Texas A&M University (TAMU), founded in 1876, is deeply rooted in tradition, and its students are well known for their intense “Aggie spirit.” Located in College Station, Texas, the university enrolls more than 43,000 students. In November 1999, preparations for the annual football game against the University of Texas (UT) were in full swing. As usual, Bonfire, an annual event that symbolizes the Aggies’ “burning desire” to beat their archrival, was the center of attention. The Bonfire tradition began in the 1920s with a pile of wood and trash, and over the years it grew to immense proportions, reaching 109 feet tall in 1969 before campus regulations set in the late 1970s limited the height to which it could be built. About 40,000 to 50,000 people attended the burning of the Bonfire every year, and many more watched the event on television.

Bonfire was a student-run operation, with about 5,000 students involved in planning, organizing, training, fundraising, supervision, and construction each year. Student leaders, known as “Red Pots” for the color of their hard hats, coordinated Bonfire and oversaw safety at the site. Each structure required nearly two months to build, and planning began early in the spring semester. Students worked with a landowner to obtain the trees and then helped cut and transport them to campus. Some students worked directly on the stack of logs, whereas others served in support roles, such as providing food, water, and first aid.

THE COLLAPSE OF THE 1999 BONFIRE

Around 2:30 a.m. on November 18, 1999, just one week before Bonfire would have been set alight on Thanksgiving Day, tragedy struck. In a matter of seconds, the enormous stack of eighteen-foot logs, weighing more than 1 million pounds, began to collapse and, as it was designed to do when burned, fell into itself. Many who had been working on the stack were trapped inside the collapsed structure of logs. As campus officials, including members of the university’s Critical Incident Response Team (CIRT), arrived at the site, at least two deaths and numerous injuries were apparent. The number of students working on the stack when it collapsed was still unknown, as was the number of missing persons. Given the magnitude of the accident and the difficulty of disassembling the structure, it took more than seven hours to confirm the list of unaccounted-for students and to notify their parents. The last victim was located twenty-four hours after the collapse. In the end, twelve Aggies died—eleven students plus one alumnus—and twenty-seven were injured.

IMMEDIATE RESPONSE

Members of the university’s CIRT arrived at the accident site within thirty minutes. CIRT was established to respond to critical incidents involving students and to serve as a university contact. Among the goals of CIRT are to coordinate the university’s response to critical incidents and to offer support and counseling to members of the university community and their families. Members of CIRT, which include representatives from a wide variety of campus departments and programs, some of which are Athletics, the Corp of Cadets, the Provost’s Office, Residence Life, Security and University Police, TAMU Federation of Aggie Mothers’ Clubs, University Relations, and the Vice President for Student Affairs, participate in training at least once a year. Given the magnitude and implications of the Bonfire collapse, nearly every campus office became involved in the response. The Corp of Cadets, for example, is traditionally heavily involved in Bonfire, and some cadets died in the collapse; the Provost was involved in the decision to cancel classes a day early for the Thanksgiving break in the week following the accident; and Residence Life staff was busy responding to campus residents affected by the events.

Word of the accident spread quickly, and many people, including the national media, began arriving at the accident site. Coordinated by CIRT, the immediate response to the accident was swift and complex. University staff members were dispatched to local hospitals where injured students had been taken and family members and friends had begun to gather. A private room for family members of those missing, injured, or killed was set up in the campus Student Center, which was also the location of the information center. A command post was set up in the office of the Vice President for Student Affairs. A memorial service was held that evening.

Important issues regarding communication, media, families, and counseling were addressed by CIRT. A toll-free phone number for inquiries was put in place, although phone and cellular services were overloaded by the volume of calls. The university granted all media requests (offering alternative interviews if the requested person was unavailable) and gave frequent press briefings to the media to provide facts on the investigation and information on students, funerals, and memorial services.

Other follow-up responses included ongoing communication with students and families, provision of counseling services, and fundraising. Two funds were established from the contributions that poured into the university after the disaster. One, managed by the Association of Former Students, assisted families with expenses incurred as a result of the accident. The second, managed by the Texas A&M Foundation, funded a permanent memorial to those who died. Additionally, representatives of the university attended each funeral service, and the university provided free transportation (buses, vans, chartered plane flights) for students and administrators wishing to go.

HISTORY AND INVESTIGATION

The logs for Bonfire, which came from land that needed to be cleared, were donated to A&M. A completed Bonfire could weigh more than 2 million pounds—about the same as two 747 jumbo jets. Students were in charge of the engineering and construction of Bonfire, and historically, the university’s involvement in the design and construction of the structure had been limited. Although restrictions were placed on the height and diameter of Bonfire, they were not well communicated or enforced. When the 1999 Bonfire collapsed, it stood 59 feet tall—4 feet over the university-imposed limit—and there were two more layers of logs to be added to the stack. In all, the 1999 Bonfire was to burn 7,000 logs.

A week after the collapse, university president Ray Bowen appointed an Independent Special Commission on the 1999 Texas A&M Bonfire to determine the cause of the collapse. The commission was headed by Leo Linbeck, Jr., the chairperson of a Houston-based construction company and not an alumnus of A&M. Linbeck hired five companies outside Texas to investigate various aspects of the accident. The commission met for the first time on December 3, 1999, just two weeks after the collapse, and began to evaluate the historical design of Bonfire and analyze physical and behavioral factors in the collapse. The commission’s final report, issued on May 2, 2000, determined that “wedging, vertical log orientation, overbuilding, and ground slope combined to reduce hoop stress, while weak wiring and lack of wrap-around cables combined to reduce hoop strength. The combination of these caused the Bonfire collapse.” However, a behavioral analysis found other contributing factors.

Investigators for the commission examined three major controls or barriers designed to prevent problems and encourage safe and reliable procedures:

1. Individual human performance barriers, including adequate skills, knowledge, and good judgment.

2. Effective programmatic barriers, including adequate levels of procedural guidance and methods to identify and resolve problems.

3. Strong organizational and management barriers, including effective risk identification and management and adequate management and supervisory actions.

Although a system of multiple barriers can help prevent serious problems, multiple failures of those barriers can result in catastrophe, as happened at Bonfire.

Although these three control barriers were not directly responsible for the collapse, the commission examined them to identify failures that were relevant to the accident. Four subbarrier failures were determined to be relevant. First, student skills and knowledge—an individual barrier—were found to be inadequate for an engineering project of the magnitude of Bonfire. Over the years, student leaders had made important design decisions without a clear understanding of the impact of those decisions on the structural integrity of Bonfire. Second, with regard to programmatic barriers, there were no formal written design and construction plans for the structure. Third and fourth, with regard to organizational barriers, an active risk management plan was lacking, and cultural bias impeded risk identification. Specific problems led to specific actions instead of comprehensive action to address a larger problem. For instance, excessive injuries led to training programs, and excessive drinking resulted in alcohol awareness programs, but a combination of problems was not considered collectively and did not trigger a broad, overall reexamination of Bonfire. “This tunnel vision in decision making is due, in the Commission’s view, to a cultural bias in which legitimate courses of action outside past experience or contrary to the University’s predisposition are often not considered.” The report concluded, “The collapse was about physical failures driven by organizational failures, the origins of which span decades of administrations, faculty, and students. No single factor caused the collapse, just as no single change will ensure that a tragedy like this never happens again.”

TRADITION AND CULTURE

Long-standing traditions are an integral part of the culture of Texas A&M University. There is a saying at A&M that speaks to that culture: “From the outside looking in, you can’t understand it. From the inside looking out, you can’t explain it.” Although not everyone agrees on the future of Bonfire, some of the students who survived their injuries expect it to continue, and parents of some of those who died support its continuance. The father of one student who died is passionate in his belief that it should continue. If it ends, he believes his son’s death would be senseless. The mother of another student contends that, more than just a big fire, Bonfire symbolizes the Aggie family. Some students and alumni have suggested that Bonfire might be moved off campus if the university cancels it; others warn that canceling the tradition might adversely affect alumni donations to the university.

Efforts to end the Bonfire tradition, some stemming from before the collapse, are unpopular. A large group of faculty has criticized Bonfire as “a needless waste of natural resources, a symbol of a lack of concern for the environment and a very conspicuous source of embarrassment for this institution within the international community.” One faculty member who has spoken out against Bonfire feels it is personally and professionally risky to do so. He has been told that the highway in town “runs both ways,” implying that he should leave if he does not like it there. President Bowen and others stress that the Aggie Spirit is stronger than a single tradition and will exist throughout the life of the university.

FUTURE OF BONFIRE

Although the commission had the task of determining the cause of the collapse of Bonfire, President Bowen faced the decision of whether to continue the decades-old tradition. In the week following the tragedy, a memorial service was held in place of Bonfire, and A&M defeated rival Texas in front of the largest crowd ever to witness a football game in the state of Texas. After the commission’s final report was issued, the president considered feedback from many stakeholders, including parents of those killed or injured, commission members, faculty, students, the A&M Foundation, Aggie Moms, and alumni before announcing his decision.

A new process included more oversight by the university and increased safety by involving professionals in the log cutting and in the design and construction plans for Bonfire. But plans to restructure the Bonfire project to ensure safety and facilitate its return by 2002 were plagued with problems and controversy. In 2000, a student-planned memorial paid tribute to the students who died or were injured. In 2001, groundbreaking and dedication of a permanent memorial took place. There have been efforts at creating an off-campus, unsanctioned “Student Bonfire,” but the future of the original Bonfire project remains uncertain. Texas governor Rick Perry has made remarks suggesting his support of the reinstatement of the tradition at his alma mater despite the lingering concerns of university officials.

DISCUSSION QUESTIONS

1. How can the competing demands of various stakeholders (e.g., students, parents, alumni, faculty, staff, trustees, legislators, community members) be balanced effectively? What principles should guide decision making?

2. What are the objective of the case

3. What is the role of tradition and culture in institutions and organizations? How should leaders balance those qualities with other considerations, such as safety and change? What are the ethical dimensions of a situation like this? How should the university respond to a group attempting to organize an off-campus bonfire?

4. Should all organizations have a written crisis management plan in place? What elements would be most critical to include? What factors are most critical to effective crisis management?