Review of Events Associated with the Keefer Regulator Sewer Overflow: August 2006 to May 2008 June 25, 200 Mike Price & Associates Inc.
Table of Contents 1. Introduction...1 1.1 General... 1 1.2 Understanding... 1 1.2.1 Directions from City Manager... 1 1.2.2 Work plan, budget and timeline... 2 2. Methodology...3 2.1 Interviews... 3 2.1.1 Staff Interviewed... 3 3. Preliminary Findings...5 3.1 Timetable of events... 5 3.2 Areas of non-compliance... 11 3.2.1 Compliance with legislation... 11 3.2.2 Compliance with Procedure F-5-5... 11 3.2.3 Operator Certification and the Ottawa Wastewater Collection System... 12 3.2.4 Compliance with MOE District requirements... 14 3.2.5 Compliance with internal procedures... 15 3.3 General findings... 15 4.3.1 Related to the O&M of Keefer regulator... 15 4.3.2 Incident reporting... 18 4.3.3 Addressing risks at the front line... 19 4. Conclusions...20 4.1 Reason for overflow event occurrence... 20 4.2 Reason for event discovery, by some, in the Spring 2007... 20 4.3 Reason for connection with beach postings in 2008... 21 4.4 Areas of non-compliance... 22 4.4.1 The owner or owner s representative,... 22 4.4.2 The front line management,... 23 4.5 Areas for improvement... 23 5. Recommendations...25 5.1 Recommendations... 25 5.2 Next steps... 26 Appendix A...27 SAMPLE BRIEFING NOTE... 27 Lead in the drinking water.... 27 Issue / Background... 27 Key Points... 27 Questions and Answers... 28 Appendix B...29 Incident reporting protocols for field incidents... 29 Level 1 Incident... 29 Level 2 Incident... 29 Level 3 Incident... 29 Appendix C...30 Mike Price & Associates Inc. i
Review of Events Associated with the Keefer Regulator Sewer Overflow: August 2006 to May 2008 Appendix D...31 Mike Price & Associates Inc. ii
1. Introduction 1.1 General The purpose of this study was to undertake a review as directed by the City Manager regarding events surrounding a malfunction of a CSO regulator that allowed sanitary sewage to be discharged into the Ottawa River for a period of approximately 15 days in August 2006. It was anticipated that up to 30 interviews of City staff might be needed and then a report generated for the City Manager. The deliverables in the report would address the following: 1. a timetable of key events in the whole process 2. a timeline of what transpired to cause the incident, and the steps taken afterwards to rectify the situation 3. key notes from every interview 4. my personal observations and conclusions 5. a list of incidents where there was non-compliance with legislation, regulations, by-laws or standard operating procedures 6. a review of implications within and external to the Public Works Department (morale, reputation, lawsuits and charges pending) 7. key recommendations for remedial action, communication and training to mitigate further mishaps 1.2 Understanding 1.2.1 Directions from City Manager Council has directed the City Manager to conduct a thorough review of the August 2006 sewer overflow at the Keefer regulator and report back to Committee and Council. The City Manager anticipated bringing a staff report forward for consideration by the Planning and Environment Committee and Council in July and August of 2008. Specifically the review was to: Read all readily available and relevant information relating to the event in August 2006 and subsequent events up to and including May 2008 are to be reviewed. Interview staff associated with the events between August 2006 and May 2008. Identify recommendations for consideration and/or implementation to prevent a reoccurrence of the incident. Prepare a draft report that is to be completed by Friday June 20 th 2008 and discussed with senior staff. Deliver the Final report on or before June 27, 2008. Mike Price & Associates Inc. 1
1.2.2 Work plan, budget and timeline I arrived in Ottawa on Sunday June 8 th 2008 and, after being briefed by the City Manager and Deputy City Manager of Public Works & Services on Monday June 9 th 2008, prepared the following work plan and timeline document which was submitted to Steve Box in the City Manager s Office later that day. The list of people to interview was reviewed and set at around 20. Given the number of interviews the following plan was identified. Phase Function Estimated Number of Days I. Planning Develop and confirm work plan Meet and be briefed by key senior management June 9, 2008 1 II. III. IV Interviews of Staff Plan the questions and arrange for interviews List all the required reference data Carry out interviews personally Analysis of Operating Protocols and Procedures Material being requested of interviewees Review material for inconsistencies Draw conclusions and draft recommendations Identify gaps and non-compliance Background Research Review possible legislation that impacts on CSO s Identify any areas for improvement 3 1 1 V. Interim Report Prepare draft interim report due before June 20 th Verbally present findings to City Manager and/or Deputy City Manager on or before June 13 th 1 VI. Final Report/Presentation Final report due on or before June 27 th To retain all notes from interviews 1 Total Number of days 8 Mike Price & Associates Inc. 2
2. Methodology 2.1 Interviews Material that was supplied by the Director of WSB was extremely useful in determining the job functions of the various members of staff and what their roles may or may not have been in the incident. This material and copies of e-mails, memos and reports provided the background for me to generate a list of questions for each interviewee. 2.1.1 Staff Interviewed Aaron Burry Director Parks and Recreation Gerald Taylor Supervisor Sewer Inspections, WSD Luc Dugal Section Manager Sewer maintenance Barrie King Program Manager Waste Water Collection Dave McCartney Manager Wastewater and Drainage Services Felice Petti Manager Strategic & Environmental Services Dixon Weir Director Water & Wastewater Services Branch Curtis Rampersad Program Manager Infrastructure Assessment, Water Resources Eric Tousignant Senior Engineer Water Resources Louis Julien Senior Engineer Water Resources Krista Kreling Analyst Environmental Health, Public Health Wayne Newell Director Infrastructure Services Jean-Guy Albert Program Manager Inspections, Public Health Dr David Salisbury Former MOH Public Health Richard Hewitt DCM Public Works & Services Alain Gonthier Manager Infrastructure Management Isra Levy Acting MOH Public Health Ken Brothers Former Director PW&S Chris Melanson Operator level II Sewer Inspections Steve Burns District Manager MOE Ottawa Office Mike Price & Associates Inc. 3
Where requested by an employee, staff from Labour Relations, the Union or the Association was in attendance. Steve Burns of the Ministry of Environment had Investigator Clint King from the MOE-EIB in the room with him during the conference call. Mike Price & Associates Inc. 4
3. Preliminary Findings 3.1 Timetable of events Date EVENT COMMENTS July 31 st 2006 August 1 st 2006 Early August 2006 After August 4 th or 5 th Aug 15 th 2006 Rainfall event started Keefer Regulator activated automatically to allow overflows of combined sewage into Ottawa River via John Street overflow pipe. Regulator failed to return to pre-storm condition allowing flows to continue overflowing into River and not passing through the Sewage Treatment Plant. Impacts of storm passed by but the drop pipe outlet remains completely plugged with debris. Gate is stuck in closed position. Raw sanitary sewage is now passing through the overflow directly into the river. Staff technician in WSB was routinely downloading flow data remotely from the John Street overflow pipe in question. Noticed an anomaly and went to the site to verify that there was flow in the pipe even though there was no recent rain event. Normal occurrence in heavy rainfall. System was designed to operate this way. Blockage of a regulator or the outflow pipe due to debris is not uncommon. At this point the flow is not a CSO but an overflow of sanitary sewage (SSO) and reportable to MOE as a spill. Pre-amalgamation this regulator was maintained by the Region and it had monitors and alarms directed to an on-call supervisor s pager. Post-amalgamation the alarm system was no longer available. Pre-amalgamation Region staff would routinely check the key regulators after a major storm event. Post amalgamation the staff shortage meant no post storm checks were routinely carried out Contacted his Supervisor in operations and cc d three other Supervisors by e-mail at 2.27pm on August 15 th and advised that there was flow in the overflow pipe even though no rainfall. Operations supervisor dispatched a crew to the site who used high Mike Price & Associates Inc. 5
Mid- August 2006 Nov 7 th 2006 Ottawa Public Health recorded very elevated E. coli counts at the Petrie Island Beach and posted the beach as unsafe for swimming throughout the period that the spill was occurring. They did not know why the counts remained so high after the rainfall event had long passed. The matter generated considerable media attention. At meeting with MOE staff they request that Ottawa start reporting annually on the CSO overflows. pressure water hose to clear debris. Gate returned to normal position and bypass of raw sanitary sewage ceased. Crew returned to yard after end of day shift and filed the completed work order. The field staff and especially their Supervisor failed to comprehend the magnitude of the event and to differentiate between a normal overflow during a storm event and an extended sanitary spill in dry weather. The event should have been reported to MOE spills action centre at this point in time. The total overflow event lasted approximately 15 days and the SSO flow rate was estimated to be 50,000 cubic metres per day. The sewer-shed is very large and this sanitary sewage flow might have been between 5% and 10% of the normal dry weather flow at the sewage treatment plant. No-one had connected the beach postings to the continuing spill. The MOE had issued letters to all municipalities on April 26 th 2006 asking for reporting regarding compliance with F-5-5. MOE first started request to Region in 1996. Letter to Manager WSB on May 18 th 2006 asking for data on certain events. Meeting with Ottawa staff June 27 th 2006 where data on CSO flows requested. Mike Price & Associates Inc. 6
Mid-March 2007 April 23 rd 2007 (3pm) April 25 th 2007 May 1 st 2007 May 2 nd 2007 May 16 th 2007 May 23 rd 2007 Senior Engineer in ISB is preparing data to go in the first annual CSO report to the MOE. He is reviewing data from 2006 and sees a discrepancy between a modeled overflow of a few hours and real overflow of hundreds of hours in duration. He contacts Operations and receives confirmation of closed regulator that was cleared on Aug 15 th 2006. Time coincides with end of flows. He contacts the WSB Manager and his ISB Program Manager by e-mail and advises them of the issue and that he mentioned this event to MOE staff during a discussion on another matter. Advised MOE that the whole event would be documented in the upcoming 2006 annual report on CSOs. He sends draft CSO report/letter to WSB Manager for his review and transmittal to MOE. He supplies the estimated magnitude of the overflow and numerous other relevant details to his ISB Program Manager and the WSB Manager. WSB Manager directed his Program Manager by e-mail to prepare a report to MOE describing the event in 2006. This would be done independently of the CSO report. Letter is sent to Bryan Dickman of MOE regarding the malfunction of the Keefer regulator. Stated in letter that incident never formally reported to MOE. Copied only to Manager WSB and the Senior Engineer ISB. First Annual Report on CSOs for 2006 is issued to MOE. MOE District Manager is given brief overview of conversation between his engineer and the Ottawa engineer regarding the gate being stuck in early August 2006. In the e-mail dated May 01, 2007 the Engineer clearly states to the Manager WSB and his Program Manager in ISB that this incident was never officially reported to MOE Letter is sent to MOE with very limited circulation internally within the City. Given the magnitude of the spill, plus the fact that the ISB Engineer was unable to substantiate that the spill had ever been reported to MOE, the issue should have been elevated to the Director and the DCM. Staff could not provide any clear direction, or protocol, for issues management within the Department. Mike Price & Associates Inc. 7
Mid- February 2008 April 2 nd 2008 April 3 rd 2008 Senior Engineer in ISB is preparing Part B of Report on Combined Sewer Area Pollution Prevention and Control Plans. Wanted to see if there was any correlation between beach postings and CSOs. Obtained data from PH and found correlation not only for CSO events, but for the August 2006 SSO event. He also mentions this connection in casual conversation to fellow employee who is a member of the Fallingbrook Community Association, which encompasses Petrie Island beach. Senior Engineer reads about PH report on beaches in the press. Calls PH analyst to explain his findings regarding the possible correlation to overflows and even the SSO event. He advises his supervisor in ISB. He sends e-mail to PH. Director of WW is cc d on an e-mail from the Senior Engineer to the WSB management staff and indirectly made aware of link between overflows and beach postings. Manager WSB told his Program Manager to add PH to the Spills reporting protocol. MOH and Director of WW are at Committee during the discussion on the PH 2007 beach report. He advised his program manager of the connection. This information never moved anywhere else in the organization. The connection between spill and beach postings is mentioned in public meeting of Fallingbrook Community Association on March 25 th 2008. Minutes were distributed on April 19 th 2008. PH analyst advises her Program Manager immediately. He immediately writes an e-mail to the MOH explaining the possible connection of spill to Petrie Island beach postings. The information was never circulated within the PW&S Department and never reached the DCM level. At this point both have been e- mailed the very preliminary information their respective staff have, regarding the possible connection between overflows and beach postings at Petrie Island. Mike Price & Associates Inc. 8
April 23 rd 2008 May 5 th 2008 May 7 th 2008 May 13 th 2008 May 15 th 2008 May 20 th 2008 May 20 th 2008 PH report on beaches 2007 went to Council. Manager WSB advises verbally the Manager SES of connection between the beach postings and SSO event. Manager WSB takes local politicians on tour of ROPEC. Mentions the likely connection between regulator gate malfunction and the Petrie Island beach postings. DCM first becomes aware of whole issue while his Director WSB was heading to a meeting with East End Councillors regarding Petrie Island beach. Intent of meeting was to brief Clrs and prepare for press conference and timing of the release of the information. Director WSB receives more detailed information from ISB staff regarding possible correlation of beach postings to regulator malfunction. Local politician holds press conference to announce that the beach postings in August 2006 were now explainable. DCM issues statement to Council to explain event in 2006 and mentions it was reported to MOE at that time. MOH announces his departure from City of Ottawa right after the Council meeting. Staff of Parks & Recreation is present at the tour and this is first time P&R are made aware of any of the events. Staff person calls Director of P&R immediately. DCM asks Director WSB for more information and is briefed over following week as information becomes available. Based on discussion between the Manager WSB and the responsible Supervisor the assumption was that the incident had been reported. (The Senior Engineer in ISB, back on May 1 st 2007, had advised this WSB Manager by e- mail that he could not substantiate any reporting to MOE.) Mike Price & Associates Inc. 9
May 22 nd 2008 May 27 th 2008 May 28 th 2008 DCM issues sequence of events memo to Council regarding the event and still assumes spill had been reported to MOE. DCM issues new statement to Council retracting the mention of reporting the spill to MOE when it occurred in August 2006. Key Supervisor terminated as a result of internal review. Director WSB still believed staff had reported incident to MOE in 2006. The key Supervisor, during an interview with Director WSB on May 26 th, retracted his statement regarding reporting the August 2006 event to the MOE - SAC. Assignment of ORO designation to staff person holding Level IV Certification. Mike Price & Associates Inc. 10
3.2 Areas of non-compliance 3.2.1 Compliance with legislation There are numerous pieces of legislation that apply to the Public Works and Services Department. Specifically governing the actions of the Corporation and staff associated with the regulator incident the following appear to have some relevance. 1. Ontario Water Resources Act. Regulates water pollution, approvals of sewage facilities, licensing of sewage works operators. 2. Safe Drinking Water Act. Accreditation of the operating authority, QMS standards. 3. Environmental Protection Act. Part X, Regulation of spills. 4. Lakes and Rivers Improvement Act. Discharge of contaminant into rivers. 5. Federal Fisheries Act. Discharge of deleterious substance into water frequented by fish. 6. Ontario Conservation Authorities Act. Similar requirements to Federal Fisheries Act. 7. Canadian Environmental Protection Act. Report releases of contaminants to water. 8. Corporate due diligence and exercising all reasonable care by establishing a proper system and taking reasonable steps to ensure effective operation of the system. 9. MOE policy document for controlling CSO s known as procedure F-5-5 3.2.2 Compliance with Procedure F-5-5 Procedure F-5-5 is a supporting document for Guideline F-5, Levels of Treatment for Municipal and Private Sewage Treatment Works Discharging to Surface Waters. The Procedure applies to sewage treatment works with combined sewer systems such as in Ottawa. (A combined system is a wastewater collection system which conveys sanitary sewage and storm water runoff in a single pipe, called a combined sewer, to a sewage treatment plant.) There are three goals of Procedure F-5-5: a. Eliminate the occurrence of dry weather overflows b. Minimize the potential for impacts on human health and aquatic life resulting from Combined Sewer Overflows (CSO) c. Achieve as a minimum, compliance with body contact recreational water quality objectives (Provincial Water Quality Objectives, PWQO) for Escherichia coli (E. coli) at beaches impacted by CSOs for at least 95% of the four-month period (June 1 to September 30) for an average year. The requirement governing Ottawa s wastewater collection system requires that, Mike Price & Associates Inc. 11
1. during a seven month period commencing within 15 days of April 1st, capture and treat for an average year all the dry weather flow plus 90% of the volume resulting from wet weather that is above the dry weather flow, 2. compliance with body contact recreational water quality objectives at beaches impacted by CSOs for at least 95% of the four-month period (June 1 to September 30) for an average year and, most importantly, 3. eliminate the occurrence of dry weather overflows (this occurred as a result of the gate malfunction) This procedure applies to CSO events however, once the regulator malfunctioned the flow would be considered a spill of sanitary sewage and is reportable to the MOE Spills Action Centre immediately upon discovery. This was not done. 3.2.3 Operator Certification and the Ottawa Wastewater Collection System The operator certification program became a mandatory program in 1994 with the coming into effect of O. Reg. 435/93, made under the Ontario Water Resources Act. Drinking and wastewater operators have been governed under O. Reg. 435/93 until the coming into effect of O. Reg. 129/04 on August 1, 2004. Thus since August 2004, and during the events under review, the City has needed to be in conformity with Ontario Regulation 129/04. 3.2.3.1 Owners responsibility Owners have been assigned specific responsibilities under O. Reg. 129/04 as listed below. Responsibilities File an application for facility classification or reclassification Ensure the certificate of facility classification is displayed in workplace Ensure that every operator who directs work on the facility holds a licence applicable to that facility, or a conditional licence Ensure that a copy of the licence of every operator in their employ is displayed at the workplace of the operator, or if this is not practical, then at the premises from which the workplace is managed Designate an overall responsible operator (ORO); notify Director if relying on section 15 (2) ( back-up ORO) for 60 days in any 12 month period Designate one or more operators as operators-in-charge (OIC) Ensure that records are maintained of the amount of time each operator works as an operator-in-charge Ensure that logs or other record-keeping mechanisms are provided to record information concerning the operation of the facility; authorize persons to make entries in log or other record keeping mechanism Ensure that logs and other record-keeping methods are accessible in the facility for at least 2 years after each entry in it is made Mike Price & Associates Inc. 12
Ensure that operators and maintenance personnel have ready access to operations and maintenance manuals that contain plans, drawings, and process descriptions sufficient for the safe and efficient operation of the facility Ensure that the manuals are reviewed and updated at least once every two years Ensure that every operator employed in their facility is given 40 hours of training each year Keep records of the training operators receive, containing specific information, and submit copies of summaries to the Director when requested to do so. There is a requirement to have a Licensed Operator designated as the overall responsible operator (ORO) as well as the shift operator in charge (OIC) for Wastewater Collection Systems. There has been no written record given, regarding the assignment an ORO to the operational supervisors or the wastewater collection and drainage staff since amalgamation. The Supervisors assumed that the Program Manager was the ORO. The Program Manager is a P Eng, registered in BC, has an operator license of a level below that of the system, and as such he cannot be the permanent ORO. (A Professional Engineers, accredited in Ontario, would not have to meet the experience qualifications if they obtain an 85% pass on the exam for a level IV operator.) The Program Manager stated that the shift schedule was the designation vehicle and the senior official (supervisor) on call was the OIC. This shift schedule has been in place since 2002. None of the material produced for me identifies who was holding what designation at the time of the incident. 3.2.3.2 Classification of the wastewater collection system Sewage works are to be operated by persons holding a valid operator s licence of the same type as the type of facility. At least one operator must hold a licence of the same class or a higher class than the class of the facility. Thus a first step in deciding what certificate an operator should hold is to have the facility classified. Sewage works are divided into two types of facilities in the Regulation 129/04, the first is a wastewater collection facility. A wastewater collection facility means a sewage works that collects or transmits sewage but does not treat or dispose of sewage. Based on the classification of the system an operator designated must hold the required certification. I was advised that Ottawa is a Level IV system and therefore a Level IV operator has to be designated. Since amalgamation it is not clear whether anyone has been officially designated and clearly told that they are the overall responsible operator of the collection system. On May 28 th 2008 the only Level IV supervisor in the wastewater unit was verbally advised by the Division Manager that he was now considered the ORO. Mike Price & Associates Inc. 13
3.2.3.3 Record keeping for operation of system The operator-in-charge or a person authorized by the operator-in-charge must record the following information on each operating shift: the date, the time of day the shift began and ended, and the number or designation of the shift names of all operators on duty during the shift any departures from normal operating procedures that occurred during the shift, and the time they occurred any special instructions that were given during the shift to depart from normal operating procedures, and the person who gave the instructions any unusual or abnormal conditions that were observed in the facility during the shift, any action that was taken and any conclusions that were drawn from the observations; and any equipment that was taken out of service or ceased to operate during the shift, and any action taken to maintain or repair equipment during the shift. The owner must ensure that all logs and other record-keeping methods are accessible at the facility for at least two years after each entry in it was made. Nobody interviewed supplied me with any hand written documentation. Only copies of electronic e-mails or completion notes on the City s Work Order system appear to be the records kept. 3.2.4 Compliance with MOE District requirements Staff at the Manger level and below was unaware of exactly when the Ministry of Environment District staff had requested reporting on CSOs into the overflow pipes and thus the Ottawa River. The staff thought that, at a November 2006 meeting, MOE first requested an annual report on the CSOs be supplied to them. The MOE District Manager stated that the first written requests for CSO data started with the Region back in 1996. On April 27 th 2006 a letter went from the Ministry to all Ontario municipalities stating that they wanted storm event combined sewer overflows to be brought into compliance with procedure F-5-5. On May 18 th 2006 a letter from the MOE was sent to the Manager of WSB requesting field data on certain CSO events At a meeting on June 27 th 2006 the MOE staff requested data on all CSOs and STP by-passes.. They were suggesting, volume, duration, location and wastewater characteristics (BOD, TSS, e- coli) for each event and each location, which would have been onerous to say the least. They agreed to accept a report based on modelling and flow simulation rather than 100% field measurements. The letter of May 16 th 2007 from the Program Manager to the MOE engineer regarding the regulator malfunction did not refer to the event other than overflow. The event was considered Mike Price & Associates Inc. 14
by MOE staff to be a spill of sanitary sewage and complete disclosure and reporting was required as soon as it was discovered. This was not fully complied with. The May 23 rd 2007 report submitted by Ottawa, for CSO overflows for the year 2006, was received by the MOE on May 25 th 2007. The MOE inspects the Ottawa sewage treatment plant annually but has not yet started inspections on any municipal sewage collection systems. The municipality is responsible for compliance with all regulations. They feel the City of Ottawa is moving towards compliance with Procedure F-5-5 through its Real Time Control Plan and the Pollution Control Plan. 3.2.5 Compliance with internal procedures Operations staff has internal procedures that identify who is to be contacted in the event of a spill into the environment. The internal procedures have not been incorporated into a City of Ottawa Standard Operating Procedure. While internal procedures have not been harmonized since amalgamation, they do exist in some form or another. Yet, the internal procedures were not followed in a comprehensive manner, as nobody contacted anyone outside their own immediate unit or Division. 3.3 General findings Numerous non-regulatory issues were discovered during the interviews. They have been grouped into various categories and known best practices identified where applicable. 3.3.1 Related to the O&M of Keefer regulator 3.3.1.1 Alarms Pre-amalgamation, the regulator, known as the Keefer regulator, was operated and maintained by the Region of Ottawa-Carleton. As designed, it was equipped with monitors and alarms that would register with the pager of the on-call operator. While the system was cumbersome it worked and the operators knew when the gate was moving. However, the alarms would go off numerous times as the flows fluctuated during the storm. Post amalgamation, when the regional staff combined with the new City of Ottawa organization the monitors and alarms were not operating. Initially at amalgamation the Operations staff was combined first and Maintenance staff of the Region sometime later. When staff from the Regional Maintenance was combined with the Ottawa staff, the alarm pagers were not working. As a result they were not available in August 2006 and no alarm was raised. Nobody can adequately explain the reason for the alarm discontinuance. Post event in 2008, the staff is planning to quickly install flow monitors and alarms in the overflow pipes to detect flow should the regulator malfunction again. This is an appropriate best practice. Mike Price & Associates Inc. 15
3.3.1.2 Post storm inspections Pre-amalgamation the regulators were routinely checked after major storm events as it was not uncommon to have debris partially blocking the gate. However the chamber is deep and requires 4 members on the work crew due to the requirement for Confined Space Entry safety procedures. Post amalgamation the staff shortage in the wastewater O&M section led the front line managers to eliminate this level of service. Consequently the jammed gate was not detected as quickly as it might have been pre-amalgamation even without the alarms. The front line management staff allocating the severely limited resources post amalgamation was not addressing risk as part of their decision making process. The risks to the corporation need to be factored into decisions that are made around service level cuts. Thus cutting back on debris clearing activities at storm inlets may have contributed to the debris that blocked the regulator gate. 3.3.1.3 Regular maintenance inspections The regular maintenance inspection pre-amalgamation was done once per month and after significant rainfall events. The maintenance is still done monthly but had been reduced to what the program Manager considers a minimum as the regulators will be replaced when the Real Time Control project (RTC) is put into effect in approximately 18 months. The regular maintenance work was usually done the last week of the month. It is likely the spill event would have gone on until the end of August without the intervention by the staff person downloading flow data from a monitor. The need for an adequate and regular inspection would have been identified at the time of the design of the regulator and should have been incorporated into the manuals and SOP s needed by the maintenance staff. The lack of current SOPs for the regulator is now clearly an urgent matter as the newly assigned ORO (as of May 28 th 2008) did not operate the regional collection system pre-amalgamation and is in need of clear and concise O&M procedures. Now that the regulator maintenance has been reduced to a minimum the risk of other mechanical malfunctions, such as chain breakage and rust friction on the float mechanism, has risen. This needs to be addressed as to whether it is an acceptable risk. 3.3.1.4 Knowledge of regulator purpose and design The O&M for the regulators was supervised by the same person who looked after them in the Region. I was unable to interview him as he was terminated at the end of May. However I do have notes from his interview with the Division Director. Over the course of his 35 year career with the Region and City he only recalls 10 similar events when the gate was stuck. The current Program Manager has no idea what the regulator is designed to do, nor why it is needed. The owner is required to ensure that operators and maintenance personnel have ready access to comprehensive operations and maintenance manuals that contain the plans, drawings and process descriptions necessary for the safe and efficient operation of the facility. Mike Price & Associates Inc. 16
There was no indication of SOP s or manuals being available to any staff interviewed relating to the Keefer regulator. It was felt that the former supervisor knew what the regulator was designed to do and that any flow in the overflow pipe after the storm event had passed had to be sanitary sewage and therefore reportable by him to the MOE as a spill of SSO. I am not sure anyone else charged with the day to day operation of the collection system truly understands the exact role of the regulator and therefore when conditions change from CSO to SSO. Several people saw the volumes reported in the year 2007, identified as an overflow in August 2006, and compared to volumes of CSO were not surprised at the total volume. What is disconcerting is that several front line staff did not initially recognise this as an SSO event and therefore a spill. The crew dispatched to the regulator, when the flow was detected in the overflow pipe, went out on an inspection Work Order. They had to use high pressure hoses to clear the debris blocking the gate. They do not keep any logs or diaries but record the work done on the Work Order form and file it upon their return. Similarly the Supervisors do not keep records, diaries or log-books. They rely extensively on e-mails and the check-off boxes on the Work orders. The record of the stuck gate was not clearly flagged for the Supervisor to read the next day. He failed to note the magnitude of the malfunction and no communication was undertaken with anyone else. 3.3.1.5 Flow monitoring downstream There is a flow monitor downstream of the Keefer regulator that records depth of flow against time, in the overflow pipe. It is one of the more reliable monitors and uses ultra-sound to measure depth. Occasionally the data would be spiked or erratic and needed to be verified before entering into the City s database. The Technician started in his role as a monitoring operator with the Region in Dec 1998, just prior to amalgamation. The depth of flow and time data from this monitor is usually downloaded remotely and the data entered into the Department s database for future analysis. This data is used to calculate the volume of CSO flow by-passing the sewage treatment plant and going directly into the river. The technician, who was downloading the data remotely, saw that two weeks after the storm event there was some flow in the overflow pipe. He was concerned that his computer was reading erroneously so visited the site to verify flow. If he had backed up the depth of flow and time data for many days he might have been able to surmise the flow had been constant for two weeks. He had no need to do this at that time for his assigned work and did not think to analyse why or how long the regulator had been malfunctioning. By going to the site and seeing and hearing flow he would not know volumes. The monitor would show depth and he would only have assumed an issue with the gate at that point in time. When he had verified flow he advised his direct supervisor then later sent an e-mail to the key supervisor responsible for the regulator plus cc d his supervisor and the third supervisor in the wastewater collection section advising them of flow and that there must be a problem with the regulator gate that needs rectifying. He heard back from his supervisor a short while later that the regulator had been returned to normal working condition. When he worked for the Region the monitors were alarmed to the supervisor pagers. They did not function well and often hundreds of events were going to the pagers at all hours of the day Mike Price & Associates Inc. 17
and night. He recalls he learnt that the alarms and pager system were not operational from his supervisor, sometime in 02/03. This level II operator keeps a record of key incidents in a personal diary. He is not aware of any direction or requirement for staff to keep log-books or diaries. 3.3.2 Incident reporting 3.3.2.1 Field crews and front line supervisors It appears that the crews and especially the front line supervisors (the OICs) are not using diaries or log-books to record key events. There is too much reliance on Work Order form checking plus e-mails. Both of which can be easily lost. The inter-office e-mail traffic is increasing to the point where many are considered junk and never read. For some the e-mail is considered as the CYA vehicle. Whether it is read and digested is immaterial as the sender can say I told you. As stated earlier this is not in conformance with Ont. Reg. 129/04. 3.3.2.2 Issue briefing notes There appears to be a lack of any formal internal process that informs all staff when and how to advise senior management on critical issues. There does appear to be some form of no surprises protocol that starts at the Manager level and goes up to the DCM level but this protocol is not widely known or used. If a written document did exist then staff training could have been focussed on internal communication skills. Briefing notes on items would be useful to senior management on issues coming before Council, on issues that may become a risk to the Corporation and on incidents that may become media items. An example would have been the determination of correlation between the SSO event and the beach postings. A briefing note to the Director would have assisted when dealing with the PH report at Committee (and Council) as well as when meeting with the local Councillors regarding the Petrie Island Beach postings. The Director of the Section, back in August 2006, was similarly totally unaware of any incident related to the regulator malfunction. The key information was held below the Director level and within two branches of the Department. A sample of an internal Briefing Note (Related to drinking water) is attached as Appendix A 3.3.2.3 Incident reporting protocols There has been a lack of awareness of the need to advise or report within the Department. While staff is relied upon to deal with most situations there is a requirement that senior management be advised of key issues or critical incidents. There is a No surprises protocol in Public Works and Services that only exists at the Manager, Director and DCM level, but nobody below this level is aware of it. Often there are risks to the Corporation or information known only by senior staff that can impact the situation but if they are not advised, they cannot take action. Mike Price & Associates Inc. 18
For field staff this incident reporting is even more important and some guidance is required to explain who needs to tell whom and under what conditions. If all the front line staff and supervisors had informed the senior staff at key stages in this event then the situation would not have got out of hand and put the Corporation at legislative, financial and reputation risk. A sample incident reporting protocol is attached as Appendix B. 3.3.2.4 Communications within the Department There did not appear to be a clear communication protocol in place in 2006 for internal communications within the various divisions and departments. There is a need to move the right information up, down and across the organisation to the correct person(s). Thus when reporting incidents to another Department, such as from PW&S to PH, it needs to be determined, at what level in the organisation ( or to which person) does the information go initially and ensure that the information will be distributed to the correct people who need to know in order to take action. Similarly for serious incidents, the reporting should be person to person live and not through any electronic messaging. Thus when information of an important nature has to be relayed late on a Friday evening, and acted upon immediately, it must go into a Department to the correct person and be moved throughout that unit to all the necessary people. Clear lines of communication need to be identified and incorporated into the department s revised protocols and Standard Operating Procedures. The Spills Event Protocol is the prime example that needs updating. 3.3.3 Addressing risks at the front line Typically, as a result of amalgamation of many small municipal public works functions there is imbalance of staff in the new structure. While the small municipalities had staff multi-tasking, the larger ones, like the Region, had dedicated staff. The Transportation function tends to get the resources it needs as first priority. As a consequence, the sewer O&M unit ends up with insufficient staff for the required level of service expected. Compound the problem by the wish to cut staff in the early years and you have a high risk of something going wrong. The sewer maintenance section found itself in this predicament. At amalgamation, (2000), they lost 18 FTE s. Then in 2002 they were directed to cut 15 FTE s (17 actually went) and had to make some serious cuts in levels of service supplied in order to manage with the 26 field staff remaining from pre-amalgamation to post amalgamation. These cuts were made in their best judgement but did not address risks and consequences. The Manager was advised by the Program Manager of the cuts by a copy of a memo dated March 26 th 2003. One area that is very labour intensive is grille cleaning of debris. If the grilles and bar screens are not cleaned there is risk of flooding at the storm inlet. Also, debris gets swept into the sewer system causing problems elsewhere and possibly at the regulators in the combined sewer area. Ideally the WSB should initiate some form of Risk Management Model that can be easily understood and used by the Wastewater staff. A conceptual outline is attached as Appendix C. Mike Price & Associates Inc. 19
4. Conclusions 4.1 Reason for overflow event occurrence The overflow of sanitary sewage into the Ottawa River for +/- 15 days, as a result of the Keefer regulator malfunction, occurred physically due to debris clogging the regulator outlet and preventing the gate from operating as designed and returning to its normal operating position. The change from a CSO to a SSO event went unnoticed for two weeks due to a number of checks and balances NOT being in place. Many of these did exist pre-amalgamation when the Region was responsible for the regulator. They are listed below. 1. The field crew did not flag the malfunction as a major incident or even spill for their Supervisor. 2. The Supervisor failed to note the completed Work Order as a spill event and therefore a reportable incident. 3. There was no designated ORO or OIC (or back-up) at time of the event. 4. The spills protocol had not been updated to reflect the new City organization. 5. The alarm system on the overflow pipe flow monitor was inoperable. 6. No SOP s or manuals for the maintenance of the regulators. 7. Below minimal FTE s assigned to sewer maintenance activities with resulting reduced levels of service and higher risks. 8. The field staff did not have an SOP for an inspection of the regulator after a major storm event. 9. The monthly maintenance on the regulator and its mechanical parts was down to an absolute minimum due to its pending replacement in 18 months. 10. There was no internal incident protocol to require reporting vertically up the staff levels within the Department. 4.2 Reason for event discovery, by some, in the Spring 2007 In the Spring of 2007 staff were preparing the first annual report for the MOE on the volumes of Combined Sewer Overflow s for 2006 when it was noticed that the CSO event of early August continued well beyond the end of the rainstorm. The volume of total flow was estimated and only made available to a limited number of staff. Those copied on the May CSO report were the same ones directly involved with the findings, namely the Manager WSB, and Senior Engineer in ISB. The overflow event was reported to the MOE at the same time as the CSO report was sent in May 2007. At this time there was no connection made between the SSO event and the high bacteria count, with resultant beach postings, at Petrie Island Beach. Mike Price & Associates Inc. 20
Given the magnitude and duration of the SSO there should have been a wider circulation of the CSO report and SSO letter that went to the MOE in May 2007. Possibly the connection to the beach postings would have been made a year earlier than it was and saved Ottawa Public Health Department the resource allocation, time and money spent on the beach pollution investigations. The lack of circulation was not done deliberately to hide the data, especially as it was given to the MOE and is therefore considered in the public domain. The reason is more due to lack of clear reporting protocols which can be summarised as follows. 1. Lack of clear and written internal departmental incident reporting protocols for field staff. 2. Lack of well documented need to know procedures, such as briefing notes, for internal communication. 3. Lack of any clear communication protocols to advise other Departments of appropriate events. 4. Staff think functionally in silos and only concerned with events that directly impact them or their work. 5. Staff still working and thinking along lines of communication based on their former municipality prior to amalgamation. 6. Staff have not been trained in legislation compliance procedures nor clearly told their authorities and responsibilities regarding any and all legislation impacting their work. 7. No clear and written reminders to professional and MOE certified staff that they are accountable for their actions, or lack of action, under pertinent legislation. 8. Nobody responsible departmentally for quality assurance in regard to compliance with current legislation associated with the O&M of the complete wastewater collection system. 4.3 Reason for connection with beach postings in 2008 In the Spring of 2008 the Public Health Department prepared a report to Committee on the Petrie Island beach postings and the results of their investigations into the cause of the high bacteria counts in 2006. At the same time Public Works staff was trying to model a connection between CSO events and beach postings. They did see a correlation with the CSOs and also felt there was an extremely good correlation between the very high bacteria counts at Petrie Island beach and the regulator malfunction in August 2006. As a result of the information from the PH report appearing in the newspapers staff from Public Works realised that the connection had not been communicated to those who really needed to know. At this time a staff person in Public Works contacted a staff person in Public Health with the pertinent information. The same conclusion regarding communication protocols applies here as for the section above. (a) Lack of clear and written internal departmental incident reporting protocols for staff. Mike Price & Associates Inc. 21
(b) Lack of well documented need to know procedures, such as briefing notes, for internal communication. (c) Lack of any clear communication protocols to advise other Departments of appropriate events. (d) Lack of regular meetings with staff in other Departments who have similar issues or work in common areas. (e) Staff aligned functionally in silos and only concerned with events that directly impact them or their work. (f) Staff have not been trained in legislation compliance procedures nor clearly told their authorities and responsibilities regarding any and all legislation impacting their work. (g) No clear and written reminders to professional and MOE certified staff that they are accountable for their actions, or lack of action, under pertinent legislation. 4.4 Areas of non-compliance While many pieces of Ontario legislation apply to the Ottawa wastewater collection system the following are the key areas where the Corporation as the Owner or the staff as the operator failed to meet their responsibilities. 4.4.1 The owner or owner s representative, 1. Did not ensure the certificate of facility classification for the collection system was clearly displayed in the workplace 2. Did not ensure that every operator dealing with the regulator (a Class IV facility) holds a licence applicable to that facility, or a conditional licence 3. Did not clearly designate an overall responsible operator (ORO) 4. Did not clearly designate one or more operators as operators-in-charge (OIC) 5. Did not ensure that records are maintained of the amount of time each operator works as an operator-in-charge 6. Did not ensure that logs or other record-keeping mechanisms are provided to record information concerning the operation of the regulator; authorize persons to make entries in log or other record keeping mechanism 7. Did not ensure that logs and other record-keeping methods are accessible in the facility for at least 2 years after each entry in it is made 8. Did not ensure that operators and maintenance personnel have ready access to operations and maintenance manuals that contain plans, drawings, and process descriptions sufficient for the safe and efficient operation of the facility 9. Did not ensure that the manuals are reviewed and updated at least once every two years 10. Did not ensure in 2006 (at time of event) that every operator employed in their facility is given 40 hours of training each year 11. Did not, in 2006, keep records of the training that the operators receive. Mike Price & Associates Inc. 22