The President of Texas A&M University, in response to the tragic events surrounding
the collapse of the bonfire stack, appointed a five member Commission of
Inquiry charged with finding the cause of the collapse, as well as all other facets related
to the incident. The Commission’s charge read in part:
To satisfy itself that the truth about what caused the accident is known as far as
it can be discovered and to report its findings and conclusions with recommendations
for corrective actions, if warranted.
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Created as a fact-finding body, the Commission’s purpose was to ascertain the
truth about the accident and was charged with the responsibility to focus on safety and
training, engineering and design, soil and site conditions, materials and other factors of
construction, transportation, and student leadership/development.
Leo Linbeck, Jr. was appointed as the Chairman of the Commission. He is the
CEO of Linbeck Construction Corporation, a large Houston Construction Company and
has a reputation for integrity and openness and has extensive experience in the construction
industry. The other members of the Commission include Veronica Kastrin
Callaghan of El Paso, a vice-resident of an industrial real estate company; Major
General Hugh G. Robinson of Dallas, U. S. Army Retired, and a West Point Graduate
with a master’s degree in civil engineering from MIT; Allan Shivers, Jr. of Austin,
owner of a consulting and investment company and the son of a former Governor; and
William E. Tucker of Fort Worth, the Chancellor emeritus of Texas Christian University.
None of the members of the Commission have any direct tie to A&M.
Shortly after its creation, the Commissioner named two management consultants,
neither with any ties to the University, to assist with their fact-finding mission.
Employed by McKinsey and Company, the consultants coordinated the efforts of the scores of experts that were utilized by the Commission during the conduct of their
inquiry. |
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The University Police Chief, a retired FBI agent, described the investigation as a
scientific inquiry rather than a criminal investigation. Shortly after the collapse, a consultant
hired by the University stated that soil tests performed by his company after the
accident found nothing unusual about the ground at the bonfire site. He further stated
that a soil failure did not cause the collapse. Specializing in foundation evaluation and
design, his company took four borings from near the spot where the center pole was sunk
into the ground. In discussing the results of the tests, he compared the bonfire stack to a
large grain silo, which typically is tall, heavy, but not too large in circumference.
More than 2,300 documents and photographs were released under the Texas Open
Records Act, including photographs, which revealed the presence of beer cans and bottles
at scene. One of the documents released was a December 9, 1999 memo from a professor
of mechanical engineering appointed as the head of the A&M staff team to assist the
commission in their inquiry. His memo stated that the bonfire stack, at the time of the
collapse, was not forty feet as originally reported, but the four-tiered stack was already 59
feet high and had two more stacks to go before being completed.
His memo to the Commission reported the height, which does not include the
seven-foot outhouse on top, as being eighteen feet on the first tier, sixteen feet on the
second, fourteen feet on the third, and eleven feet on the fourth. The fifth tier was designed
to have been nine feet and the sixth is typically four to five feet in height. Therefore,
the completed height would have been just over seventy feet, rather than the fiftyfive
foot standard set by the university. He cautioned, however, against drawing any
conclusions from this revelation.
The Texas Rangers offered the Department of Public Safety’s laboratory to assist
with the inquiry, but indicated that the agency would not investigate the incident since it
was not a criminal matter. OSHA, however, sent their regional investigators to examine
the site. The agency is required by law to investigate accidents involving privately
owned heavy equipment and there were several cranes at the scene, which were owned or
leased by private companies.
In a related incident, the local newspaper (The Eagle 12-3-99) reported that a
student with more than 200 hours of experience operating a crane was one of two drivers
on-duty when the collapse occurred according to documents released by the University.
It is a violation of the student-written Bonfire Handbook, but not of A&M policy, for a
student to operate heavy equipment at the site. The State of Texas, however, does not
have a set of rules governing who can drive a crane, according to the National Commission
on Certification of Crane Operators based in Fairfax, Virginia. OSHA also does not
require a license for the type of crane that was being used by the student.
The use of alcohol was a theme discussed throughout the investigation in relationship
to the bonfire collapse, particularly after the disclosure that empty containers were
found and photographed at the scene of the collapse. Two of the students killed in the
collapse were alleged to have been intoxicated at the time of their deaths according to
toxicology tests released to the media. The revelation prompted the Texas Alcoholic Beverage
Commission (TABC) to start its own investigation into the incident because one of the
deceased was a minor. According to the TABC, the investigation was primarily intended to
be a “source investigation” to determine where the minor acquired the alcohol.
The legal limit in Texas is .08. One of the deceased allegedly tested at .316, or
almost four times the legal limit. The other deceased student allegedly tested at .161, or
twice the legal limit. According to published reports, the tests disclosed that the former
student killed in the collapse also has a small amount of alcohol in his system at the time
of death. Eight of the deceased, however, did not have any traces of alcohol in their
system and the test results on the twelfth victim were not available.
An article in the local paper on December 18th, however, reported that a second
toxicology report found lower levels of alcohol in the two deceased students than the first
test. The second tests were conducted by orders of the Justice of the Peace and were
intended to confirm the results of the first tests. Private companies performed both tests,
the first by a firm located in Irving, Texas and the second by a firm located in Pennsylvania.
Officials declined to disclose the results of the second tests, but a family friend of
one of the victims disclosed that the second test indicated a result of .09 rather than .316
as was alleged by the first test. The rescue workers reported smelling alcohol on both of
the deceased students, which promoted the Justice of the Peace to order the tests. The
toxicology reports were taken from vitreous fluid, a jellylike substance taken from the
victim’s eyes, and not from the victims’ blood.
Only one of the twenty-seven students injured in the collapse had a blood test
performed on them. This fact was discovered in response to TABC’s subpoenas served at
the two hospitals. College Station Medical Center reported that the hospital did not
perform any toxicology exams to determine alcohol content. State law does not require testing unless law enforcement officials request a test to be performed. A test was performed
on a nineteen-year old student taken to St. Joseph’s. Test results indicated that
there was a trace amount of alcohol present.
Bonfire night is typically one of the most active nights of the year for Brazos
County Law Enforcement Agencies because of the large number of parties and activities
associated with the event. Those who work on the bonfire are required to sign a pledge
card promising that they will not drink and get on the stack, but there is a history of
alcohol related problems. As early as 1985, students blamed drinking as a contributing
factor for bonfire related injuries. Since the activity is a student function, university
officials rely upon the students to enforce the rules.
Over the years, a number of injuries such as allergic reactions to the pine trees,
crushed hands, teeth knocked loose, and cuts from mishandled axes have been reported.
There have also been complaints about the way women are treated during the event,
particularly during the 1987 and 1988 bonfires.
Following the collapse, the Justice of Peace ruled that the cause of death for all twelve victims of the bonfire collapse was accidental. Therefore, he did not order autopsies
to be performed on the bodies of the deceased. With the exception of large metropolitan
counties, most counties in Texas do not have a Medical Examiner or Corner. A
Justice of the Peace, by law, performs the function of corner. Each county has a minimum
of four JPs and their jurisdictions coincide with the boundaries of the county commissioners’
precincts. In more densely populated counties, however, the number of JP’s
may be increased to a maximum of eight.
On May 2, 2000 the Special Commission on the 1999 Texas A&M Bonfire released
its final report. Compiled at a cost of approximately $2 million, the report revealed
that:
The 1999 Bonfire collapsed due to a number of both physical and organizational
factors. Structurally, the collapse was driven by a containment failure in the first
stack of logs. Two primary factors caused this failure: the first was excessive
internal stresses driven primarily by aggressive wedging of second stack logs into
the first stack. The second was inadequate containment strength. The wiring used
to tie the logs together provided insufficient binding strength. Also, steel cables,
which in recent years had been wrapped around the first stack, were not used in
1999, further reducing containment strength. These two factors - excessive internal
stresses and weakened containment strength - combined to cause the collapse.
The physical failure and causal factors were driven by an organizational failure.
This failure, which had its roots in decisions and actions by both students and
University officials over many years, created an environment in which a complex
and dangerous structure was allowed to be built without adequate physical or
engineering controls.
This organizational failure is complex but includes such things as the absence of
an appropriate written design or design process, cultural bias impeding risk
identification, and the lack of a proactive risk management approach.
The Commission’s report determined that the weather was not a contributing
factor in the collapse. It had not rained in the days leading up to the collapse and the sky
that morning was clear and the temperature fluctuated between 40 and 50( F. The wind
direction was from the south/southeast with a speed of five to seven miles per hour with
no gusts. The report also ruled out sabotage or any criminal activity.
Two investigations were on going at the time this report was prepared. The Texas
Board of Professional Engineers, a nine-member board based in Austin, continues to
research two issues. First, the Board intends to determine whether or not administrators
and the University violated the law by their failure to involve professional engineers in
the project. Second, the Board is considering whether engineers on the faculty ignored
their ethical duty by failing over the years to raise concerns about the bonfire structure.
The College Station Police Department is also continuing its investigation of the
collapse, which is a matter of course following an unnatural death. Police are charged with
determining whether any criminal activity was involved and they are seeking to determine
if any crimes were committed related to negligence. In addition, police wish to determine if
there was any violation of the Texas Engineering Practice Act of 1937. The Act was created to protect public safety by regulating the design and construction of buildings and other
structures. Provisions of the Act require that any public work costing more than $8,000.00
be designed and supervised by a licensed professional engineer. The exact amount expended
on the construction of the 1999 bonfire has yet to be determined.
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