Report on Emergency Management of The Walkerton Water Tragedy

At its core the Walkerton Water Crisis of May 2000, occurred because a well operator did not check that sufficient chlorine residual was present in the water pumping from well 5 in Walkerton township. The town of Walkerton had received over 134 mm of rain from May 08 to May 12, 2000.

During that time, contaminated groundwater from a freshly manured farm field across the road from the well, had leached into and contaminated the well's aquifer with E. coli 0157:H7 and Campylobacter bacteria. So, on the 13th 14th and 15th of May 2000, when the PUC workers checked the well, but did not bother to ensure that a 0.5mg/L chlorine residual was present to purity the water, a catastrophe was begun, which left 7 people dead and over 2300 sickened (some permanently) in a town of only 4800.

It would be easy to blame Frank Koebel, the foreman of the PUC or his brother Stan Koebel the general manager, for the crisis. ' Yes, it was their actions.... that contributed to the Escherichia coli bacteria water pollution disaster in Walkerton' (Gallon, 2000), through their failure to check chlorine residual levels on the wells. However, the crisis was not just one person’s fault. Nothing exists in a bubble, and the ability of Frank and Stan Koebel to neglect checking chlorine residuals was the result of an imperfect system that allowed multiple, avoidable failures to occur that compromised Walkerton’s water supply and placed the population at risk.

In this essay, I will briefly examine the events of the Walkerton water crisis from the standpoint of the five pillars of emergency management. It will be found that the crisis resulted from the lack adherence to or implementation of the principals of emergency management.

Emergency Management contains five essential principals or 'pillars' that define functions and roles of stakeholders in an emergency event that are designed to achieve the avoidance of a hazard, lessening the impact of a hazard, or recovering from a hazard event. The pillars are: Prevention, Mitigation, Preparedness, Response and Recovery.

Prevention

The first pillar is Prevention and is defined as: 'Actions taken to stop an emergency or disaster from occurring. Such actions may include legislative controls, zoning restrictions, improved operating standards/procedures or critical infrastructure management'. (EMO) Preventative actions are 'taken BEFORE the emergency'. They are 'ideologically based' and are usually found through use of a Hazzard Identification and Risk Assessment' (EMO).

Had a HIRA been done for the water system before the tragedy, a series of serious but preventable vulnerabilities would have come to light: the contaminated well - well #5 was built in 1979 when standards for wells were less severe; it was a shallow well, and was closer to the surface than any other well in Walkerton. Well 5 was covered with a cracked rock face through which surface contaminants could leak directly into the aquifer unfiltered. Well 5 was built on a flood plain and was vulnerable to contamination from flooding from a nearby farm field. The water quality of well 5 was deteriorating, as was noted in reports from 1996 and 1999 and the contaminants found in the water at those times was E coli. Thus, had legislation dictating where and how wells could be safely constructed, and legal requirements for land use surrounding clean water wells, the contamination would have prevented the hazard before it occurred.

A second layer of prevention that failed prior to the event was the absence of automatic chlorinators and turbidity monitors at the well head. Chlorinators ensure enough chlorine is being used in well water to kill bacteria. The standards are to have 0.5 mg/L of chlorine present after 15 minutes which guarantees that bacteria have not overcome the chlorination process. Turbidity monitors check for particulates in the water to ensure it is clear and free of unwanted substances. The chlorinators at well five were manual, not automatic, and required checking every day to ensure chlorine levels. However, they were not checked regularly, and required records were falsified. Had automatic chlorinators and turbidity monitors with alarms been placed on the well, before the event, they would have immediately alerted authorities that the chlorine was being overcome by bacterial agents and the tragedy would have been prevented.

A third layer of failed prevention occurred as a result of out of date protocols for the reporting and notification of the Ministry of the Environment of bad water samples. In 1996 the Ontario Government privatized the testing of water and placed the responsibility for water standards on the towns and cities of Ontario. Prior to privatization, water standards were maintained by the province and a series of protocols existed for the inter-government testing and notification of failed water samples.

After privatization of water testing in 1996, there were no hard rules in place, only the pre-existing protocols that were once used by the government. Thus, when the facility used by Walkerton to test their water samples, A&L Labs, notified Stan Koebel by phone and later by fax on May 17 2000 that water samples had tested positive for E. coli bacteria, Stan did not notify anyone. Instead, he began 'flushing' and 'over-chlorinating' the entire Walkerton water system in an attempt to remove the contamination. Again, had a law existed that required labs to notify the MOE of failed water samples it is likely the tragedy could have prevented.

A fourth preventable factor was the lack of legislated qualifications and of Well operators. Stan and Frank Koebel never finished high school, and while they were generally competent well operators, they lacked the education and training necessary to understand the impact of contaminated drinking water on the populace. Both men frequently drank 'raw' untreated water from the wells and believed it was safe. That belief appears to have created a culture of disregard for accepted practices, which caused the lack of strict record keeping of Chlorine residuals at the wells, or accurately attributing locations of water samples sent for testing. Had the education and training of well operators been legislated, with legal and criminal consequences for malpractice prior to the tragedy it is probable the crisis would have been prevented.

Mitigation

Once a hazard has been identified, and all efforts have been expended through legislation and zoning to prevent a hazard from occurring, we move the second pillar which is Mitigation. Mitigation is defined as: 'the process by which the impact of potential emergencies may be reduced, deflected or avoided all together. It is one of the most critical phases as it involves the recognizing of hazards and coming to terms with their effect.' (EMO )

Unlike prevention, mitigation activities can be performed during all five stages of an emergency, because it is always possible to do something to lessen the impact. Indeed, the 5 pillars are all forms of mitigation at various stages in a crisis. However, those specific actions taken to lessen the impact that are 'risk focused, and evidence driven' might be said to be specifically mitigation focused.

All attempts to mitigate the E. coli crisis in Walkerton largely failed in the early stages of the event because the hazard had not been clearly identified, and therefore the amount of risk was misunderstood by well-intended but ill-informed people. For instance, the crisis moved from the prevention stage to the mitigation stage when E. coli bacteria entered the water system sometime, 'on or shortly after May 12.' (O'Connor, pg.7)

At that exact point it was no longer possible to prevent the hazard, but merely lessen its impact. Water samples were taken from the system by Stan Koebel on the morning of May 15 and submitted for testing. On May 17, Stan was notified first by phone, then by a follow-up fax, that several of his samples were heavily contaminated with E. coli. That was the 'evidence factor' that demonstrated a risk was occurring and that mitigation attempts to lessen. Stan apparently tried to solve the problem himself by attempting to flush the system with chlorination, rather than notify the Mayor that a contamination had occurred and to activate a boil water advisory. The township of Brockton, which included Walkerton had an emergency plan which included the issuance of boil water advisory. Stan's lack of understanding of the risk, demonstrated by his unconcern for the evidence of E. coli in the water samples, was a clear failure to mitigate the impact of the contamination hazard.

An example of a (potentially) legislated regulation used to prevent a hazard, that could also have acted as mitigating factor during an emergency, was the requirement that private laboratories immediately notify the MOE of contaminated water samples. The O’Connor report estimates that if the MOE had known of the contamination in a timely manner, they could have notified the municipality and an estimated 300 to 400 people could have avoided becoming ill. (O'Connor, pg. 4.) Indeed, had a law existed that required well operators to immediately notify their superiors of contaminated water samples, on pain of criminal prosecution, Stan would have undoubtedly notified the mayor and city council on the 17th as well. This was a failure to mitigate by both the province and the Walkerton PUC.

Two further examples of failed attempts to mitigate demonstrate the difficulty of mitigation when a clear hazard has not been identified. On May 19 a pediatrician in Owen Sound, Dr. Kristen Hallet contacted the Owen Sound Health Unit and notified them of her suspicion that E. coli was causing the illness of two children she had examined at Owen Sound hospital the previous day. 'The health unit began an investigation, and reached Mr. Koebel by phone in the afternoon.... he was asked if there was anything wrong with the water and he replied that the water was 'OK'.... even though he knew of the adverse result of the samples from May 17. (O'Connor, pg. 9) Notification of the possibility of E. coli would have mitigated the onset of the crisis.

A second failed attempt to mitigation occurred on Saturday May 20th when an employee of the PUC, Robert McKay anonymously 'contacted the MOE Spills Action Committee in Toronto, which functioned as an environmental emergency call center. 'He informed the SAC that samples from Walkerton’s water system had failed lab tests.' (O'Connor, pg.11) The SAC contacted Stan Koebel 'who led the caller to believe that the only tests that had failed were from the construction project. He did not reveal that water from the distribution system had failed as well.'(O'Connor, Pg.11). The above demonstrates that a centralized authority with power to control resources or EOC is essential to optimize mitigation measures, but it is impossible to fully mitigate when a hazard is only suspected but not identified.

Preparedness

The third pillar in emergency management is preparedness. It is defined as: 'Actions taken prior to an emergency or disaster to ensure an effective response. These actions include the formation of emergency response plans, business continuity/continuity of business plans, training, exercises and public awareness, and education. (EMO)

The township of Brockton did have an emergency preparedness plan, but the plan was largely pointless because a definite hazard had not been identified, only a general threat demonstrated by the increasing number of stricken citizens. And by the time the first confirmed results indicating E. coli, occurred on May 21, medical responders had been functioning for over four days. Preparedness and response are closely related in that the response actualizes the preparedness plans, with resources and training put into place during preparedness phase. So, during the Walkerton emergency when health responders confronted an initial and unknown hazard, their response was based on a 'probable threat' and utilized the preparedness plans and training that might be used for any general emergency, until a more specific hazard was identified.

A second way of quantifying the preparedness of Walkerton for the crisis, is to assess their degree of readiness using 'the six pillars of preparedness'. The six pillars framework defines the six categories of preparation that are put in place prior to the emergency. They include: Public awareness, Emergency Info, Exercises, Training, Emergency Ops Center, and Emergency plans. Fema's definition clarifies the intent of the six pillars:

'Since emergencies often evolve rapidly and become too complex for effective improvisation, a government can successfully discharge its emergency management responsibilities only by taking certain actions beforehand. This is preparedness.

Preparedness involves establishing authorities and responsibilities for emergency actions and garnering the resources to support them: a jurisdiction must assign or recruit staff for emergency management duties and designate or procure facilities, equipment, and other resources for carrying out assigned duties. This investment in emergency management requires upkeep: the staff must receive training and the facilities and equipment must be maintained in working order. To ensure that the jurisdiction's investment in emergency management personnel and resources can be relied upon when needed, there must be a program of tests, drills, and exercises.' (Fema, 1996, pg. 3)

So how prepared was Walkerton in terms of the Six Pillars?

1. Emergency Plans: The township of Brockton had an emergency plan but it was never activated because the contamination was identified and a boil water advisory announced immediately after identifying the cause.
2. Emergency Ops Center: There was no emergency ops center for the crisis. The press was initially invited to meet with the mayor and public officials at a local restaurant, but realizing the awkwardness of the location, changed their Ops center to the Brockton council offices. The media scrum included the members of the Ministry of the Environment, the Walkerton health inspector, Dr. McQuigge, the mayor, town councillors, the head of the PUC and Stan Koebel.
3. Training: There was clearly medical training of responders which included the establishing a hierarchy of control and chain of command and communications. However, the training of the well operators was not sufficient.
4. Exercises: This writer could find no record of emergency exercises, although the swift response by medical personnel clearly indicated some medical exercises had taken place.
5. Emergency Information: There is no formal record of emergency information being released to the public until the boil water advisory, although neighbours were notifying each other to use bottled water as early at the 18th of May.
6. Public Awareness and Education: The citizens of Walkerton did not know that their water system was at risk, even though it had been identified as 'at risk” by provincial authorities as early as 1979. The town council knew that the PUC was notified about water standards by the MOE, but accepted Stan Koebel's word that he would deal with whatever violations of the Ontario Drinking Water Objectives protocols existed.

So, from the standpoint of the six pillars, Walkerton was not prepared for the Catastrophe.

Response

The fourth pillar of Emergency Management is Response. It is defined as: 'The provision of emergency services and public assistance or intervention during or immediately after an incident in order to protect people, property, the environment, the economy and or services. This may include the provision of resources such as personnel, services and/or equipment.' (EMO) Response is 'protocol based' and 'operations focused'. Fema defines response as:

'... time-sensitive actions to save lives and property, as well as for action to begin stabilizing the situation so that the jurisdiction can regroup. Such response actions include notifying emergency management personnel of the crisis, warning and evacuating or sheltering the population if possible, keeping the population informed, rescuing individuals and providing medical treatment, maintaining the rule of law, assessing damage, addressing mitigation issues that arise from response activities, and even requesting help from outside the jurisdiction.' (Fema, 1996. pg.04)

The response to the Walkerton outbreak was initially medically oriented and protocol driven, but unfocused and confused. On May 18th, Dr. Kristen Hallet, a pediatrician in Owen Sound suspected that two children she had examined might be infected with E. coli. However, her only proof was the symptoms, which she communicated to the director of the Owen Sound Health Unit, Dr. Murray McQuigge on the morning of Friday, May 19th. The health unit immediately dispatched Beverly Middleton, an Owen Sound health inspector, to Walkerton to make inquiries. Ms. Middleton contacted the Walkerton Hospital, a home for seniors, and two schools.

She learned the hospital had fielded numerous calls about bloody diarrhea, and vomiting; a dysentery outbreak had occurred at the senior’s home, and as many as 35 students were absent from school due to illness. James Schmidt, the public health inspector for Walkerton, was also notified that the hospital had received multiple calls with similar symptoms, and excessive absenteeism at the local school and therefore initiated his own parallel investigation, as protocol dictated.

The shift from an unfocused to a focused response occurred on morning of Saturday May 20 when 'the laboratory at Owen Sound Hospital determined that the stool sample from one of the two children Dr. Hallet had examined on May 18 was presumptive positive for E. coli 0157:H7. When the laboratory notified the Owen-Sound-Bruce-Grey-Health-Unit of the presumptive result' (O'Connor, pg. 73) the response moved to a level higher.

The Owen Sound Health Unit immediately notified the hospital at Walkerton, so they could begin remediation activities. They 'also contacted hospitals in Hanover and Owen Sound and Mt Forest'. The responders at the health unit were concerned that patients who could not receive care at Walkerton, would travel to other hospitals, and the medical response in all surrounding cities needed to be consistent. Also, by 1:30 in the afternoon Murry Patterson, assistant director at the health unit notified Dr. McQuigge, of the presumptive results of the E. coli tests. Dr. McQuigge immediately returned to Owen Sound by early evening to take control of the emergency.

Another part of the initial confusion in response to the outbreak concerned finding the source of the hazard even after E. coli was identified. In May 2000, there were few records of E. coli contamination through water, and once the authorities identified the hazard, they thought it was food bourn. An E. coli outbreak 7 years earlier at the Jack in the Box food franchise in the USA, was caused by under-cooked meat, and resulted in over 750 people becoming sick. The excessive publicity surrounding that event was responsible for E. coli 0157:H7 becoming branded as the 'hamburger disease'.

So, when E. coli was identified as the cause of illness on May 20, the probable source of contamination was thought to be food bourn, and health workers began charting food graphs to determine commonalities in patient behaviour that might detail the source of the infecting bacteria through food. Thus, even though they knew the cause was E. coli they were severely hampered in their ability to respond completely because they couldn't find and mitigate the bacteria's source.

On Sunday May 21 a major step in response was taken when 'Murry Patterson, Assistant director of the health unit, consulted with Dr. McQuigge and Clayton Wardell, the director of health protection, recommended the issuance of a boil water advisory' (Ibid, pg. 80) The advisory was issued at 1:30 pm on May 21st and was broadcast on local AM and FM stations. What is remarkable about the advisory is that the source of bacteria had still not been confirmed. Earlier that day, ' the laboratory at the Owen Sound hospital called the health unit to confirm the earlier presumptive E. coli O157:H7 result'(O'Connor. pg. 73). This was the first confirmation of E. coli O157:H7 of the crisis. The lab also reported a presumptive result of E. coli O157:H7 for another patient. The only commonality between all the patients was the water and so the advisory was issued as a mitigating response to a probable cause, not yet proven.

Another form of response occurred 'after the boil water advisory... when the Owen Sound Health Unit established a strategic team to address the outbreak (Ibid. pg91). 'At the health unit’s request, the Walkerton, Hanover, and Owen Sound hospitals had forwarded patient line-listings – the names of patients who had been examined at these hospitals – to the health unit.... Throughout May 22, public health staff contacted these patients to obtain their residential addresses as well as information about onset dates of symptoms, the patients’ consumption of Walkerton water, and the dates that stool samples had been collected from the patients. ' (Ibid. pg.91 - 92)

'As the outbreak team began to plot the epidemiological curve, it became apparent that most individuals in Walkerton had become ill at about the same time... A large map of Walkerton was placed on the wall of the health unit’s office, and the patients’ addresses were highlighted on it. When the process was complete, the map was, in the words of Mr. Patterson, “covered with yellow highlighting.” The infection was widespread – the patients lived throughout the area served by the Walkerton water distribution system. (Ibid. pg. 92) 'On the evening of May 22, the health unit concluded that the municipal water supply was causing the E. coli O157:H7 outbreak in Walkerton.' (Ibid. pg.92) The MOE lab confirmed the existence of E. coli in the water mains on May 23. (CBC News May 10, 2010)

Thus, from May 18 to May 22, the response by the Owen Sound Health unit, which initially began as unfocused attempts to save lives, gradually became more focused until they were able to identify the cause and source of the outbreak, as well as control and manage a large scale medical response through multiple hospital facilities. The above is only a tiny portion of the numerous forms of response taken by medical professionals. It again underscores the absolute imperative of understanding the hazard and its risk during an emergency event.

Recovery: is the final stage of emergency management and 'is the process of restoring a stricken community to a normal or near normal state'. It is 'normalcy focused and community based' (EMO). Recovery could be said to have a short term and a long-term goal. Recovery begins the moment the endangered community achieves control over the hazard and its inherent risk. In the short term, it is designed to provide the immediate needs of the community, for instance food or water, medical care, and the means and resources to survive the emergency. In the long term, it involves the returning to normal of everyday activities, restoring schools and businesses, maintaining the rule of law, the returning to work, and daily routines that comprise the status quo.

In Walkerton, the first goal after the crisis peaked was to provide a regular supply of clean drinking water. The local arena was used as a distribution center for bottled water. While the distribution of bottled water began as a temporary measure, the amount of work that had to be performed on the Walkerton water distribution system eventually necessitated that water be provided until the following December.

Medical care was another requirement. An E. coli infection in a healthy adult will usually last for 7 to 10 days. There is really no treatment for it except constant hydration. However, some residents, particularly the aged and very young children have weakened immune systems, and E. coli can devastate their intestinal tract and cause significant kidney damage. So, while the short-term stress on the medical system would gradually decrease as infected adults became progressively healthier, some people who acquired kidney damage would continue to be burdened by suffering.

Once recovery efforts transitioned to longer term goals the focus became housing and water resources. One of the principal concerns for Walkerton residents was the fear that housing prices would decrease the value of their homes by 50 % because of the contamination in the pipes supplying their property. The PUC, hired outside engineers and contractors to clean and/or replace the entire Walkerton water distribution system. Every pipe to and from every house and business was either replaced or flooded with powerful chlorination, then tested to ensure that the water was fully disinfected. In addition, well 5 was closed as a mitigation technique directed towards future risk.

Longer term recovery might include payments from the class action lawsuit launched against the Ontario Government by persons and businesses that had been harmed by the outbreak. For instance, people who lost money and work as a result of the contamination; or businesses that had to close or lay off employees, and incurred substantial monetary loses for reasons that were in no way their fault. Eventually the Ontario Government started to settle some of the financial claims of residents, and as of 2008 over 65 million dollars was paid out in settlements to victims of the contamination. (Perkel. Feb 07, 2008)

As part of the long-term recovery, the 'O’Connor Inquiry' was impaneled in June 2000, to study the crisis at Walkerton to determine the causes and effects of the tragedy in order to create a more perfect water control system for the province. The Walkerton Inquiry report was released in 2002, and eventually made over 100 recommendations for the safe operation of water systems in Ontario.

A second-long term solution designed to restore confidence not only in the Walkerton water system but water throughout Ontario was the Walkerton Clean Water Center. The Clean water center is a not for profit water facility that operates as a PR vehicle to demonstrate the latest and best solutions for domestic water supplies in Ontario, and is considered a world class facility. The Center provides free tours for persons, schools and institutions that wish to study the process of handling and distribution of clean water for municipalities.

In conclusion, I have considered the Walkerton Water Tragedy of May 2000 from the standpoint of the 5 pillars of Emergency Management Framework. I've demonstrated that significant failures occurred in the Prevention, Mitigation and Preparedness phases of the emergency, for multiple reasons that prevented or delayed a quick resolution of the event. However, those failures were to a large degree tempered by the exemplary actions by the medical community during the Response phase. And that while Walkerton is still recovering from the trauma of the event, even after 19 years, practically all that could be done to return the town to normal, has been done. And while the memory of the event will always be traumatic to those who lived through it, the lessons learned from the emergency will benefit other towns and cities throughout Ontario and Canada in the future.