INDEPTH: INSIDE WALKERTON
Walkerton report highlights
CBC News Online | January 2002
The most serious case of water contamination in Canadian history could have been prevented by proper chlorination of drinking
water, according to a judicial inquiry report about Walkerton, Ontario's fatal E. coli outbreak.
Justice Dennis O'Connor's report also points to the region's public utilities managers and Ontario government cutbacks as contributors to the tragedy.
Seven people died and 2,300 became ill after Walkerton's water supply became contaminated with manure spread on a farm near the town, the report concludes.
The report, released in two parts over the winter and spring of 2002, contains hundreds of findings and recommendations.
From part one of the report
issued January, 2002:
This is how Justice Dennis O'Connor summarized the inquiry's findings:
Up to 400 illnesses could have been prevented if water manager Stan Koebel had monitored the chlorine levels daily and had notified authorities right away that the water was contaminated.
The Ontario government failed to make reporting of positive tests for contamination mandatory when water testing was privatized in 1996.
Government cuts at the province's Environment Ministry made it less capable of identifying and dealing with problems at Walkerton's water utility.
The local health unit was quick to respond to the crisis with a boil-water advisory, but it should have been more wide-spread. Many Walkerton residents were not aware of the warning.
- Seven people died, and more than 2,300 became ill. Some people, particularly
children, may endure lasting effects.
The contaminants, largely E. coli O157:H7 and Campylobacter jejuni,
entered the Walkerton system through Well 5 on or shortly after May 12,
The primary, if not the only, source of the contamination was manure
that had been spread on a farm near Well 5. The owner of this farm
followed proper practices and should not be faulted.
The outbreak would have been prevented by the use of continuous chlorine
residual and turbidity monitors at Well 5.
The failure to use continuous monitors at Well 5 resulted from short-comings
in the approvals and inspections programs of the Ministry of
the Environment (MOE). The Walkerton Public Utilities Commission
(PUC) operators lacked the training and expertise necessary to identify
either the vulnerability of Well 5 to surface contamination or the resulting
need for continuous chlorine residual and turbidity monitors.
The scope of the outbreak would very likely have been substantially
reduced if the Walkerton PUC operators had measured chlorine residuals
at Well 5 daily, as they should have, during the critical period when
contamination was entering the system.
For years, the PUC operators engaged in a host of improper operating
practices, including failing to use adequate doses of chlorine, failing to
monitor chlorine residuals daily, making false entries about residuals in
daily operating records, and misstating the locations at which microbiological
samples were taken. The operators knew that these practices were
unacceptable and contrary to MOE guidelines and directives.
The MOEís inspections program should have detected the Walkerton
PUCís improper treatment and monitoring practices and ensured that
those practices were corrected.
The PUC commissioners were not aware of the improper treatment and
monitoring practices of the PUC operators. However, those who were
commissioners in 1998 failed to properly respond to an MOE inspection
report that set out significant concerns about water quality and that identified
several operating deficiencies at the PUC.
On Friday, May 19, 2000, and on the days following, the PUCís general
manager concealed from the Bruce-Grey-Owen Sound Health Unit and
others the adverse test results from water samples taken on May 15
and the fact that Well 7 had operated without a chlorinator during that
week and earlier that month. Had he disclosed either of these facts, the
health unit would have issued a boil water advisory on May 19, and 300
to 400 illnesses would have been avoided.
In responding to the outbreak, the health unit acted diligently and should
not be faulted for failing to issue the boil water advisory before Sunday,
May 21. However, some residents of Walkerton did not become aware of
the boil water advisory on May 21. The advisory should have been more
The provincial governmentís budget reductions led to the discontinuation
of government laboratory testing services for municipalities in 1996.
In implementing this decision, the government should have enacted a regulation mandating that testing laboratories immediately and directly
notify both the MOE and the Medical Officer of Health of adverse results.
Had the government done this, the boil water advisory would have been
issued by May 19 at the latest, thereby preventing hundreds of illnesses.
The provincial governmentís budget reductions made it less likely that
the MOE would have identified both the need for continuous monitors
at Well 5 and the improper operating practices of the Walkerton PUC.