Intervenor: vol. 27, no. 1 - 2, January - June 2002

CELA at the Walkerton Inquiry

Part I Report of the Walkerton Inquiry: an Overview

In January 2002, the much-anticipated Report from Part I of the Walkerton Inquiry was released. The Report was based upon nine months of public hearings, which featured testimony from 114 witnesses, including Walkerton residents, local officials, senior civil servants, scientific experts, former Ministers of the Environment, and the Premier of Ontario.

The primary focus of Part I was to identify the circumstances which caused the outbreak of the waterborne disease that resulted in seven deaths and extensive illnesses within Walkerton in May 2000.

In the Part I Report, Mr. Justice O'Connor makes a number of key findings about the cause of the outbreak. In particular, he found that:

  • the contaminants responsible for the outbreak (E. coli O157:H7 and campylobacter jejuni) entered one of Walkerton's supply wells (Well 5) around May 12, 2000;
  • the primary, if not only, source of these contaminants was manure that had been spread near Well 5 in accordance with proper agricultural practices;
  • these contaminants likely passed through the thin overburden and highly fractured bedrock into the aquifer that fed Well 5;
  • the outbreak would have been prevented by the use of continuous chlorine residual monitors and turbidity monitors at Well 5;
  • the failure to use such monitors resulted from shortcomings in the approval and inspection programs of the MoE, and from deficiencies in the training programs of the Walkerton Public Utilities Commission (PUC);
  • the PUC operators engaged in a series of improper operating practices (inadequate chlorination, falsified records, improper monitoring and water sampling, etc.,) which should have been detected and remedied by the MoE's inspection program;
  • adverse test results from the PUC's May 15th water sampling were not sent immediately to the MoE or medical officer of health, which delayed the issuance of the boil water advisory;
  • despite warnings from health officials, the Ontario government failed to enact a regulation requiring laboratories to immediately notify the MoE and the medical officer of health about adverse water sampling results; and
  • the Ontario government's budget reductions made it less likely that the MoE would have identified the improper operating practices of the PUC and the need for continuous monitors at Well 5.

At the Inquiry, lawyers for the Ontario government had argued that the PUC manager (Stan Koebel) was primarily responsible for the Walkerton Tragedy. This argument was flatly rejected by Mr. Justice O'Connor:

Stan Koebel and the others at the Walkerton PUC are responsible for their own actions and for the consequences of those actions. Failures by the MoE in overseeing the operation of the Walkerton water system do not excuse those actions, nor do they lessen the responsibilities of the individuals involved…

At the Inquiry, the government argued that I should find that Stan Koebel was the sole cause of the tragedy in Walkerton and that I should also find that government failures, if any, played no role - the suggestion being that if it were not for Stan Koebel's failures, the tragedy would not have happened. I reject that argument completely. It totally misconceives the role of the MoE as overseer of communal water systems, a role that is intended to include ensuring that water operators and facilities perform satisfactorily. When there is a failure in the operation of a water facility, as there was in Walkerton, the question arises whether the MoE in its role as overseer should have prevented the failure or minimized the risk that it would occur…

I have concluded that the MoE failed in several respects to fulfill its oversight role in relation to Walkerton's water system. Some MoE programs or policies were deficient because they should have identified and addressed one or both of the two operational problems at Walkerton referred to above [inadequate chlorination and lack of continuous monitors], but did not do so. Other programs and policies were deficient because they reduced the likelihood that the two problems would be identified and addressed.

In light of these and other findings, the Part I Report goes on to offer 28 recommendations for regulatory and policy reform in order to strengthen the protection of drinking water in Ontario. Among other things, Mr. Justice O'Connor recommends that:

1. the role of medical officers of health and local health units should be clarified and enhanced in relation to drinking water safety;

2. there should be better coordination between local MoE and health officials in relation to drinking water safety;

3. a standardized Boil Water Protocol should be prepared for use by local health officials;

4. the MoE should develop criteria for identifying "groundwater under the influence of surface water", and should require continuous chlorine and turbidity monitors for such groundwater if used as a source of drinking water;

5. the MoE should improve its information data system in order to retain and integrate all relevant records for waterworks approvals, inspections and reports;

6. waterworks approvals should be time-limited and periodically reviewed by the MoE;

7. MoE inspection programs should include annual inspections (both announced and unannounced) of municipal water systems, and a written protocol should be developed to guide such inspections;

8. the government must provide adequate resources to ensure that MoE inspections are thorough and effective, and to ensure that MoE inspectors receive appropriate training;

9. there should be timely followup activities by the MoE to ensure that remedial actions are promptly undertaken by operators whose water systems are found to be deficient; and

10. training programs for waterworks operators should be expanded and improved, and all operators in Ontario should be tested and certified within two years.

Interestingly, upon the release of the Part I Report, the Premier and the Minister of the Environment committed to implement the above-noted recommendations.

It is anticipated that the Part I recommendations will be supplemented and expanded upon in the Part II Report, which should be released by June 2002. In particular, the Part II Report (which goes beyond the specifics of the Walkerton Tragedy) will contain comprehensive recommendations relating to all aspects of drinking water protection in Ontario, including:

  • protection of drinking water sources;
  • treatment, distribution, and monitoring of drinking water;
  • operation and management of drinking water systems; and
  • the full range of functions involved in the provincial regulatory role.

A future issue of the Intervenor will provide commentary on the findings and recommendations of the Part II Report from the Walkerton Inquiry released in May 2002.
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Richard Lindgren is a CELA lawyer.