Texas A&M Bonfire Analysis

     Change and the risk of failure are an inevitable aspect of production where danger is a pervasive and accepted cost of doing business. We build defenses against failure and may grow complacent as continuous production pressures dominate attention. Defenses erode over time while danger is masked by the absence of bad events and production pressures and incremental changes drive us to the margins of safety. The gradual breakdown of defenses over time that increases the risk of adverse events can be described as a drift toward failure. Often, we don’t recognize the drift until an event occurs. Near misses alert us to the proximity of danger; sharing this information is one way to avert disaster.

This drift toward failure contributed to the actions and decisions that led to the fatal bonfire construction include:

• A culture that encouraged and facilitated the activity through hands-off oversight.
• Previous collapses did not result in serious injury and did not significantly increase safety measures (bonfire was moved to a less populated area on campus).
• The bonfire grew incrementally in magnitude until the structure exceeded that of commercial design yet no professional oversight was involved in response to this design evolution.
• Historically proven design had changed piecemeal.