PPZ3C: Module 11 | The Walkerton Tragedy | Questions
1) Thoroughly explain three (3) reasons why the Walkerton Tragedy occurred (other than
bacteria being in the town's water supply). In other words, what were some of
...
PPZ3C: Module 11 | The Walkerton Tragedy | Questions
1) Thoroughly explain three (3) reasons why the Walkerton Tragedy occurred (other than
bacteria being in the town's water supply). In other words, what were some of the
issues/mistakes along the way that caused this to be such a tragedy? Answer in full sentences
and organize your answer in the following manner:
There are several reasons as to why the Walkerton Tragedy occurred and this includes reasons other
than bacteria being in the town's water supply. Three of these additional reasons are outlined below.
Judge Dennis O’Connor detailed the events and causes that led to the outbreak. As with many public
health disasters of catastrophic proportions, multiple unfortunate events occurred that resulted in the
disaster. By examining the events in May 2000, one can evaluate the physical causes, the role of the
public utility commission (PUC) operators, the role of the Walkerton public utility commissioners, the
role of the Ministry of the Environment (MOE), and how government budget reductions and policy
affected the events.
Reason #1: The role of the public utility commission (PUC) workers.
Walkerton is a rural agricultural area. Between May 8th and May 12th, 2000, heavy rainfall resulted in
surface runoff containing E. coli O157 and Campylobacter jejuni entering a well supplying drinking water.
The bacteria came from manure that had been spread on a nearby farm. Although the well was
chlorinated, the amount of chlorine used was routinely less than the amount required, and bacteria and
organic matter overwhelmed the system. The chlorine residual level should have been monitored
manually; however, for more than 20 years, it had been the practice of PUC employees to make fictitious
entries in their daily operating sheets.
The workings of fraudulence at the PUC included a host of improper operating practices, such as
misrepresenting locations at which samples were taken, operating wells without chlorination, making
false entries into daily operating sheets, failing to monitor daily chlorine residuals, inadequate
chlorination, and submitting false annual reports to the MOE. The two men who ran the PUC had been
grandfathered into their positions and lacked formal training. They had little understanding of how
chlorination worked, or of the health risks associated with improper treatment and monitoring. They
believed that Walkerton's water was safe and frequently drank it in its untreated form. Although they
were required to have 40 h of training each year, this training did not take place and no system was in
place to enforce it.
Reason #2: Lack of enforcement and action by the MOE.
In Ontario, the MOE is the ministry primarily responsible for promulgating and enforcing regulations and
policies that apply to municipal water systems. The MOE had inspected the Walkerton system in 1991,
1995, and 1998 and identified many problems. E. coli was detected in treated water, the chlorine
residuals were low, and there were repeated failures to submit the required number of samples. One of
the most important deficiencies within the MOE was the lack of a computerized information system to
make critical historic information accessible to those responsible for monitoring. An inspection report
detailing these problems was given to the Walkerton public utility commissioners; however, the
commissioners were largely concerned with the financial side of the operations and did not address the
MOE report. No follow-up occurred. Enforcement was made difficult given that the regulatory
responsibilities were governed by guidelines as o
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