting a career at risk.  The regular look for new and better ways of doing things. 1526