Exercise #036 · Catastrophic Infrastructure Failure · December 14, 2005

Taum Sauk Upper Reservoir Failure

A 1.3 billion-gallon dam failure at 5:12 AM in a rural county whose PSAP learned about it from 911 callers, not the EAP.

Released: 1.3 billion gallons in ~12 minPeak discharge: ~273,000 cfsWave crest: 20 ftTime of breach: 5:12 AM CSTInjured: 5 (Toops family)Fatalities: 0 — due to timing, not design
Dam FailureFlash FloodRural PSAPEAP FailureMulti-AgencyInfrastructure

1Opening

At 5:12 on a December morning in 2005, the upper reservoir of AmerenUE's Taum Sauk pumped-storage hydroelectric plant on top of Proffit Mountain failed catastrophically. 1.3 billion gallons of water — enough to fill roughly 2,000 Olympic swimming pools — cascaded down the mountain in 12 minutes.

The wall of water hit Johnson's Shut-Ins State Park below with a 20-foot crest. It obliterated 281 acres of the park. It swept vehicles off Highway N into adjacent fields. It destroyed the home of state park superintendent Jerry Toops, washing him, his wife Lisa, and their three young children — including a 7-month-old — across the road and into a debris field in predawn darkness and December cold.

No one was killed. That outcome was not by design. It was December, and the park campground was empty. If it had been July, the death toll would likely have been catastrophic.

2Dispatch Timeline

What the comm center saw, and when. Color coding indicates the operational dimension.

~04:00 CST
DISPATCHLisa Toops falls asleep on a couch feeding their infant. All five family members are in the park superintendent's residence inside Johnson's Shut-Ins State Park, directly in the flood path ~1.75 miles below the reservoir.
~04:39 CST
CRITICALPump Unit #2 shuts down automatically based on a faulty sensor reading of elevation 1,591.6 ft. The reservoir is already above that level — the sensor, with its detached housing, is reading false. Pump Unit #1 continues running.
05:08–05:12
CRITICALWater begins overtopping the reservoir parapet wall at the northwest face. Sensors fail to trigger automatic shutdown. Overflow scours the downstream embankment for ~6–7 minutes before Unit #1 is manually shut down from Bagnell Dam at ~05:15.
05:12–05:15
CRITICALThe northwest section of the rockfill dike collapses. A 656-foot breach opens. The entire reservoir empties in ~12 minutes. Peak discharge: ~273,000 cfs — roughly the Mississippi's flow past St. Louis at flood stage. A 20-ft crest accelerates down the mountain.
05:12–??
EAPAmerenUE's Emergency Action Plan required notification to downstream agencies. The EAP's actual notification of local emergency services and the Reynolds County PSAP is not publicly documented with precision. Evidence suggests the warning chain ran toward NWS before reaching local 911 dispatch.
~05:15+
COMMSAmerenUE / Bagnell Dam control center contacts NWS St. Louis forecast office to report the failure. NWS begins processing the notification and initiating flash flood warnings. NOAA Weather Radio All Hazards broadcasts become the primary public notification mechanism.
Post-breach
DISPATCHThe Toops home is destroyed. Jerry, Lisa, and three children — including 7-month-old Iker — are swept into darkness in December floodwaters. They survive by clinging to trees and debris. Someone reaches 911. Reynolds County dispatchers begin receiving reports of flooding, a destroyed house, and missing persons — with no pre-notification that a dam had just failed upstream.
05:15+
ESCALATIONNWS issues flash flood warnings for Reynolds County and downstream areas including Lesterville along the Black River. Voluntary evacuation orders issued. Missouri State Highway Patrol, Reynolds County Sheriff's Office, and rescue teams converge on Johnson's Shut-Ins. All five Toops members located alive, hypothermic and injured.
06:00–08:00
COMMSThe lower Taum Sauk reservoir absorbs the bulk of the released water and holds. Downstream towns spared significant flooding. Damage largely confined to Johnson's Shut-Ins State Park. Reynolds County comm center coordinates rescue operations and mutual aid.

3The Dispatch Picture

The Reynolds County Sheriff's Office and PSAP serve a county of roughly 6,000 people across 818 square miles of Ozark hill country. There is no municipal 911 center — emergency calls go to the sheriff's dispatch, which handles everything from traffic to search-and-rescue to dam failures it wasn't told were possible.

That morning, dispatchers woke up to a catastrophic flooding event the same way the public did: calls started coming in, and nobody in the warning chain had called them first. AmerenUE's Emergency Action Plan for the Taum Sauk facility — required by FERC — had notification procedures. The gap this exercise explores is what happened between the failure of that private-sector EAP and the moment Reynolds County dispatchers picked up their first 911 call.

Dispatchers initially responded to a flooding event and a missing family, not a dam failure — until information developed on scene. That time gap between "unknown-cause flooding" and "dam breach" shaped every decision in the first hour: what to brief responders on, what to tell downstream agencies, and whether to issue evacuations without knowing whether the lower reservoir would hold.

"I heard a roar — like a group of F-14s combined with a fleet of trains. And then the water hit me like a head-on collision."— Jerry Toops, Park Superintendent, Johnson's Shut-Ins State Park

4Where Judgment Mattered

The EAP question. AmerenUE was required by FERC to maintain an Emergency Action Plan for Taum Sauk. That plan had notification procedures. The Reynolds County PSAP was not in the practical notification chain in a way that reached a dispatcher who could act on it before 911 calls started.

Acting before you know the cause. Call #1 described a destroyed house and missing family. Without knowing a dam had failed, dispatchers were treating a flood. With that context, everything changes — responder hazard briefing, downstream notification, scope of evacuation. Dispatching resources immediately while asking questions that characterize the hazard is the trainable disposition.

Downstream threat under uncertainty. The lower reservoir absorbed the bulk of the water and held. Dispatchers didn't know that. When a dam fails and downstream containment status is unknown, the conservative posture is to treat every downstream community as threatened until information says otherwise — voluntary evacuation advisories, downstream PSAP notification, and getting someone on the phone with whoever can confirm containment.

Responder safety when the hazard type is unknown. A flash flood from rain runoff is a different responder risk than a dam-breach wave. The peak flow had passed before responders arrived — but dispatchers at the time of dispatch didn't know that. The training point is the questions that accelerate understanding of hazard type: "Is the water still rising?" "What was the water level before it hit?" "Did anyone see where it came from?"

Normalization of deviance. AmerenUE had known the sensor housings were unreliable since October 2005. Operators created a workaround. The system kept running. Nothing bad happened — until one morning at 5 AM, the workaround failed at the worst possible moment. In comm centers, the parallel is procedures that haven't been reviewed, CAD notes that get ignored, systems running on deferred maintenance, training gaps that persist because "nothing's gone wrong yet."

5Discussion Questions

No right answers. Tap a question to expand the analysis. Use one or all — whatever fits your time.

1Dispatching call #1 without knowing what happenedYour PSAP receives a call reporting a house destroyed by flooding and a family missing inside a state park. You have no prior notification. What do you do with call #1, and how does your response change if the second caller tells you "the whole mountain came down"?

This is a cascading information problem. Call #1 describes a structural collapse and missing persons — it warrants immediate dispatch of whatever resources Reynolds County has available, including notifying state patrol. The challenge is that without knowing a dam has failed, you're treating a flood event.

Hold the call type loosely. Dispatch the resources the first call demands. Keep asking characterizing questions — "what else just happened?" "how big was the water?" "did you see where it came from?" When a second caller adds "the whole mountain came down," everything changes: responder hazard briefing, downstream notification, scope of evacuation.

The trainable disposition is parallel action. "We don't wait to respond — we respond and gather information simultaneously." Waiting for information before dispatching costs lives. Continuing to gather after dispatching is what protects them.

2Your relationship to private-sector EAPsAmerenUE had a FERC-required Emergency Action Plan. That plan had notification procedures. Your PSAP was not notified before calls started. What does that tell you about your relationship to private-sector EAPs in your jurisdiction?

This is a structural gap that exists in many jurisdictions. FERC, EPA, and state agencies require EAPs for dams, chemical facilities, and industrial infrastructure — but those plans are written between the facility and the regulatory body. Your PSAP may or may not be in the notification chain, and even if it is, the practical question is: does your dispatcher on the 3 AM shift know who calls them and what that call means?

Discussion starter for supervisors: pull your county's dam inventory and ask who holds the EAPs. Are any of those EAPs current? Does any notification procedure route to your center in a way a dispatcher would actually recognize? This is a pre-incident planning gap, not an ops failure — but it becomes an ops failure the morning the dam breaks.

3NWS warnings and where your center sits in the flowThe warning system that actually worked at Taum Sauk was NOAA Weather Radio — NWS issued flash flood warnings and residents with weather radios heard them. Your 911 center was not in that loop. What's your center's relationship to NWS warnings, and how does that flow work in your jurisdiction?

In many jurisdictions, NWS warnings flow to Emergency Management, not to the 911 center directly. Your PSAP may be downstream of a chain that runs: event → NWS → county EM → public alert → 911 calls start coming in. That's backwards from a dispatch perspective. By the time you're receiving 911 calls about a flash flood, the event is already happening to someone.

In the Taum Sauk case, NWS was the functional public notification mechanism — but they also weren't notified until after the failure was underway. Explore: does your county EM have a direct line to your PSAP for NWS-level events? Do you receive Wireless Emergency Alerts simultaneously with the public, or after? Who in your county is the first call for the NWS warning coordination officer at 3 AM?

4Responder safety briefing when you don't know the hazardResponders were dispatched to a state park to locate a family swept by floodwater. There was a 20-foot initial wave crest and significant ongoing flow. What does that mean for your responder safety briefing on a call like this?

Without knowing the source of the flooding, dispatchers can't effectively brief responding units on the hazard they're entering. A flash flood from rain runoff is a different responder risk profile than a dam-breach wave that's already emptied. The peak flow had passed by the time responders arrived — but dispatchers at the time of dispatch didn't know that.

You can only brief on what you know. The training point is what questions to ask that would accelerate your understanding of the hazard type. "Is the water still rising?" "What was the water level before it hit?" "Did anyone see where it came from?" These aren't just good customer service — they're responder safety questions.

5Triaging an immediate victim rescue against a potential downstream threatThe lower reservoir absorbed most of the water and held — sparing Lesterville and downstream communities. But dispatchers didn't know that. How do you prioritize when you don't know the scope of the downstream threat?

When a dam fails and you don't know downstream containment status, the conservative approach is to treat every downstream community as threatened until you have information otherwise. That means voluntary evacuation advisories, downstream PSAP notification, and getting someone on the phone with whoever can tell you what the lower reservoir's status is.

The challenge: Reynolds County dispatchers had the most immediate victim situation (the Toops family rescue) plus a potential catastrophic downstream threat — simultaneously. How do you triage? This is a supervisor decision as much as a dispatcher decision. When do you call in off-duty staff, when do you call for mutual aid dispatch support, and who makes that call at 5:30 AM?

6Normalization of deviance in the comm centerAmerenUE had been aware of the faulty sensor housings since October 2005 — and continued operating. A near-miss at the reservoir in September was caught manually. How does "it's been fine so far" thinking manifest in comm centers?

This is normalization of deviance. AmerenUE knew the sensors were unreliable. They created a workaround. The system kept running. Nothing bad happened. So the workaround became the norm. Then one morning at 5 AM, the workaround failed at the worst possible moment.

In comm centers, this shows up as: procedures that haven't been reviewed because "we've always done it this way," CAD notes that get ignored because "that caller always calls," systems running on deferred maintenance because "it works fine," and training gaps that persist because "nothing's gone wrong yet." The question isn't whether your center has a Taum Sauk — it's which one it is.

6Knowledge Check

Five questions. Answer, then submit for inline feedback. Progress saves locally.

Q1.The Taum Sauk reservoir sensors had been known to be unreliable since October 2005. Operators continued running the facility using manual workarounds. What failure mode does this best illustrate?
Q2.Reynolds County dispatchers received 911 calls about a destroyed house and missing family before they knew a dam had failed. What is the most important dispatch action in the first 60 seconds of that first call?
Q3.The lower reservoir absorbed most of the released water and held, sparing downstream communities. But at the time of dispatch, that status was unknown. How should dispatchers handle a potential downstream threat under those conditions?
Q4.AmerenUE's EAP included a notification requirement for local emergency services in the event of a dam failure. Evidence suggests the Reynolds County PSAP received no pre-failure warning. What is the most practical corrective action for a PSAP to take before a similar event?
Q5.The Toops family survived because it was December and the campground was empty. Had it been July, the death toll would likely have been catastrophic. What does this "luck factor" tell us about how we evaluate our emergency response systems?

7Sources & Further Reading

Primary Investigation
Federal Energy Regulatory Commission, 2006 · FERC No. 2277
Dam Safety Analysis
Association of State Dam Safety Officials · damfailures.org
Canadian Dam Association Bulletin, 22(4), 16–25, 2011
Weather / Warning
Reference
Comprehensive overview with primary-source citations

8Your Notes

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