A Case Study: THE WALKERTON TRAGEDY

You Snooze………You Lose!!

Walkerton Public Water System Operated by the Walkerton, Ontario, CA PUC Stan Koebel-general manager, brother Frank was the foreman 3 groundwater sources with chlorine treatment

Events…..May 8-15, 2000 Heavy rains, totaling more than 5 inches Heaviest almost 3 inches Well #5 was the primary source of water May 13,14,15 - Frank Koebel performed daily rounds Standard practice of not checking chlorine Fictitious log entries

Events….. May 15 Stan Koebel returns after one week away turns Well #7 on without chlorination a new chlorinator had been installed 3 bac’t samples taken by PUC employee labels did not show sample location from PUC workshop?

Events…..May May samples taken one from the distribution system 3 from a water main construction site May 16- all samples are received by the lab May 17- lab advises Stan Koebel: 3 samples from the construction site are positive for total and fecal coliforms (E. coli) other sample suspect 6 days to notify health authorities

Events…..May First indications of widespread illness members of the public contact the PUC Stan Koebel assures them ‘the water is safe to drink” More illness, bloody diarrhea, vomiting Doctor contacts Health Unit suspecting E. coli. Health authorities begin an investigation

Events…..May 19 Stan informs the Health Unit that he thinks the water is ‘OK’ does not mention positive samples or that Well 7 had been operating without chlorination If health authorities were aware of test results and Well #7….with no chlorination…..  Boil Water Notice!!!!

Events…..May 19 & 20 Stan begins flushing and super chlorinating the residual is elevated in the system and at the wellheads a few days later Stool sample from a child tests E.coli positive outbreak is expanding rapidly Stan informs health authorities of the system residuals false impression created

Events…..May 21 E.coli is confirmed Health authorities issue boil order over AM/FM radio Doctor contacts Mayor requesting further public notification-no further steps taken

Events…..May 21 & 22 Walkerton experiences its first death Health authorities take 20 water samples Hospital receives 270 calls for serious abdominal pain & diarrhea Child is airlifted to London, Ontario for emergency treatment. Stan provides for the first time the May 17 test results Directs Frank to change the Well 7 log to imply that it had operated with a chlorinator, and provides altered logs to health authorities

The Fallout….. 7 people die 2,300 people became ill Many suffer permanent organ damage It was all preventable!

A Community Devastated…… & Loss of Confidence in Services Suffering friends and family of lost ones Uncertainty about the future – will it happen again?

What Went Wrong?? What Could Have Been Done To Address This?

Chlorine residual & turbidity monitoring daily at Well #5. Operator training Inadequate chlorine dosages Inadequate monitoring False chlorine residual log entries Poorly documented bacti sampling locations Intentional violation of regulations PUC Board members not well informed and may have delegated their responsibilities

What Went Wrong?? What Could Have Been Done To Prevent This?? Health authorities needed to be more aggressive Lab should notify health authorities of lab results directly Boil Water Notice should have been more broadly disseminated Stan misrepresented and concealed information Test results Chlorinator not operating

Anatomy of the Physical Causes The Well Shallow Casing extended ~ 15 feet Water table 8 – 40 feet Nearby surface water influence Fractured rock Pathogenic bacteria quickly moved from the land surface to the ground water supply

Anatomy of the Physical Causes The Farm Manure spreading, farm owner not faulted The owner of the farm was using best management and widely accepted practices

Lessons Learned Who is ultimately responsible for the health of your customers? What are the weak links in your operations? Does anyone in your utility approach their job like the Koebel’s? In the event of an emergency do you have a plan (ERP) in place? Do you know what to do? Could this happen in your community?

Stan The Man

Walkerton Not An Isolated Case Milwaukee, Wisconsin Cabool, Missouri New York State Fairgrounds Centers For Disease Control –Reporting Waterborne Disease Incidents and Investigations