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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.
Causality is part of The Engineered
Network. To support our shows including
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https://engineered.network/ today. Flint
Michigan. Some people described what's
happened and is still happening with the
water supply in Flint, as being a case of
the first world country with a third
world water supply. It's a bit harsh, but
the fact is we all need water. Before we
get into exactly what happened at Flint
and as I say what is still happening,
I need to start a little bit about the
importance of water. I've worked on
numerous Water Treatment Plants
and dams, fresh water pipelines in my
career, and if there's one thing I've
learned is that you have to take it
seriously: very seriously!
Clean, fresh, safe drinking water is the
cornerstone of life and in order for our
basic needs to be met, in order to
survive as an animal we require oxygen,
water and food in that order of
importance. With oxygen, without it our
brains will suffer permanent damage
within minutes and we'll die within an
hour or so without oxygen. Water's next. We
die without water after three days on
average although some have been shown to
survive up to 12 days without water but
that's pretty unusual. That's water
deprivation of course but, bad water can
cause all sorts of illnesses and may not
kill you as quickly, but it can still
kill you. For water, we can survive but
without food we can go for about three
weeks on average provided we have water
and obviously those with more "storage" if
you'd like
will last longer than those without and
of course local conditions will affect
the end result. Assuming that someone
doesn't come along
to the planet and suck up all the air
then it all starts with water. Now in my
observation people have become
accustomed to having it: it's always
there, it's always clean and it's safe to
drink, and most people in Western culture
haven't walked miles to the nearest well
and then brought that water home or even
pushed and pulled a lever up and down to
pump water out of a well, or ever owned a
rainwater tank. Water just comes out of
the tap (or faucet depending what country
you live in)
and when I was a kid bottled water
wasn't even a thing. Now town
planners knew that running water from
the tap was a critical part of our
society 100 if not hundreds, maybe
even thousands of years ago, they built
water towers to maintain water pressure,
they built dams to store rainwater. They
built barrages across flowing rivers to
separate tidal flows. Built Water
Treatment Plants to ensure the water was
safe to drink and built huge, enormous
networks of pipework under the ground
into people's homes to ensure they had
fresh water to drink, clean and wash with.
The people that we put in charge of our
drinking water supplies take it very
seriously. They have done for many years
and they will for years to come, but in
many ways it's become a commodity. One
that's being traded and bargained for
despite the fact that is technically an
essential service that we all require.
It's being outsourced: the dollar costs
are getting driven down all the time, and
when you're in management the need to
cut down those costs to get the cheapest
bidder in to run the treatment plant or
whatever it might be,
well that pressure can lead to
compromises. Sometimes there are
different water sources that you can
choose from, some cases not, but not all
sources are created equally. Some will
come from aquifers of varying degrees of
quality, others from dams, others from
rivers, and each will have their own
unique water quality profile.
Some will require more treatment than
others and some require long pipelines
to bring them to where the waters
actually needed to be used and all of
this will affect the final cost. The cost
of the water and a cheaper source
upfront may not always be cheaper in the
end once you've treated it, but in the
search for cutting costs, they cut
corners and ultimately in the case of
Flint they cut one corner too many and
things started to go wrong. So let's talk
specifically about Flint Michigan. Now
for many years the water supply was
sourced from the Detroit Water and
Sewage Department but they were
considered to be too expensive and the
city was in tough times and looking for
alternatives that were cheaper. On April
the 16th, 2013, the city decided to sign
up with the Karegnondi Water Authority
(KWA for short) and they decided it would
be cheaper to build a pipeline from Lake
Huron to Flint to source their water
from there. The proposal and
recommendation came from the
infrastructure development director
Howard Croft and the Utilities
Administrator Daugherty Johnson III.
It was signed off by the then
emergency manager Ed Kurtz. The
pipeline was due for completion during
2016 (this year). However the agreement
with Detroit water was up for renewal at
that point. Now Detroit offered a
short-term contract to see them through
until the pipeline was ready but the
cost was considered to be too high and
the Flint officials decided that a
temporary water source would be used
instead and that water source that they
chose was to be the Flint River. The
water source for Flint was switched in
March of 2014. Some customers in Flint
could tell the difference immediately
with the taste and the NDS (that's Non-
Dissolved Solids), as well as the odour
being very different from the Detroit
water. And it was on the 8th of September,
2014
that Flint city officials advised their
customers to begin boiling their water
after several cases of Escherichia-coli
surfaced in the community. Of note also
on the 13th of October,
General Motors issued a notice to stop
using the water supply from the council
because it was corroding steel
components in their manufacturing plant.
Further testing of the water quality
within a few weeks of that
determined that there were dangerous
levels of Tri-Halo-Methanes (TTHM for
short) present in the water and these
are, they're a by-product of over-
chlorination. In January of 2015,
news leaked from Virginia Tech
University, in their studies they
detected unsafe levels of lead in the water
samples they'd taken on campus. It was
initially thought to be an isolated case
however Virginia Tech continued to
investigate, irrespective. On the 10th
of February, 2015
Veolia Water were engaged to
independently assess the situation.
Veolia run multiple Water Treatment
Facilities around the world (including
some here) On the 18th of March, 2015 they
delivered their report recommending
$3M USD be invested with
improvements to the Water Treatment
Facility. There was no mention of lead
levels at that time. By September the
same Virginia Tech team that had earlier
in the year reported lead detected at
their campus, had sampled water now from
252 individual premises and they
found that the city's 90th percentile
lead level was in fact 25ppb
and this exceeded the 15ppb
EPA action threshold. On the
15th of September, 2015 these figures
were officially released to the public
and there was somewhat of an outcry.
Further tests over subsequent weeks
found that several end customer premises
had lead levels 3 times that legal
limit.
On the 2nd of October, 2015 it was
officially acknowledged
and an action plan was released to
address the problem by Flint officials.
For the blood testing of the children
from Flint showed levels of 2.5%
before the switch, rising to 6.3%
approximately one year after the switch
of water supply. Three major schools were
some of the highest lead level areas
that were measured in Flint. One school
tested at 6 times the legal limit. On
the 16th of October, 2015
Flint officials switched the water back
to Detroit water, and on the 10th of November,
2015 the United States Environmental
Protection Agency became officially
involved. On the 14th of December that
year, a state of emergency was declared
in Flint, Michigan. At this point in time
it seems like a very crazy idea, that a
country like America, with so many people,
access to all the technology that they
could ever want, could have something
like this happen. It's an interesting
chain of events that led us to the
lead poisoning, and to where we are today.
And understanding exactly where it went
wrong, need to explain a few things first.
I guess whenever I've
looked into this, I had to ask where was
the Chemist? Where were the Engineers? The
corrosion specialists? See Corrosion
Control Plans (or CCPs) they're standard
pretty much for all Water Treatment
systems I've ever seen, that I've ever
worked on and frankly not just in
Australia but around the world including
America but Flint didn't have one. Now
I'd suggest maybe they didn't think they
needed one since their water when they
were sourcing it from Detroit at least,
didn't have any adverse effect on the
reticulation system. I'm not sure, it
seems bizarre to me that they wouldn't
have one. Certainly in the end lead was
the biggest problem but like I said it
was like, Flint's issues like
pulling a thread and all the actions and
reactions created the next set of actions
and reactions and the worst problem of
all, end up being the lead but, where did
it go wrong? So the EPA's lead and copper
rules require water utilities serving
more than 50,000 people to
establish a plan to monitor and control
corrosion. Now that, in my opinion is even that
number is ridiculous there should be a
CCP for any sized water reticulation
system, not just 50,000. The excuse given
by the Flint officials was that they'd
mistakenly suggested they were set up
for a city of 50,000 not 100,000
which was the actual population
of Flint, in a statement on the 10th of
October, 2015
that was when Howard Croft resigned. To
me that's such a ridiculous cop-out I
can't get my head around it. Anyway
irrespective of that, how do we protect
pipes from corrosion, in non-
Flint reticulation systems? Well, what
I've typically seen used is ORP which is
an abbreviation for Orthophosphate.
We add Orthophosphate
at the Water Treatment Plant and
plants I've worked on, and it's used as a
corrosion inhibitor. Now since Detroit
had been adding that for years into the
water supply and then pumping that out
to Flint for nearly 50 years, their own
Water Treatment Plant didn't have any ORP
dosing system installed. Well they didn't
need it...until they switched!
Now the ORP, how it works is it creates a
thin film and they call it a Passivation
Layer and it chemically insulates the
pipe wall from the chlorine disinfectant.
I know it's not technically an
insulator...
I'm an Electrical Engineer so I prefer
to think of things like an insulator
okay, but it's a protective layer: think
of it like that. It separates the
Chlorine that would otherwise react with
the metal, be it Iron, Lead or Copper
inner walls of the pipes. Now many
countries around the world still have
Lead pipes in use today and millions of
people aren't dying from lead poisoning.
So it can't be that simple. The thing
with ORP is it's always under attack
just from particulate erosion. So
suspended particles not dissolved solids
but suspended particles, as the water
travels through the pipe. Kind of like a
very gentle sandblasting and an
erosive effect. So we keep
dosing it to ensure there's a healthy
protection layer, but it's not just
particulate erosion, the chemistry of the
water will deteriorate it as well and
without any Phosphate at all in the
water, the passivation layer is ever so
gradually eroded as time passes. The
water from the river in addition to that
was a more acidic pH, than the water from
Detroit, and rather than correcting it, it
was allowed into the reticulation system
which further dissolved the protective
layer slowly released the pipes' metal
back into the water supply. Quick lesson
on pH: pH of 1 is highly acidic and
14 is highly basic. 7 is what
we refer to as a neutral solution. In
water treatment we always keep the pH a
minimum buffer amount on the basic side
of neutral. 7.5 to 8.5 pH is typical
enough. The amount of Acid Lime dosing in
place for pH correction is relative to
the water source and the cost to dose in
order to trim the pH. We dose with 1
chemical to treat one problem it will
affect the pH usually, so we'll
trim with another chemical to bring the
pH back again. Now when Flint switched
from Detroit's water it went from about
8 (a pH of 8) in December of 2014, and
it slid down to about 7.3 by the August
of 2015 and that's very odd because they
should have been trimming that pH to a
set point. They should have a target
value either fixed rate flow-paced
however they want a dose, but
irrespective they should have had some
kind of a target, but it says to me that
either they weren't trying to trim it or
they didn't think it was a problem or it
was a fixed rate dose or they weren't
paying much attention. I guess that's
probably worse, if they weren't paying
attention.
Irrespective it was not controlled by
any stretch the imagination.
Now Chlorine concentration is another
one that's worth considering as
well. The Detroits' waters' average
Chlorination (or Chlorine concentration I
should say) was 11.4ppm,
that was in 2014 as it
arrived at the plant, however in August
of 2015, it was measured in Flint at
85ppm and it's no
wonder it smelled. Rather strong
concentration of chlorine. Now that
occurs to me that it was probably an
overcorrection and that was a reaction
to the e-coli contamination problem from
mid-2014. So what they did is they
increase their dosage of Ferric Chloride
which is a coagulant for organic
particulates and that makes them
flocculate and makes them easier to remove,
but this increased the Chloride
concentration as a direct result.
Flocculation's simply a process whereby
smaller suspended solids will clump
together and group allowing them to be
more easily filtered out by sand filters
or different kinds of filters. So as you
add more Ferric Chloride you then need
to trim something else, so you one thing,
you need to trim another. The water
chemistry, it's not as straightforward as
you'd like it to be. Now multiple studies
showed that the corrosive rates of Lead
increase when Chloride:Sulfide ratio is
greater than 0.58. Now to compare
Detroit's water had a ratio of 0.45
which was less than that, but the Flint
River treated water, at its worst was
measured at 1.6. That ratio: 1.6
more: nearly 3 times as much. Not just
a bit worse...a lot worse! The worst part
of it for me though is that the first
sign of trouble was there was
discolouration of the water in mid-2014,
only a few months after they switched to
the river water source.
Now that was caused by the breakdown the
passivation layer that we previously
discussed, and that discoloration was
actually caused by rust: the Iron pipes
were the first ones to show damage, and
that was that rust colouration.
That should have been the first
sign that something was seriously wrong.
The thing that a lot of people don't
realize about Chlorine though, is that
Chlorine is essential to protecting us
from bacteria and there's only a very,
very small number of bacteria and
viruses in existence that can survive
when dosed with Chlorine, which is why
it's used for water disinfection. It's
very effective. Chlorine concentration
though, it deteriorates over time, they
call it the Chlorine Residual as in
residual level, and you can't stop it, and
we measure Free Chlorine levels in water,
post-treatment to ensure that the
minimum is retained at the outlet of the
Water Treatment Plant so that by the
time it reaches your place, it's traveled
through the pipelines,
reservoirs, towers, it has to be a minimum
Chlorine Residual presence at the
delivery point, and when I say "delivery point"
I mean the tap (or the faucet) whatever you
want to call it. So we want that Chlorine to
be in the water because if it isn't, it
can't kill the bacteria that it could
pick up along the way as it passes
through the whole reticulation network
on its way to your door and to the point
of delivery. Problem was, once the
passivation layer had eroded, the
Chlorine Residual in the lines, it began
to react with the metal directly:
specifically the Iron in this case, and
that reaction, started to consume a lot
of the Chlorine that was in the solution.
And I say the solution: I mean the water
of course, and that meant that the e-coli
bacteria could grow, leading to people
getting sick because the Chlorine that
was supposed to kill it off and keep it
at bay had been consumed by a chemical
reaction with the Iron in the pipe
because there was no passivation layer.
So what did the Flint officials do at
the Water Treatment Facility to fight
that? They added more Chlorine! So that
then accelerated that reaction with the
Iron and the Lead and that released more
into the water system. So we know Lead is
nasty stuff.
"Something, something, Roman reference,"
right? I mean the debate goes on if there
was actual
a cause of illness in Roman times, but we
well know the effects of lead poisoning
from modern medicine. Some of the symptoms
include partial or full blindness. Can
cause hallucinations and hearing loss.
Slurred speech, kidney failure which
leads to dialysis. Insomnia, depression,
short-term memory loss, infertility.
Tingling pains in the fingers and toes,
constant fatigue, the list goes on and on.
It's actually pretty terrible. But the
effect of Lead on children in particular,
it's horrible. Because it leads to
learning difficulties, permanent life-long
disabilities. Now we don't use Lead pipes
anymore, but in 1990 the American Water
Works Association estimated that there
were millions of Lead service lines in
the United States alone. The obvious
question is: why do we use metal pipes at
all? They're cheap, they're easy at work,
they last a long, long time
basically. Polymer pipes (or Poly-pipes
for short) they're great, but they're a
relatively new thing and they don't have
the same longevity. Retrofitting pipe-
work with non-metallic pipes is normally
done on a failure/replacement basis,
because replacing all of that
infrastructure would bankrupt most local
governments. It always comes back to
money. Always. So even now they're back on
Detroit water. It could take many, many
years to re-passivate or re-line the
pipes, however you want to think about it,
and as this is being recorded some
locations in Flint are still seeing
unacceptable levels of Lead in their
water at the delivery point. I wonder
also though, just how rigorous water
testing is in other parts of the country
and the world for that matter as a
direct result of this incident? You can
never, ever take your eye off the ball
not for a second. So what actually went
wrong here besides the chemistry of the
water? Who we really is to blame, and what
are we learn from this? Well I suppose,
don't use metal pipes wherever you can
and especially not Lead! Got it. But
honestly the problem I guess I have is
well, where were the Engineers? The
Chemists and the Biologists in all of
this, at the Flint Water Treatment Plant?
I spent a decade in water and wastewater
and periodic sampling at treatment
plants, that happens daily, weekly, monthly
and at reservoirs. There are key sample
points in the network: customer premises,
you name it they test it! Originally
every plant I worked at had its own
laboratory, and they would test
their own water samples from their own
local reticulation network and
reservoirs and in one plant we had a
SCADA client in the corner of the lab
and I remember the sound of the
centrifuge spinning up and down as they
ran tests on that water. They've centralized
them now so they could afford better
test equipment, and they've cut the
number of Chemists on the payroll I'm
sure, but hopefully not too few. But to
not understand something like corrosion
that's fundamental. Absolutely
fundamental. To switch water sources are
not to understand the balance the water
needs to have in its chemistry in order
not to destroy your pipe-work
infrastructure that you need to deliver
your water to your customers is frankly,
it's ridiculous. It's criminal.
You're entrusted not just with taking
care of an asset. That pipe in the ground
is an expensive asset and beyond that
the entire city's population depends on
that to survive. Their health, their
well-being. And in an effort to save money
it's cost an immeasurable amount more
than that in the long run. Let's not even
think about the lawsuits and the class
actions that's gonna cost them dearly
in months and years to come, but beyond
the money, it comes back to supervision
and putting the right people in charge.
There are people that blame Kurtz, Croft
and Johnson in varying degrees. There are
others as well that are implicated, but
with so much of that still under wraps
and being closely guarded it's difficult
to know at least today for sure who was
pushing for the river water solution
maybe we'll never know. Maybe there's
enough hands in the ring that we won't
be able to single out any one individual.
But in the end I suppose to me it
doesn't matter so much as about the
individual but it's clear though to me
that the people that were entrusted to
run the Flint Water Treatment Plant and
the water quality testing, weren't qualified
to do so and if they tried to fix the
dosing issues at the plant there's been
no evidence presented that I can find
that they ever even tried. The wrong
people were running the system. Clearly
they weren't supervised by the right
people either the wrong people were put
in charge and it didn't take very long
at all for everything to completely fall
apart. If you're enjoying Causality and
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This was Causality. I'm John Chidgey.
Thanks for listening.
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