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[Music]

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Chain of events, cause and effect.

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We analyze what went right and what went wrong,

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as we discover that many outcomes can be predicted, planned for, and even prevented.

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I'm John Chidgey, and this is Causality.

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Thank you.

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Walkerton

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Walkerton, Ontario, Canada has a population of about 5,000 people and lies approximately

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2 hours drive from Toronto, which by contrast is Canada's largest metropolitan city at 6 million

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people. In the early 2000s, the water supply to Walkerton was supplied by 3 groundwater wells

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numbered 5, 6 and 7. Well 5 was 15 metres deep, capable of supplying 56% of the town's water

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supply needs in isolation with Well 6, 72 meters deep with a maximum supply of 52% in

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isolation and Well 7 was 76 meters deep the deepest with a maximum supply of 140%

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of the town's water supply needs. Well 5 used sodium hypochlorite solution for chlorine dosing

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whereas Wells 6 and 7 both used chlorine gas for disinfection.

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The water distribution system had approximately 42 kilometres or 26 miles of water mains with

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two standpipes providing pressure equalisation and approximately 20 hours of reserved storage.

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A basic control system and SCADA controlled and monitored the wells and standpipes.

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The Walkerton Public Utilities Commission or PUC for short were charged with the safe operation

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and maintenance of the water supply system in Walkerton. So let's talk about the incident itself.

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On the 8th of May 2000, a series of storms and steady rain over a five-day period totaled some

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134 millimeters of rainfall. The volume of rainfall accumulation led to inevitable surface

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saturation and subsequent runoff which led to some minor localized flooding in the area. On the 12th

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of May some of that rainfall runoff entered Well 5. On Monday the 15th of May

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Stan Koebel returned on shift and noted that well seven was not operating. Every Monday,

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and this was no different, the operators collected their weekly samples from each of the wells and

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from key sample points in the distribution system. Around this time a construction project was

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was underway that required the installation of 615 metres or 2,000 feet of replacement

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water mains on Highway 9 in South West Walkerton between Wallace Street and Circle Drive.

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On Wednesday 17 May at 9:14am the A&L Laboratory faxed the results from the Highway 9 project

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water samples to the PUC. All three samples indicated positive for total coliforms and E. coli.

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At 2:37pm that afternoon, the remaining tests from the A&L lab were faxed to the PUC

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with a sample labeled Well 7 treated, positive for total coliform and E. coli. Further, the tests

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indicated coliform bacteria greater than 200 CFU/100mL, E. coli greater than 200 CFU/100mL,

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and a Heterotrophic plate count of 600 CFU/mL. By Thursday, the 18th of May, the number of

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illnesses had increased significantly, with a seven-year-old and nine-year-old admitted to the

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Owen Sound Hospital, and about 20 students from the Mother Teresa School reported in sick.

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Members of the public, including concerned parents, had contacted the Walkerton PUC

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to confirm the water was safe to drink, however were not told that anything was wrong.

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By Friday 19 May, 8 people had a documented three-day history of symptoms,

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with now more than 25 absent from the Mother Teresa School, 8 from Walkerton Public,

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and 3 residents from the Maple Court Villa retirement home were also affected.

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Dr Kristen Hallett, a paediatrician from the Grey-Bruce Health Services,

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had two patients referred to her from the hospital with similar symptoms.

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At approximately 9:00am that day, Dr Hallett contacted Dr Murray Quigg, the local medical

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officer of health (MHO) to inform him that her food history investigation of those patients

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indicated contaminated water was the most likely cause, with E. coli the most likely pathogen.

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During that day, James Schmidt, the public health inspector in Walkerton, received multiple calls

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and proceeded to call Mr. Koebel at 2:21pm directly, asking him about any issues with

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the water supply, to which Stan Koebel indicated he thought the water was 'OK'.

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On Sunday, the 21st of May, at approximately 1:30pm, a public health advisory was issued by

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the Health Unit to the Walkerton community not to drink municipal water from the tap,

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recommending boiling all water before consumption. The MHO also took their own independently

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collected water samples from multiple locations in Walkerton and their results on the 23rd of May

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all showed E. coli contamination, leading to all schools being closed the following day.

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On the 25th of May, the Regional Police Force directed the Ontario Provincial Police to begin

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a criminal investigation into the incident. With incidents such as these, the health impacts can

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take weeks, months or even years to fully play out, and those most at risk are our most vulnerable

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in society:€“ children, the elderly, and those with pre-existing medical conditions that are

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ill-equipped to fight off an illness like this. The number of people killed directly or indirectly

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due to this incident has been debated since shortly after the incident, with either two,

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three or four others indirectly linked, and not all are conclusively proven to have been linked

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to the incident though there is strong evidence to suggest that they were. The following people

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lost their lives either in whole or in part due to this incident. Melville Dawe 69 years old May 19th.

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Lenore Al 66 years old, May 22nd. Mary Rose Raymond 2yrs old, May 23rd. Robert Brodie 89yrs old,

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May 24th. Edith Pearson 82yrs old, also May 24th. Vera Coe 75yrs old, also May 24th.

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Laura Rowe 84yrs old, on May 29th. Betty Trushinski 56yrs old, May 31st.

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So what on earth went wrong? The Honourable Dennis R O'Connor was appointed to lead the

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Walkerton Commission into this incident, producing a final report in two parts,

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the first of which was released in January 2002.

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The source of the contamination was found to be Well 5,

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with runoff from a farmer's paddock, with the fecal coliforms from the

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livestock excrement being washed into the drinking water.

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The investigation unsurfaced several disturbing behaviors and events

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leading up to the incident. Prior to the rainfall event on the 5th of May, Stan

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Koebel left Walkerton to attend a conference in

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Windsor for which he was away until the 14th of May during which time the rainfall event had

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occurred. In his absence his brother Frank Koebel was in charge of the PUC in Walkerton. When Stan

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left for the conference he was aware that the chlorinator on Well 7 was not functioning

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correctly since Well 7 was brought back into service on the 2nd of May. In fact the well hadn't

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been in service since the 10th of March. It wasn't uncommon to rotate water supply from each of the

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wells. But rather than shut Well 7 off, Stan Koebel instructed Frank to replace

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the chlorinator in Well 7 with the replacement unit that had been on the

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PUC premises in Walkerton for nearly 1-1/2yrs. Upon Stan's return

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he found that Frank had still not fitted the replacement chlorinator to Well 7

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and that Well 7 had still been running during that time. Well 7 pumped

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unchlorinated water into the system from the 3rd of May to the 9th of May as it

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the only well being used during that period, there was no new chlorine being injected into

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the water main system for that time. The correct course of action would have been to leave

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Wells 5 and/or 6 running while the chlorinator in Well 7 was replaced and then to return

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Well 7 to service, an activity that would have taken about a day of end-to-end activities

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to complete...absolute maximum. Chlorine residual needs to be maintained to ensure that any

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bacteria are killed before the water is consumed, but that's something we'll "explore" separately.

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Despite the fact that both Stan and Frank Koebel were aware that chlorination was required

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at all times as mandated in the Ontario Drinking Water Objectives and Bulletin 65-W-4, "Chlorination

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of Potable Water Supplies", when interviewed following the event, they believed that unchlorinated

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water from Well 7 was safe because it was from a deeper well. In addition, PUC staff

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would regularly drink raw unchlorinated water at the well because it was cold, clear and

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clean and "tasted better" than chlorinated water did. Multiple years of reinforcing the

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idea that it's safe to drink it today so it'll be safe to drink it tomorrow led to a mistaken

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belief that chlorination was in fact optional for Well 7. In the history of the plant,

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there had been no incidents like this, which also fed a mistaken belief that anything like

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this could actually happen. Every day operators were required to visit each well and make a

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recording of the following: the water flow totalizer, the chlorine chemical usage and

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the current chlorine residual. On the 13th of May at 4:10pm 0.75mg/L

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of chlorine concentration was recorded for Well 5. There was no entry for Well 6.

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By cross-checking the water volume recorded against the amount of Hypochlorite dosed during

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that period it was calculated that it was completely impossible to have a chlorine

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residual that high given how little Hypo was dosed during that period. The investigation

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also found that for more than 20 years it had been regular practice for PUC operators

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to not measure the actual chlorine residual but instead write down a fictitious value

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to put an entry in the box. Reviews of the logs showed a significant number of readings of 0.5

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and 0.75mg/L despite there being no correlation between the documented chlorine residual levels

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and chemicals consumed during those respective periods.

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Testimony from Stan Koebel was that multiple PUC staff had been filling sample containers from the

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PUC workshop which was down the line from Well 5 and labelled them as taken from other locations

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in the network. During the inquiry, when he was asked to explain why sample bottles had been

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submitted with the incorrect source information written on them, he answered, and I quote,

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"simply convenience or just couldn't be bothered." One more point about the behavior of

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both Stan and Frank Koebel that was uncovered in the investigation. Frank Koebel, on his brother's

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instructions, altered the daily operating sheet for Well 7 on May 22-23 in an apparent

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attempt to conceal from the MOE that Well 7 had been operating without a chlorinator for an

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an extended period, and that demonstrates that they were fully aware that running without

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a chlorinator was not an acceptable practice and yet they did it anyway.

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The Walkerton PUC operators therefore in summary, firstly, set inadequate doses of chlorine

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based on the water flows, secondly, they did not repair the faulty chlorination equipment

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in a timely manner, thirdly, they didn't regularly monitor chlorine residual every

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day. Fourthly, they made false entries in their daily logs, four days where readings

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were not taken. Fifthly, they intentionally mislabeled locations that microbiological

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samples were taken. And finally, they attempted to conceal facts after the event to protect

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themselves. The operators were fully aware their practices did not follow the Ministry

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of the Environment (MOE) guidelines and their directives. And having said that, the A&L

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laboratory also failed by not reporting their findings of potentially unsafe drinking water

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to the MOE. The A&L laboratory policy was only to send report results to their client

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directly and there was no requirement to notify the MOE or the local medical officer of health

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should they have found a problem in their tests. Mr Robert Deakin, the laboratory manager

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at A&L claimed he was unaware of section 4.1.3 of the ODWO guideline stating that the lab

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should notify the MOE District Office of indications of unsafe drinking water were they found.

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On Wednesday 17 May, the alarm could have been raised by the A&L Laboratory alerting

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the MOE or the MOH which would have resulted in a boil water notice being issued four days

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earlier that would have significantly reduced the spread of the outbreak. But they didn't.

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It's unclear how many lives would have been saved had that happened. However, there's

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no question the death toll would not have been as high. So let's talk a little bit about E. coli

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and what the problem with it is. Escherichia coli, or E. coli for short because it's a lot

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easy to say technically O157:H7 was the primary pathogen. The other was Campylobacter

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Jejuni which were the two bacteria then most responsible for the majority of deaths and

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illnesses in this incident. Once infected with E. coli, the intestinal symptoms last for about four

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days and can persist for longer. After 24 hours, bloody diarrhea is common and in some cases severe

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abdominal pains and cramping. Generally, it resolves itself without treatment other than

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just rehydration and the replacement of the body's electrolytes. However, for some people, particularly

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children under five years of age and the elderly, E. coli infection can be far more serious,

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causing hemolytic uremic syndrome, HUS, after five to ten days of infection, leading to anemia,

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low platelet counts, and in some cases kidney failure. In the most extreme of cases,

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these complications can result in death. Campylobacter Jejuni is the most common

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variant and it was implicated in the Walkerton incident as well. And in that case, diarrhea

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usually lasts 2-7 days with a significantly lower probability of fatality than for E. coli.

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The report had many recommendations, 28 in fact, but we'll look at one specific one and four others

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that fall broadly under the same key category. The first is recommendation 11, continuous

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monitoring. From the report I quote, "The MOE should require continuous chlorine and

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turbidity monitors for all groundwater sources that are under the direct influence of surface

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water or that serve municipal populations greater than a size prescribed by the MOE."

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This happened in 2000. So, a bit of history. In 1996, I worked at the Stanwell

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Power Station. That's a 1.4GW baseload power plant outside of my hometown of Rockhampton,

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in Queensland. When I joined, the so-called Effluent Outfall was being monitored with

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a local data logger for monitoring a small number of water quality measurements. The

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project I was asked to execute was for the continuous monitoring of both the inlet and

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outlet of the Northern Stormwater Dam to bring the data back into the plant DCS, Distributed

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Control System. At the time, the EPA was requiring hourly water quality samples be taken, however,

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the system that I installed would take multiple samples every single minute, far exceeding

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the requirements.

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That was 4 years before the Walkerton incident and the community of Stanwell had 1/3rd

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of the number of residents living there.

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The point though is that continuous monitoring using either a local data logger or a centralised

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SCADA system was well and truly tested and available technology that was not that expensive

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that could have been fitted easily into the Walkerton water treatment system had they

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wanted to.

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In the past 20 years working in water treatment facilities of all different sizes, but particularly

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in South East Queensland, I've never seen a system that relied solely on manual measurements,

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except occasional cross-checking for equipment calibration.

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Better safe than sorry.

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Moving on to the other recommendations, of which there's four: 20, 21, 22 and 23, and

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they all broadly discuss training. So I'll read each and then I'll summarise and then

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I'll summarise all of them at the end. Recommendation 20, I quote, "The government should require

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all water system operators, including those who now hold certificates voluntarily obtained

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through the grandparenting process, to become certified through examination within two years

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and to be periodically recertified." So yes, please ensure the people that are in charge

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of the plant are actually certified to do so and you have two years to get it done by

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the way and plan to recertify them every so often, that's a good idea, you should get

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on that and spoiler alert, they did following the incident.

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Recommendation 21, the materials and I quote, "The materials for the water operator course

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examinations and continuing education courses should emphasize in addition to the technical

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requirements necessary for performing the functions of each class of operator" and

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part is in italics, "the gravity of the public health risks" back to normal text, "associated

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with a failure to treat and or monitor drinking water properly, the need to seek appropriate

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assistance when such risks are identified and the rationale for and importance of regulatory measures

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designed to prevent or identify those public health risks." So in other words, make sure your

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operators understand that they could kill people if they don't do their jobs properly. A little dose

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of fear when you're dosing chlorine goes a long way.

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Recommendation 22:

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I quote, "The government should amend Ontario Regulation 435/93 to define 'training'

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clearly for the purposes of 40 hours of annual mandatory training with an emphasis on the

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subject matter described in Recommendation 21."

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End quote.

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Now this is subtle, but it's really important.

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I'm an RPEQ, Registered Professional Engineer in Queensland and a Chartered Professional

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Engineer in Australia (CPEng), and

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in order to maintain those qualifications and certifications, I'm required to undergo

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recordable and audited Continuous Professional Development or CPD for short.

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Now, that CPD could include training, but it stipulates that it must be training that's

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relevant to my discipline amongst other things.

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It's not like I spoke to this guy in the corridor and he taught me how chlorine works so I'm

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like trained now.

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No, it needs to be structured, reviewed, relevant training that's recorded and tested, otherwise

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there's no point.

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And when I write down my CPD, I guarantee you, Engineers Australia, check it.

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Alright, Recommendation 23, last one.

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I quote, "The government should proceed with the proposed requirement that operators

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undertake 36 hours of MOE-approved training every three years as a condition of certification

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or renewal. Such

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courses should include training in emergency issues with water treatment and pathogen risks,

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emergency and contingency planning, the gravity of public health risks associated with the failure

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to treat and/or monitor drinking water properly, the need to seek appropriate assistance when such

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risks are identified, and the rationale for and importance of regulatory measures designed to

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prevent or identify public health risks." That was a long couple of sentences but this kind of

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repeats and expands on the previous three points which I think probably could have been worded in

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a more intertwined way but in essence yes, make the training regular: 3 years.

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The key training points are very good though.

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They're focused on abnormal operation, how to deal with emergencies and yes let's remind

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them again and again that they could kill people if they don't do their job properly.

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To wrap up on training we did actually speak about that on Episode 27 about Gare de Lyon

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and it's worth repeating here.

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When operators are asked to operate any kind of plant, they need to be taught the consequences

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of incorrect operation.

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And whilst it sounds obvious for something like water treatment, we all drink water,

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and hence we could make a lot of people sick or even kill them if we make mistakes in how

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we treat, or in this case don't treat, our water before it's consumed.

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People think that training's about learning how to do something correctly over and over

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and over, and yeah, that's part of it...

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but the most important part of operator training isn't how to start it up, shut it down, or

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run or test or maintain it necessarily. It's how you handle upsets, unplanned activities,

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worst case scenarios, and in this case an E. coli outbreak. Training in this case would

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have been as soon as the results came back and they were bad, shut it down. Shut it all

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down. Warn people. But they didn't. Understanding the importance of the laboratory testing as

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a measure of water quality rather than thinking that you can tell there's E. coli in the water

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just by tasting it, this is a huge knowledge and competency gap that's honestly very hard

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to fathom.

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So it brings me to the final question, possibly the most important question in this whole

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incident.

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How the hell did Stan and Frank Koebel end up running a water utility in the first place?

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So let's talk about Stan for a second.

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Stan was a certified class 3 operator of a water distribution system.

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He joined Walkerton PUC in 1972 when he was 19 years old.

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His father was the foreman of the Walkerton Works Department at the time and he had an

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11th grade education.

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For the first 4 years of his career, he worked under Ian MacLeod, the then General

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Manager of the PUC, before changing to Electrical Supply and Distribution, completing a linesman

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apprenticeship.

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In 1981, he was promoted to foreman and was responsible for both water and electricity

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at PUC, and when Mr. McLeod retired in 1988, he was promoted to the General Manager position.

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The only course Stan Koebel attended following the most recent promotion was a leadership

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training course.

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In 1987, the MOE introduced a grandfathering program for water operators regarding their

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certifications.

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For those unfamiliar, a grandfather policy is a provision in which an old rule continues

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to apply to some existing situations while a new rule will apply to all future situations.

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Those exempt from the new rule are said to have grandfathered rights or acquired rights

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or to have been grandfathered in, depending on who you speak to.

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In the context of the certification, in this case, operators were deemed through experience

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to have implicit certification through demonstrated capability and therefore could be safely granted

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a certification using experience as their sole measure for qualification.

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I'll talk about that a little bit more in a minute.

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Back to Stan Koebel.

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So at the time, Mr. McLeod submitted Stan Koebel's name to the MOE as he had been certified

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as a Class 2 operator, although he had never been required to pass an examination.

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He had been recertified as a Class 3 when in 1996 the Walkerton water system was reclassified

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as Class 3.

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Again, without any MOE assessment of knowledge or skills.

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During the testimony, Stan Koebel stated that he did not know what E. coli was, nor of its

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implications to human health.

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He did not fully understand turbidity or organic Nitrogen.

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Consequently, he did not always fully comprehend portions of MOE inspection reports and correspondence.

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That's not good.

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Frank Koebel.

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In 1983, he completed courses to qualify as a journeyman linesman at the Ontario Hydro

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Training Centre.

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Prior to 1988, approximately one quarter of Frank's time was spent working on hydroelectricity

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with the remainder on the water system.

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In 1988, he was promoted to foreman in the same time period that his brother was promoted

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to general manager.

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Frank obtained his Class 2 certification via grandfathering and later his Class 3 without

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being required to complete any courses, with no competency testing or examinations just

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like his brother. During testimony, Frank Koebel also admitted to many knowledge gaps

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that matched Stan's, however, additionally, he was unaware of what Total Chlorine was

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(he didn't know what Free Chlorine was) nor was he aware of the Chlorination Bulletin

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nor Ontario Regulation 435/93 regarding requirements for the licensing and competency of operators.

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In the entirety of his 25 years he worked at Walkerton PUC, Frank Koebel admitted he

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had never attended a single training course about chlorination in any form.

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So let's talk about the fallout.

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The Ontario Government paid more than $72M Canadian dollars just in compensation

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to the victims of the incident and their families, and the total economic impact of the incident

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was approximately $155M.

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The former manager of Walkerton's Utilities Commission, Stan Koebel, was jailed for one

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year for his role in this incident.

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The former foreman and Stan Koebel's brother, Frank Koebel, was sentenced to nine months

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of house arrest.

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A total of 10,189 claims were made, with 9,275 qualifying for compensation.

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After 7 months since the Boil Water Advisory and at a cost of $11 million, the Ontario

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Clear Water Association finally announced the water was once again safe to drink.

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Despite that announcement, it took residents many years before they trusted the town water

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supply again, with many choosing to stick with bottled water instead.

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So what do we conclude from all of this?

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The depth of the ignorance, laziness and careless disregard for common sense is almost laughable

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if they hadn't managed to kill people and make approximately 2,320 people sick, which

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was effectively half the town's population.

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There are definitely some similarities to Flint, Michigan insofar as the operators didn't

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understand what they were doing.

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They fit the dictionary definition of 'incompetent' and there's a link in the show notes if you

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don't believe me.

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Grandfathering a certification on the basis of demonstrated experience isn't a very good

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idea.

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If someone is competent through experience, then surely they wouldn't mind sitting a short

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test maybe.

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What's Free Chlorine for water treatment?

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I don't know.

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It could be relevant.

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The logical flaw where experience is used as a sole indicator of competence is this:

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"Just because you've been doing something for 25 years and you're very consistent at it

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because you've had lots of practice, that just might mean you're doing it consistently

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badly or wrong for 25 years..."

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That's all it tells you.

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Experience matters.

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Yes, it does.

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Of course it does, but it has to be practically demonstrated.

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Beware anybody that opens up with the line, "I have 25 years of experience," and then

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demands respect.

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It doesn't work like that.

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The fundamental problem I have with situations like this is the promotion of the wrong people.

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If a company or a utility where nothing has gone wrong for many decades has a key player

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leave and that person has been a key reason why there have been no incidents and no issues

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for decades, and they could leave because they retire or they're just or they're downsized,

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a few years after that happens, that's when we start to see incidents occurring.

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Why is that?

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Some people call it a 'Brain Drain' or the 'Grey Drain', but it's more subtle than that.

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If you don't know enough about the detail of the technical content of the role you're hiring someone for,

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then you don't know what skills and technical knowledge that they need to have in order to function in that role.

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So you don't know what training they need either.

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So then the next generation of people in that role then compound the problem

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by subsequently hiring more people that equally don't know what they need to know

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because their new manager doesn't know what they needed to know. The cycle then spirals out of

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control until you end up with an incompetent organization and incidents happen and people

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die. In succession promotions like this, familiarity with someone already in the organization can put

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someone into a role without anyone asking relevant questions about their capabilities

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00:30:02,000 --> 00:30:06,839
like, "We know Bob. He's been here for years and he's awesome. Now, let's just let him run a nuclear

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reactor in manual for an hour, it'll be fine." Hmmm...

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There are more jobs out there than you might think where all it takes is one act of incompetence

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in the right alignment of events and someone will be injured or become sick or be killed.

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Now, if you're in a role and you're not sure about something, ask someone.

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Talk to people in similar roles like yours.

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Go to conferences if you can.

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Be curious.

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Why do we dose Hypo?

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Why does that matter?

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Why don't we run the generator at this frequency?

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Why do we need to sync to the grid before we close the circuit breaker?

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You might be surprised how people just asking simple questions can break through this kind

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of incompetency malaise.

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It's hard to see, in the case of Walkerton, what could have been done differently to prevent

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this incident without going back to that grandfathering clause.

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Maybe the way to look at it is like this.

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How are you certified?

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How are others you work with certified?

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And ask yourself, is experience alone enough?

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Spoiler alert, it isn't.

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Visit https://engineered.network/causality to learn how you can help this show continue to be

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Causality is heavily researched and links to all the materials used for the creation

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of this episode are contained in the show notes. You can find them in the text of the

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episode description of your podcast player or on our website. You can follow me on the

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Fediverse at chidgey@engineered.space, on Twitter @johnchidgey or the network on Twitter @Engineered_Net.

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This was Causality. I'm John Chidgey. Thanks so much for listening.

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[MUSIC]

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(somber music)

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(gentle music)

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(dramatic music)

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(dramatic music)

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[Music]

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(dramatic music)

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(dramatic music)

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(gentle music)

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[Music]

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(gentle music)

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(music)

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(gentle music)

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(gentle music)

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[Music]

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Many thanks to listener John Paul from Ontario, Canada for writing in and requesting this topic and bringing it to my attention.

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Good luck in your studies, John. I hope they're going well.