Page 2 - sfdcoronersverdict
P. 2

Conclusions

                               After    carefully  weighing  all  of  the  evidence,              that

                 has  been  presented, we  have  reached  the  following  conclusions

                               The  St. Francis       Dam was  defective  due  to  the  very

                 poor  quality  of  the  underlying  rock  structure  upon  which  it

                 was  built  and  to  the  fact  that  the  design  of  the  dam  was  not

                 suited  to  inferior  foundation  conditions.                 The  actual  failure

                 was  caused  either.  wholly  or  in  part  by  these  defects-

                               The  construction  of  this  dam,  without  having  the

                 design  and  foundation  conditions  passed  upon  by  independent

                 engineers  and  geologists,  and  without  more  thorough  and

                 systematic  methods  of  design,           supervision  and  inspection,

                 involved  two  basic  errors.

                               One  of  these  was  an  error  in  engineering judgment

                 in  determining  the  character  of  the  foundations  at  the  St.

                 Francis  Dam  site  and  deciding  upon  the  best  type of  dam  to

                 build  there.

                               The  other  was  an  error  in  regard  to  fundamental

                 policy  relating  to  public  safety.

                               The  responsibility  for  the  error  in  engineering

                 judgment  rests  upon  the  Bureau  of  Water            Works    and  Supply,

                 and  the  Chief  Engineer  thereof

                               The  responsibility  for  the  error  in  public  policy

                 belongs  to  those  to  whom  the  Chief  Bngineer  is  subservient,

                 including  the  Department  of  Water and  Power  Commissioners,

                 the  legislative  bodies  of  city  and  state, and  to  the  public

                 at  large.      It  is  a  logical  result  of  a  set  of  conditions  that

                 the  citizenship  has  allowed  to  develop  and  continueo                   This  is

                 the  more  fundamental  error, for  if  proper  safeguards  had  been


                 provided  in  the  city charter  and  in  the  state  laws, making  it
                 impossible  for  excessive  responsibility  to  be  delegated  to  or

                 assumed  by  anyone  individual  in  matters  involving  great  menaces








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