The most serious case of water contamination in Canadian history could have been prevented by proper chlorination of drinking water, according to a 2002 judicial inquiry report about the fatal E. coli outbreak in Walkerton, Ont.

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 concluded.

The report, released in two parts, contains hundreds of findings and recommendations, including:

  • 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. 

Part one: January 2002

The first section of Justice O'Connor's report looked into what happened in the Walkerton contamination. His key findings:

  • 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, 2000.
  • 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 MOE’s inspections program should have detected the Walkerton PUC’s 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 PUC’s 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 broadly disseminated.
  • The provincial government’s 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 government’s 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.


Part two: May 2002

The second half of the Walkerton report recommended that the Ontario government spend up to $280 million on water safety and that it implement a safe drinking water act.

The report also recommended that the government establish a special agency within the Environment Ministry to deal with water safety.

Here are other key recommendations:

Planning and standards

  • The provincial government should continue to be responsible for water protection in Ontario.
  • Drinking water standards should be high enough that a person would feel safe drinking the water. The public should be allowed to participate in setting drinking water quality guidelines.
  • Plans should be developed and required to protect watershed drinking water sources in Ontario. Source protection plans should be enforced, approved and reviewed by the Ministry of the Environment, be prepared with local consultation and be managed by conservation authorities.
  • Provincial or municipal government decisions that may affect the quality of drinking water must be in agreement with the source protection plans. The provincial government should provide the right to appeal the source protection plans and to challenge any government action thought to be against those plans. Conservation authorities should educate the public on the importance of source protection.
  • The federal government should adopt standards as good as, or better than, the standards for Ontario's small water systems across reserves, military bases, national parks and any other federal land in Ontario.
  • The Ministry of the Environment should initiate a drinking water quality management standard for Ontario, in order to accredit all drinking water producers in Ontario. They must also have operational plans drafted for the water systems to be approved by the ministry. The ministry will work with Emergency Measures Ontario to establish an emergency response plan for all water systems in the province.

Runoff and other contamination

  • The Ministry of the Environment should not allow the spreading of waste materials that is not within source protection guidelines. Also, the ministry should take responsibility for the regulation of farm activities and their impact on water supplies.
  • A farm that is large, intensive, or deemed to be at "high-risk" under the source protection plan should develop its own binding water protection plan, and municipalities cannot require them to meet higher requirements than those outlined in the existing plan. The Ministry of the Environment should work with other ministries and agricultural groups to develop these plans. A system of cost-sharing should be set up as an incentive.
  • Guidelines should be in place to ensure the safety of any materials coming in contact with drinking water, such as pipes and storage tanks.

Monitoring and staff

  • All water should be continuously monitored, with alarms and automatic shut-off systems if something goes wrong. All municipal providers should have an adequate sampling plan and samples should be taken at vulnerable times, such as after a flood or heavy rainfall. All testing should be done at laboratories accredited by the Ministry of the Environment.
  • Municipalities should review the management and operating structures of their water systems and uphold standards for their employees in the water care sector. They must submit a financial plan to the province in exchange for an operating licence. The Ontario Clean Water Agency and the provincial government should continue to be a support for the cities.
  • Training courses for all water systems operators should be required and accessible. The provincial government and the Ministry of the Environment should develop a comprehensive "source to tap" drinking water policy, covering every step of production. Also, the government should develop a Safe Drinking Water Act to encompass the treatment and distribution stage, and it should amend the Environmental Protection Act to cover these standards.
  • All owners of water systems should hold the appropriate documentation in order to obtain an owner's licence. The provincial government should create an office of chief inspector — drinking water systems, who should also hold this accreditation. The public can use this new officer to investigate suspected infractions. Emergency response measures should be established throughout communities in order to deal with infectious disease outbreaks. The province should fund all programs related to the safety of drinking water.
  • In setting drinking water standards in Ontario, the Ministry of the Environment should report to the Advisory Council on Standards which should consider replacing the total coliform test with the E. coli test. The council should also review all disinfection products used in drinking water.

Public information

  • The Ministry of the Environment should establish electronic access to information about drinking water and individual water systems in Ontario.
  • The Drinking Water Branch of the ministry should table a "State of the Drinking Water" report to be presented to the legislature.

First Nations

  • All programs should be made available to First Nations peoples on or off reserves, at a cost-recovery basis, if necessary. The government supports collaboration between several communities in this effort.