Table 6.

Synthesis of failures in the different controls

FailureOriginCategoryType
Technocracy (Ponts et Chaussées v. Génie Rural)OrganizationalPolicyFortuitous
Absence of external control (community as owner (MOA) and public body as engineer (MOE))OrganizationalPolicyFortuitous
Poor communication between owner (MOA) and engineer (MOE)OrganizationalCommunicationInduced
Skill management
4 year delay in the monitoring and maintenance plan requested by the Génie Rural from the first reservoir fillingOrganizationalRisk appreciationInduced
Relationship with time
No interpretation of the measurements by anyone responsible (and no reference measurements)OrganizationalSkill managementInduced
Risk appreciation
Guard not qualified (thus not trusted)OrganizationalSkill managementInduced
July 1959: last measurement campaign, showing important distortions of the structure (4 month delay in reporting of the results to ACJB consulting firm)HumanRisk appreciationInduced
Relationship with time
Late November 1959: significant seepage downstream of the dam and cracks in the protective mat. Crisis meeting convened (too late) on site with ACJB on 7 DecemberHumanRisk appreciationInduced
Relationship with time
3 days before the dam break: the Génie Rural requested authorization to open the bottom valve; refusal owing to the construction of a motorway bridge downstreamOrganizationalRisk appreciationInduced
EcosystemicRelationship with time
  • MOA, maîtrise d'ouvrage (project owner); MOE, maîtrise d'oeuvre (project management).