Causality 32: Walkerton

7 December, 2019

CURRENT

In 2000 the small township of Walkerton Ontario witnessed the largest outbreak of E.Coli infections in Canada’s history. The water utility claimed the town water was safe, but it wasn’t and many people paid with their lives.
In Causality Explored, (Premium ONLY) we dive into what Free and Total Chlorine Residual are, why it matters, and how a 10 minute discussion with the right people could have prevented the incident at Walkerton.

Transcript available
Chain of events. Cause and effect. We analyse what went right, and what went wrong, as we discover that many outcomes can be predicted, planned for and even prevented. I'm John Chidgey and this is Causality. This episode is brought to you by Many Tricks, makers of helpful apps for the Mac. Visit https://manytricks.com /pragmatic for more information about their amazingly useful apps. We'll talk more about them during the show. Causality is supported by you: our listeners! If you'd like to support the show you can, by supporting our sponsors or by becoming a premium subscriber. Premium subscribers have access to early release, high-quality ad- free episodes, as well as bonus episodes and to Causality Explored. You can do this via Patreon or if you prefer via our website or in our apps in the Apple, Google Play or Amazon app stores. Visit https://engineered.network/causality to learn how you can help this show to continue to be made. Thank you. "Walkerton" Walkerton, Ontario, Canada has a population of about 5,000 people and lies approximately 2 hours drive from Toronto which by contrast, is Canada's largest metropolitan city at 6M people. In the early 2000s the water supply to Walkerton, was supplied by three groundwater wells numbered 5, 6 and 7. Well 5 was 15m deep, capable of supplying 56% of the town's water supply needs in isolation. With well 6, 72m deep with a maximum supply of 52% in isolation, and well 7 was 76m deep (the deepest) with a maximum supply of 140% of the town's water supply needs. Well 5 used Sodium Hypochlorite solution for Chlorine dosing, whereas wells 6 & 7 both used Chlorine gas for disinfection. The water distribution system had approximately 42klm or 26mi of water mains with 2 standpipes providing pressure equalization and approximately 20 hours of reserve storage. A basic control system and SCADA, controlled and monitored the wells and standpipes. The Walkerton Public Utilities Commission (or PUC for short) were charged with the safe operation and maintenance of the water supply system in Walkerton. So let's talk about the incident itself. On the 8th of May, 2000 a series of storms and steady rain over a 5-day period totaled some 134mm of rainfall. The volume of rainfall accumulation led to inevitable surface saturation and subsequent runoff, which led to some minor localized flooding in the area. On the 12th of May, some of that rainfall runoff entered well number 5. On Monday the 15th of May, Stan Koebel returned on shift and noted that well 7 was not operating. Every Monday, and this was no different, the operators collected their weekly samples from each of the wells and from key sample points in the distribution system. Around this time a construction project was underway that required the installation of 615m or 2,000ft of replacement water mains on highway number 9 in Southwest Walkerton, between Wallace Street and Circle Drive. On Wednesday the 17th of May, at 9:14am the A&L laboratory faxed the results from the highway 9 project water samples to the PUC. All three samples indicated positive for Total Coliforms and E-coli. At 2:37pm that afternoon, the remaining tests from the A&L lab were faxed to the PUC, with a sample labeled well 7 treated, positive for Total Coliform and E-coli. Further the tests indicated Coliform bacteria greater than 200 CFU/100mL E-coli greater than 200 CFU/100mL and a Heterotrophic plate count of 600 CFU/mL. By Thursday the 18th of May the number of illnesses had increased significantly, with a 7yr old and 9yr old admitted to the Owen Sound Hospital and about 20 students from the Mother Teresa Cchool reported in sick. Members of the public including concerned parents had contacted the Walkerton PUC to confirm the water was safe to drink, however were not told that anything was wrong. By Friday the 19th of May, 8 people had a documented 3 day history of symptoms with now more than 25 absent from the Mother Teresa school, 8 from Walkerton Public and 3 residents from the Maple Court Villa retirement home were also affected. Dr Kristen Hallett, a pediatrician from the Grey-Bruce Health Services had two patients referred to her from the hospital with similar symptoms. At approximately 9:00am that day Dr Hallett contacted Dr Murray McQuigge, the local medical officer of Health (MHO) to inform him that her food history investigation of those patients indicated contaminated water was the most likely cause, with E-coli the most likely pathogen. During that day James Schmidt the public health inspector in Walkerton and received multiple calls and proceeded to call Mr Koebel at 2:21pm directly, asking him about any issues with the water supply. To which Stan Koebel indicated he thought: "...the water was okay..." On Sunday the 21st of May at approximately 1:30 p.m. a public health advisory was issued by the health unit to the Walkerton community not to drink municipal water from the tap, recommending boiling all water before consumption. The MHO also took their own independently collected water samples from multiple locations in Walkerton and their results on the 23rd of May, all showed E-coli contamination, leading to all schools being closed the following day. On the 25th of May, the regional police force directed the Ontario provincial police to begin a criminal investigation into the incident. With incidents such as these, the health impacts can take weeks months or even years to fully play out, and those most at risk are our most vulnerable in society. Children, the elderly, and those with pre-existing medical conditions that are ill-equipped to fight off an illness like this. The number of people killed directly or indirectly due to this incident has been debated since shortly after the incident, with either 2, 3 or 4 others indirectly linked, and not all are conclusively proven to have been linked to the incident, though there is strong evidence to suggest that they were. The following people lost their lives either in whole or in part due to this incident: Melville Dawe 69yrs old, May 19th. Lenore Al 66yrs old, May 22nd. Mary Rose Raymond 2yrs old, May 23rd. Robert Brodie 89yrs old, May 24th. Edith Pearson 82yrs old, also May 24th. Vera Coe 75yrs old, also May 24th. Laura Rowe 84yrs old, on May 29th. Betty Trushinski 56yrs old. May 31st. So what on Earth, went wrong? The Honorable Dennis R O'Connor was appointed to lead the Walkerton Commission into this incident producing a final report in 2 parts the first of which was released in January, 2002. The source of the contamination was found to be well number 5, with runoff from a farmers paddock, with the fecal coliforms from the livestock excrement being washed into the drinking water. The investigation unsurfaced several disturbing behaviors and events leading up to the incident. Prior to the rainfall event on the 5th of May, Stan Koebel left Walkerton to attend a conference in Windsor for which he was away until the 14th of May, during which time the rainfall event had occurred. In his absence his brother Frank Koebel was in charge of the PUC in Walkerton. When Stan left for the conference he was aware that the Chlorinator on well number 7, was not functioning correctly, since well 7 was brought back into service on the 2nd of May. In fact the well hadn't been in service since a 10th of March. It wasn't uncommon to rotate water supply from each of the wells. But rather than shut well 7 off Stan Koebel instructed Frank to replace the Chlorinator in well 7 with the replacement unit that had been on the PUC premises in Walkerton for nearly one and a half years. Upon Stan's return he found that Frank had still not fitted the replacement Chlorinator to well 7 and that well 7 had still been running during that time. Well 7 pumped unchlorinated water into the system from the 3rd of May to the 9th of May. As it was the only well being used during that period there was no new Chlorine being injected into the water main system for that time. The correct course of action would have been to leave wells 5 and/or 6 running while the Chlorinator in well 7 was replaced and then to return well 7 to service. An activity that would have taken about a day, of end-to-end activities to complete absolute maximum. Chlorine residual needs to be maintained to ensure that any bacteria are killed before the water is consumed, but that's something we'll explore separately. Despite the fact that both Stan and Frank Koebel were aware that Chlorination was required at all times as mandated in the Ontario Drinking Water Objectives and Bulletin 65-W-4 for "Chlorination of Potable Water Supplies." When interviewed following the event, they believed that unchlorinated water from well 7 was safe because it was from a deeper well. In addition PUC staff would regularly drink raw unchlorinated water at the well because it was "cold, clear and clean" and "tasted better" than chlorinated water did. Multiple years of reinforcing the idea that it's safe to drink it today so it'll be safe to drink it tomorrow, led to a mistaken belief that chlorination was in fact optional for well number 7. In the history of the plant there had been no incidents like this which also fed a mistaken belief that anything like this could actually happen. Every day operators were required to visit each well and make a recording of the following: the Water Flow Totalizer, the Chlorine Chemical Usage, and the current Chlorine Residual. On the 13th of May at 4:10pm 0.75mg/L of chlorine concentration was recorded for well number 5. There was no entry for well 6. By cross-checking the water volume recorded against the amount of hypochlorite dosed during that period, it was calculated that it was completely impossible to have a chlorine residual that high, given how little hypo was dosed during that period. The investigation also found that for more than 20 years it had been regular practice for PUC operators to not measure the actual chlorine residual but instead, write down a fictitious value, to put "an entry in the box." Reviews of the logs showed a significant number of readings of 0.5 and 0.75mg/L despite there being no correlation between the documented chlorine residual levels and chemicals consumed during those respective periods. Testimony from Stan Koebel was that multiple PUC staff had been filling sample containers from the PUC workshop which was down the line from well 5 and labeled them as taken from other locations in the network. During the inquiry when he was asked to explain why sample bottles had been submitted with the incorrect source information written on them he answered (and I quote): "Simply convenience, or just couldn't be bothered." (end quote) One more point about the behavior of both Stan and Frank Koebel that was uncovered in the investigation: Frank Koebel on his brother's instructions, altered the daily operating sheet for well number 7 on May 22nd/23rd in an apparent attempt to conceal from the MOE that well number 7 had been operating without a chlorinator for an extended period, and that demonstrates that they were fully aware that running without a chlorinator was not an acceptable practice and yet they did it anyway. The Walkerton PUC operators therefore in summary, firstly set inadequate doses of chlorine based on the water flows, secondly they did not repair the faulty chlorination equipment in a timely manner, thirdly they didn't regularly monitor chlorine residual every day, fourthly they made false entries in their daily logs for days where readings were not taken, fifthly they intentionally mislabeled locations that microbiological samples were taken and finally, they attempted to conceal facts after the event to protect themselves. The operators were fully aware their practices did not follow the Ministry of the Enviroment (or MOE) guidelines and their directives, and having said that the A&L laboratory also failed by not reporting their findings of potentially unsafe drinking water to the MOE. The A&L laboratory policy was only to send report results to their client directly and there was no requirement to notify the MOE or the local medical officer of health, should they have found a problem in their tests. Mr Robert Deakin, the laboratory manager at A&L claimed he was unaware of Section 4.1.3 of the ODWO, a guideline stating that the lab should notify the MOE district office of indications of unsafe drinking water, were they found. On Wednesday the 17th of May the alarm could have been raised by the A&L laboratory alerting the MOE or the MOH which would have resulted in a boil water notice being issued 4 days earlier. That would have significantly reduced the spread of the outbreak, but they didn't. It's unclear how many lives would have been saved had that happened, however there's no question the death toll would not have been as high. So let's talk a little about E-coli and what the problem with it is. Escherichia coli or E-coli (for short, because it's a lot easier to say) technically O157:H7, was the primary pathogen the other was Campylobacter Jejuni, which were the 2 bacteria the most responsible for the majority of deaths and illnesses in this incident. Once infected with E-coli, the intestinal symptoms last for about 4 days and can persist for longer. After 24 hours bloody diarrhea is common and in some cases severe abdominal pains and cramping. Generally it resolves itself without treatment other than just rehydration and the replacement of the body's electrolytes, however for some people particularly children under 5yrs of age and the elderly, E-coli infection can be far more serious. causing Hemolytic Uremic Syndrome (HUS), after 5 to 10 days of infection leading to anemia low platelet counts and in some cases kidney failure. In the most extreme of cases these complications can result in death. 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[End Sponsor] The report had many recommendations (28 in fact) but we'll look at 1 specific one, and 4 others that fall broadly under the same key category. The first is recommendation 11. Continuous monitoring. From the report I quote: "The MOE should require continuous chlorine and turbidity monitors for all groundwater sources that are under the direct influence of surface water, or that serve municipal populations greater than a size prescribed by the MOE." (end quote) This happened in 2000, so a bit of history. In 1996 I worked at the Stanwell Power Station that's a 1.4GW baseload power plant outside of my home town of Rockhampton in Queensland. When I joined the so-called Effluent Outfall, was being monitored with a local data logger for monitoring a small number of water quality measurements. The project I was asked to execute was for the continuous monitoring of both the inlet and outlet of the Northern StormWater Dam, to bring the data back into the plant DCS (Distributed Control System). At the time, the EPA was requiring hourly water quality samples be taken however the system that I installed would take multiple samples every single minute. Far exceeding the requirements. That was 4 years before the Walkerton incident and the community of Stanwell had a third of the number of residents living there. The point though is that continuous monitoring using either a local data logger or a centralized SCADA system was well and truly tested and available technology that was not that expensive that could have been fitted easily into the Walkerton water treatment system had they wanted to. In the past 20 years working in Water Treatment Facilities of all different sizes but particularly in SE Queensland I've never seen a system that relied solely on manual measurements, except occasional cross-checking for equipment calibration. Better safe than sorry. Moving on to the other recommendations of which there's four: 20, 21, 22 and 23 and they all broadly discuss training so I'll read each and then I'll summarize and then I'll summarize all of them at the end. Recommendation 20 (I quote): "Tthe government should require all water system operators including those who now hold certificates voluntarily obtained through the grandparenting process to become certified through examination within 2 years and to be periodically re-certified." (end quote) So yes, please ensure the people that are in charge of the plant are actually certified to do so, and you have 2 years to get it done (by the way) and plan to re-certify them every so often. That's a good idea: you should get on that, and spoiler alert: they did, following the incident. Recommendation 21: The materials, (and I quote): "The materials for the water operator course examinations and continuing education courses should emphasize in addition to the technical requirements necessary for performing the functions of each class of operator..." (and this part is in italics) "...the gravity of the public health risks..." (back to normal text) "...associated with a failure to treat and/or monitor drinking water properly. The need to seek appropriate assistance when such risks are identified and the rationale for and importance of regulatory measures designed to prevent or identify those public health risks." (end quote) So in other words make sure your operators understand that they could kill people... if they don't do their jobs properly. A little dose of fear when, you're dosing chlorine...goes a long way. Recommendation 22: (I quote): "The government should amend Ontario Regulation 435/93 to define training clearly for the purposes of 40 hours of annual mandatory training with an emphasis on a subject manner described in Recommendation 21." (end quote) Now this is subtle, but it's really important. I'm an RPEQ (Registered Professional Engineer in Queensland) and a Chartered Professional Engineer in Australia (CPEng) and in order to maintain those qualifications and certifications I'm required to undergo recordable and audited continuous professional development (or CPD for short). Now that CPD could include training but it stipulates that it must be training that's relevant to my discipline amongst other things. It's not like "I spoke to this guy in the corridor and he taught me how chlorine works so I'm like trained now" No it needs to be structured, reviewed, relevant training that's recorded and tested otherwise there's no point and when I write down my CPD I guarantee you Engineers Australia check it. All right, Recommendation 23: (last one. I quote): "The government should proceed with a proposed requirement that operators undertake 36 hours of MOE approved training every 3 years as a condition of certification or renewal. Such courses should include training and emergency issues with water treatment and pathogen risks, emergency and contingency planning, the gravity of public health risks associated with the failure to treat and/or monitor drinking water properly, the need to seek appropriate assistance when such risks are identified, and the rationale for and importance of regulatory measures designed to prevent or identify public health risks." (end quote) That was a long couple sentences but this kind of repeats and expands on the previous 3 points which I think probably could have been worded in a more intertwined way, but in essence: yes make the training regular, 3 years? I would have said annually personally, but that's just me. The key training points are very good though. They're focused on abnormal operation, how to deal with emergencies, and yes let's remind them again and again that they could kill people, if they don't do their job properly. Think that's a good idea too. To wrap up on training we did actually speak about that on Episode 27 about Gare de Leon, and it's worth repeating here. When operators are asked to operate any kind of plant, they need to be taught the consequences of incorrect operation and whilst it sounds obvious for something like water treatment, we all drink water and hence we could make a lot of people sick or even kill them if we make mistakes and how we treat (or in this case don't treat) our water before it's consumed. People think that training is about learning how to do something correctly over and over and over, and yeah that's part of it, but the most important part of operator training isn't how to start it up, shut it down or run, or test, or maintain it necessarily, it's how you handle upsets. Unplanned activities. Worst case scenarios, and in this case an E-coli outbreak. Training in this case, would have been as soon as the results came back and they were bad, shut it down. Shut it all down. Warn people. But they didn't. Understanding the importance of the laboratory testing as a measure of water quality rather than thinking that you can tell there's E-coli in the water just by tasting it? This is a huge knowledge and competency gap, that's honestly, very hard to fathom. So it brings me to the final question, possibly the most important question in this whole incident. How the hell did Stan and Frank Koebel end up running a water utility in the first place? So let's talk about Stan for a second. Stan was a certified Class 3 operator of a water distribution system. He joined Walkerton PUC in 1972 when he was 19 years old. His father was the foreman of the Walkerton Works Department at the time and he had an 11th grade education. For the first 4 years of his career he worked under Ian McLeod the then General Manager of the PUC, before changing to Electrical Supply and Distribution, completing a linesman apprenticeship. In 1981 he was promoted to Foreman and was responsible for both water and electricity at PUC and when Mr McLeod retired in 1988, he was promoted to the General Manager position. The only course Stan Koebel attended following the most recent promotion, was a leadership training course. In 1987 the MOE introduced a grandfathering program for water operators regarding their certifications. For those unfamiliar, a grandfather policy is a provision in which an old rule continues to apply to some existing situations while a new rule will apply to all future situations. Those exempt from the new rule are said to have "grandfathered rights" or acquired rights" or to have been "grandfathered-in," depending on who you speak to. In the context of the certification in this case operators were deemed through experience, to have implicit certification through demonstrated capability and therefore could be safely granted a certification using experience as their sole measure for qualification. Talk about that a little bit more in a minute. back to Stan Koebel. At the time Mr McLeod submitted Stan Koebel's name to the MOE as he had been certified as a Class 2 operator, although he had never been required to pass an examination. He had been re-certified as a Class 3 when in 1996, the Walkerton water system was re-classified as Class 3. Again without any MOE assessment of knowledge or skills. During the testimony Stan Koebel stated, that he did not know what E-coli was, nor of its implications to human health. He did not fully understand Turbidity or Organic Nitrogen. Consequently he did not always fully comprehend portions of MOE inspection reports and correspondence. That's not good. Frank Koebel. In 1983 he completed courses to qualify as a journeyman linesman at the Ontario Hydro Training Centre. Prior to 1988 approximately one-quarter of Frank's time was spent working on hydroelectricity with the remainder on the water system. In 1988 he was promoted to Foreman in the same time period that his brother was promoted to General Manager. Frank obtained his Class 2 certification via grandfathering and later his Class 3 without being required to complete any courses with no competency testing or examinations just like his brother. During testimony Frank Koebel also admitted to many knowledge gaps that matched Stan's, however additionally he was unaware of what Total Chlorine was. He didn't know what Free Chlorine was. Nor was he aware of The Chlorination Bulletin. Nor Ontario Regulation 435/93 regarding requirements for the licensing and competency of operators. In the entirety of his 25yrs he worked at Walkerton PUC Frank Koebel admitted, he had never attended a single training course about chlorination in any form. So let's talk about the fallout. The Ontario government paid more than $72M CDN just in compensation to the victims of the incident and their families, and the total economic impact of the incident was approximately $155M CDN. The former manager of Walkerton's Utilities Commission Stan Koebel, was jailed for 1 year for his role in this incident. The former Foreman, and Stan Koebel's brother Frank Koebel, was sentenced to 9 months of house arrest. A total of 10,189 claims were made with 9,275 qualifying for compensation. After 7 months since the boil water advisory and at a cost of $11M, the Ontario Clearwater Association finally announced the water was once again safe to drink. Despite that announcement, it took residents many years, before they trusted the town water supply again, with many choosing to stick with bottled water instead. So what do we conclude from all of this? The depth of the ignorance, laziness and careless disregard for common sense is almost laughable, if they hadn't managed to kill people and make approximately 2,320 people sick, which was effectively half the town's population. There are definitely some similarities to Flint Michigan insofar as the operators didn't understand what they were doing. They fit the dictionary definition of incompetent and there's a link in the show notes if you don't believe me. Grandfathering a certification on the basis of demonstrated experience isn't a very good idea. If someone is competent through experience then surely they wouldn't mind (you know), sitting in short test, maybe? What's Free Chlorine for water treatment, I don't know...could be relevant? The logical flaw where experience is used as a sole indicator of competence is this: just because you have been doing something for 25 years and you're very consistent at it (because you've had lots of practice) that just might mean you're doing it consistently badly, or wrong for 25 years. That's all it tells you. Experience matters yes it does (of course it does) but it has to be practically demonstrated. Beware anybody that opens up with the line "I have 25 years of years of experience" and then demands respect. It doesn't work like that. The fundamental problem I have with situations like this, is the promotion of the wrong people. If a company or a utility where nothing has gone wrong for many decades, has a key player leave and that person has been a key reason why there have been no incidents, and no issues for decades, and they could leave because they retire or they're downsized. A few years after that happens that's when we start to see incidents occurring, and why is that? Some people call it a "brain drain" or the "grey drain" but it's more subtle than that. If you don't know enough about the detail of the technical content of the role you're hiring someone for, then you don't know what skills and technical knowledge that they need to have, in order to function in that role. So you don't know what training they need either, so then the next generation of people in that role then compound the problem by subsequently hiring more people that equally don't know what they need to know, because their new manager doesn't know what they needed to know. The cycle then spirals out of control until you end up with an incompetent organization and incidents happen and people die. In succession-promotions like this, familiarity with someone already in the organization, can put someone into a role without anyone asking relevant questions about their capabilities like: "We know Bob! He's been here for years and he's awesome. Now let's just let him run a nuclear reactor, in manual for an hour. It'll be fine!" (hmmm) There are more jobs out there than you might think where all it takes, is one act of incompetence in the right alignment of events and someone will be injured, or become sick or be killed. Now if you're in a role and you're not sure about something ask someone. Talk to people in similar roles like yours. Go to conferences if you can. Be curious. Why do we dose hypo? Why does that matter? Why don't we run the generator at this frequency? Why do we need to sync to the grid before we close the circuit breaker? You might be surprised how people just asking simple questions, can break through this kind of incompetency malaise. It's hard to see in the case of Walkerton what could have been done differently to prevent this incident without going back to that grandfathering clause. Maybe the way to look at it is like this. How are you certified? How are others you work with certified, and ask yourself is experience alone enough? (Spoiler alert) It isn't. If you're enjoying Causality and want to support the show you can by supporting our sponsors or by becoming a Premium subscriber. You can find details at https://engineered.network/causality with a thank you to all of our Patrons and Premium subscribers and a special thank you to our Patreon Silver Producers Carsten Hansen, John Whitlow, Joseph Antonio and Kevin Koch, and an extra special thank you to our Patreon Gold Producer known only as 'r'. Premium subscribers and Patrons have access to early release, high-quality ad-free episodes as well as bonus episodes and to Causality Explored. You can do this via Patreon or if you prefer via our website or in our apps in the Apple, Google Play, or Amazon app stores. Visit https://engineered.network/causality to learn how you can help this show to continue to be made. Of course there's lots of other ways to help like favouriting this episode in your podcast player app or sharing the episode, or the show with your friends or via social media. Some podcast players let you share audio clips of episodes so if you have a favorite segment feel free to share that too. All these things help others discover the show and can make a huge difference too. I'd personally like to thank Many Tricks for once again sponsoring The Engineered Network. If you're looking for some Mac software that can do Many Tricks, remember to specifically visit this URL https://manytricks.com /pragmatic for more information about their amazingly useful apps. Causality is heavily researched and links to all the materials used for the creation of this episode are contained in the show notes. You can find them in the text of the episode description of your podcast player or on our website. You can follow me on the Fediverse @chidgey@engineered. space, on Twitter @johhnchidgey or the network on Twitter @Engineered_Net. This was Causality. I'm John Chidgey. Thanks so much for listening. Many thanks to listener John Paul, from Ontario, Canada for writing in and requesting this topic and bringing it to my attention. Good luck in your studies John! I hope they're going well.
Duration 37 minutes and 53 seconds
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Episode Gold Producer: 'r'.
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With thanks to Jon Paul for the topic suggestion.

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John Chidgey

John Chidgey

John is an Electrical, Instrumentation and Control Systems Engineer, software developer, podcaster, vocal actor and runs TechDistortion and the Engineered Network. John is a Chartered Professional Engineer in both Electrical Engineering and Information, Telecommunications and Electronics Engineering (ITEE) and a semi-regular conference speaker.

John has produced and appeared on many podcasts including Pragmatic and Causality and is available for hire for Vocal Acting or advertising. He has experience and interest in HMI Design, Alarm Management, Cyber-security and Root Cause Analysis.

You can find him on the Fediverse and on Twitter.