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The Scope of the Report

The Report on Part 1 of the Walkerton Inquiry speaks to the events surrounding the tragedy at Walkerton and the policies that directly affected those events. It includes recommendations intended to strengthen the regulatory system around the provision of drinking water. Many of these recommendations will be elaborated on in the Part 2 report.

This first report does not address issues around privatization and who can best provide water services. The Report on Part 2 of the Inquiry will address these larger issues and others related to the treatment and delivery of safe drinking water, including privatization. The Part 2 report will be released in approximately two months (late March).

The Findings

Seven people died and more than 2,300 became ill shortly after May 12, 2000 when the deadly bacteria entered the Walkerton water system through Well 5. Some of those who became ill may endure lasting negative effects on their health.

The Report of the Walkerton Inquiry, authored by The Honourable Dennis R. O’Connor, makes it very clear that Provincial budget reductions and an inadequate regulatory regime under the Tory Government were the principal factors in explaining why the outbreak of E.coli 0157:h7 and Campylobacter jejuni was neither prevented nor dealt with in a timely fashion. The regulatory system lacked the resources and government attention needed to cope with mistakes and misdeeds in the local water systems.

The PUC manager, Stan Koebel and foreman, Frank Koebel, must clearly bear some responsibility because they were responsible for day-to-day operations at the PUC. The report concludes that the scope of the outbreak would very likely have been substantially reduced if they had measured chlorine residuals at Well 5 on a daily basis. Instead, the PUC operators engaged in a number of improper practices, including failing to use adequate doses of chlorine, failing to monitor chlorine residuals, making false entries in operating records about residuals, and misstating the locations at which microbiological samples were taken.

As inexcusable as are some of the actions of Stan and Frank Koebel, the report points to weaknesses within the regulatory system which failed to monitor and enforce proper safeguards and procedures at Walkerton. These weaknesses were aggravated by budget cutbacks and layoffs at the Ministry of the Environment (MOE).

The MOE inspections program should have detected the Walkerton PUC’s improper treatment and monitoring practices and insured that they were corrected. However, “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.” The MOE’s budget was reduced by more than $200 million under the Conservative government and the staff complement was cut by more than 750 (a reduction of over 30%).

The provincial government budget reductions also ended government laboratory testing services for municipalities in 1996. This forced most municipalities to use private laboratory testing services. Furthermore, the government failed to enact 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 Report concludes that the manager and other staff at the Walkerton Public Utilities Commission (PUC) “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.” Therefore, it is not surprising that the report recommends a number of changes that would address these shortcomings.

The Recommendations

The report makes twenty-eight recommendations that call for more resources, clearer operational procedures and stronger regulations that affect public health authorities, the MOE and the water treatment and delivery systems. The recommendations will further elaborated in the part 2 report. Five of these recommendations (recommendations 20 through 24) directly affect CUPE members who work within Ontario’s water and wastewater systems. They relate to the training and testing of water system operators and are as follows:

  • Recommendation 20. The government should require all water system operators, including those who now hold certificates voluntarily obtained through the grandparenting process, to become certified through examination within two years, and to be periodically recertified.

Both of the Koebel brothers were certified under the grandparenting process implemented in the late 1980s and early 1990s. Neither one has ever been tested as part of receiving their certification. At the time, grandparenting was viewed as an acceptable way to maintain an experienced labour force within the water and wastewater industry and ensure that water and wastewater operators were not negatively affected. The practice was used by many other jurisdictions in Canada and the United States. Clearly, the Inquiry is recommending that grandfathered operators be required to undergo testing to determine if they have the required skills and knowledge to perform their job.

  • Recommendation 21. The materials for water operator course examinations and continuing education courses should emphasize, in addition to technical requirements necessary for performing the functions of each class of operator, the gravity of the public health risks associated with a failure to treat and/or monitor drinking water properly, the need to seek appropriate assistance when such risks are identified, and the rationale for and importance of regulatory measures designed to prevent or identify those public health risks.

Evidence and testimony presented at the inquiry indicated that that the Koebel Brothers and many other operators within Ontario had not received proper instruction and education on drinking water safety and the risks associated with contaminated water. Therefore, the Inquiry is recommending that course material and examinations for operators emphasize these issues.

  • Recommendation 22. The government should amend Ontario regulation 435/93 to define training clearly, for the purposes of the 40 hours of annual mandatory training with an emphasis on the subject matter described in Recommendation 21.

System operators have been required for some time under existing regulations to undergo forty hours of training per year. Evidence presented at the Inquiry showed that the training received was not always directly related to drinking water safety. This recommendation is intended to correct this situation and require that training be defined more clearly and that it focus on drinking water safety.

  • Recommendation 23. The government should proceed with the proposed requirement that operators undertake 36 hours of MOE-approved training every three years as a condition of certification or renewal. Such courses should include training in emerging issues in water treatment and pathogen risks, emergency and contingency planning, the gravity of the public health risks associated with a failure to treat and/or monitor drinking water properly, the need to seek appropriate assistance when such risks are identified, and the rationale for and importance of regulatory measures designed to prevent or identify those public health risks.

This recommendation is designed to ensure that the additional 36 hours of instruction every three years, as indicated in the recently revised regulations be approved by the MOE and that it also focus on the dangers of untreated water as well as other threats to drinking water safety.

  • Recommendation 24. The MOE should inspect municipal water systems regularly for compliance with Ontario Regulation 435/93, enforce the regulation strictly and follow up when non-compliance is found in order to ensure that operators meet certification and training standards.

This recommendation is designed to insure that operators actually receive and successfully complete the training and testing mentioned in the above recommendations. Municipalities and PUCs have had responsibility for training in the past, but with little or no enforcement of training and testing standards. With this recommendation, the Inquiry is urging the government to see that the MOE play that monitoring and enforcement role.

Implications of Recommendations for Water and Wastewater Operators

Clearly, once implemented, these recommendations will affect water and wastewater operators in significant ways. These recommendations will be expanded upon in Part 2 of the Inquiry report, but it is clear that:

  • Operators will receive more training than they have in the past and the training will be directly related to providing safe drinking water. Forty hours of training are to be provided annually by the municipality in addition to 36 hours of MOE-approved training every three years. The exact type of courses and training are yet to be determined.
  • Operators who were certified under the grandparenting scheme will be required to receive training and testing. What the training and testing entails has yet to be determined as is what assistance operators are to be provided in helping them prepare for testing. Finally, it needs to be determined what happens to operators who fail the training and testing requirements.
  • Operators who may have undergone very little training and had no testing, may be required to do so on a regular basis. This will place considerable pressure on some of them, especially older operators who may have literacy issues.

CUPE will insist on full participation in the process to require more training and testing of our members. We will do so to ensure that operators are treated fairly and given every opportunity to participate in training and prepare for examinations or testing.