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walkerton report


TRIBE Member
from the star:

Walkerton tragedy preventable: O'Connor
E. coli report apportions blame to Koebel brothers, government overseers

WALKERTON, Ont. (CP) - The most deadly E. coli outbreak in Canadian history could have been prevented and lives saved if the brothers who ran this town's water system had properly chlorinated the water and the Ontario government had heeded warnings, a judicial inquiry concludes.

"If the required chlorine (level) had been maintained when the contaminants entered the system, substantially more than 99 per cent of bacteria such as E. coli would have been killed," Justice Dennis O'Connor says in a hard-hitting report released today in this devastated western Ontario farming town of 5,000.

"For practical purposes, this would have prevented the outbreak."

Seven people died and 2,300 fell ill when a deadly strain of E. coli contaminated Walkerton's water supply in May 2000. Unusually heavy rain swept manure from a local farm into one of the town's wells.

In a report that followed nine months of testimony from 114 witnesses, O'Connor paints a picture of a system-wide collapse that began with Stan and Frank Koebel, two brothers responsible for the town's water.

While the brothers lacked the skills to do their jobs properly and also lied and cheated to protect their jobs, O'Connor finds that there were too few checks and balances in place within Ontario's gutted Environment Ministry to catch the problems.

"It is simply wrong to say ... that Stan Koebel or the Walkerton PUC were solely responsible for the outbreak or that they were the only ones who could have prevented it," O'Connor writes.

Ontario's Conservative government, which was engaged in a widespread cost-cutting agenda, ignored repeated warnings about the impact of slashing millions of dollars from spending and cutting red tape, the judge concludes.

The release of the report marks the end of one of Canada's most-watched public inquiries.

Moments after officially releasing his report to the public, O'Connor had consoling words for the people of Walkerton and all they have endured since May 2000.

"On behalf of myself, on behalf of the people who worked in the inquiry, we simply say to the people in Walkerton that our thoughts are with you," he told a packed arena of residents, many of whom had tears in their eyes as he spoke. Walkerton Inquiry highlights

"They will be with you for the years to come and we very genuinely wish you all the best in the future."

The residents gave O'Connor a standing ovation and applauded heartily.

In his 700-page report, O'Connor identifies "two serious failures" on the parts of the brothers that contributed directly to the tragedy.

The first, in the run-up to the disaster, involved the failure of Stan and Frank Koebel to properly monitor the drinking water.

As a result, the water system was dangerously low on chlorine when E. coli bacteria from a farm field flooded into a vulnerable well.

"They should have been able to take the necessary steps to protect the community," O'Connor writes.

The second failure was the fact that Stan Koebel, the manager of the PUC, tried to cover up the emerging catastrophe that led to a delay in the issuing of a boil-water advisory to the town.

"Starting on May 19, he actively misled health unit staff by assuring them that the water was safe," the report states.

Had he not done so, as many as 400 illnesses likely could have been avoided, O'Connor concludes.

"There is no excuse for his not having informed the health unit of the adverse results at the earliest opportunity," the judicial report states.

Bill Trudell, the lawyer for Stan and Frank Koebel, said he was pleased with the report because it doesn't lay the blame solely on the brothers.

"The commissioner was clear, very clear, on more than one occasion that the governement's suggestion that Stan Koebel is responsible was not accepted," he said.

Stan Koebel is now trying to get on with his life, Trudell said.

"It's hard for him but he accepted his responsibility and I think he's trying to move on and build a life with his family."

Provincial police, who are actively investigating the tragedy, have not commented but they cannot use O'Connor's findings or conclusions to support any charges of criminal negligence.

While O'Connor's report is a stinging indictment of the two brothers, it also contains scathing criticism of the Conservative government under Premier Mike Harris, who in his own testimony at the inquiry attempted to lay the entire blame for the disaster on the Koebel brothers.

Harris couldn't immediately be reached for comment today.

The government's "distaste for regulation" was behind its failure to enact new rules after it rushed privatization of the laboratories that tested drinking water in the province in 1996, the Appeal Court judge notes.

There is no doubt that the lack of a new reporting protocol for bad water was needed, a fact widely recognized within the government at the highest level, the report finds.

The report, which was released four days early after details of the report were leaked to The Canadian Press details, was eagerly anticipated by townspeople.

Colleen Spitzig, a 33-year-old mother of four, said she couldn't be too hard on Stan Koebel despite suffering permanent kidney damage from the E. coli outbreak.

"We were all born and raised here so with any luck we can show some compassion," said Spitzig, who will have to take drugs for her condition for the rest of her life.

"Stan Koebel did something wrong, he literally got caught with his pants down, but I don't think it's right what his family is going through now."

Liberal Leader Dalton McGuinty said the ultimate blame for the tragedy lies with the Ontario government, not Stan Koebel.

"There were mistakes made along the way. There's no doubt about that, but this government made the biggest mistake when it eliminated some of the fundamental safeguards that should have been in place."

NDP leader Howard Hampton agreed.

"At the end of the day I think what is most salient is that Mr. Justice O'Connor says that the people who got a warning here, and they got repeated warnings, were the provincial government and they chose to do nothing."


TRIBE Member
People are quick to decry the government cost cutting, but I somehow doubt that whatever % money/jobs that was cut is even close to whatever % effeciency or effectiveness they cut.