System failure to blame for Walkerton, North Battleford outbreaks, says U of T study

April 29, 2003

A new study by U of T researchers suggests that front-line workers in the tainted water tragedies of Walkerton, Ont., and North Battleford, Sask., were not solely to blame for the outbreaks.

Instead, say the researchers, water contamination resulted from many failures in a complex system involving workers, local governments, regulatory bodies and provincial governments. "There are interactions and relationships across all these levels, and everybody has a role to play," says Kim Vicente, a professor in the Department of Mechanical and Industrial Engineering and co-author of the study. "When you get cracks across those relationships, you get these kinds of systems accidents."

In May 2000, seven residents of Walkerton died after drinking water contaminated with E.coli, and in April 2001, nearly 6,000 people in North Battleford became ill after drinking water contaminated with the Cryptosporidium parvum protozoan.

Vicente is an expert on human factors engineering, which examines technology that can accommodate human capabilities and limitations. He currently holds the Jerome Clarke Hunsaker Distinguished Visiting Professorship at the Massachusetts Institute of Technology in Cambridge, Mass. Along with co-author Dennis Woo, his research assistant, he examined common factors between Walkerton and North Battleford.

The study, which will be published in the June 2003 issue of the journal Reliability Engineering & System Safety, examines the two outbreaks using an analytic system known as the Rasmussen framework. This framework looks at risk management in critical systems such as aviation, health care and drinking water management.

While details of each outbreak differ slightly, Vicente found that they share common factors such as budget reductions at the governmental level and lack of regulatory oversight. "The weaknesses at these government and organizational levels tended to appear in both accidents," he says. "We need to do a better job of understanding how we build those high-level administrative and governmental systems to protect public health because we're not doing as good a job as we need to."

In a multi-layered system such as drinking water distribution, it's critical that information circulates to every level of the hierarchy to maximize co-ordination, Vicente says. The people at each level must be competent and they must have a commitment to public safety and clear guidelines with which to achieve that goal.

Guidelines, however, must be flexible. "You have to give people discretion to make decisions, but you also have to make sure that they're prepared or that they have the training and the knowledge to deal with these things."

At the same time, Vicente says, complex systems demand accountability-at all levels. "It's like an onion, and what happens is that people looking for a scapegoat usually stop at the first layer-at the front-line workers," he says. In almost every case, he explains, moving up the hierarchy reveals additional factors behind such system failures.

The research findings suggest ways that critical systems can alter their structure to improve error detection and reduce accidents and their consequences. "We need to recognize that when we deal with the issue of accountability and, more importantly, when we deal with the issue of design, we need to have in place positive, synchronized relationships so that we protect public health," Vicente says. "Humans are fallible and we have to accept and design for that, rather than expecting people to be perfect."

"We need to focus on managing risk better and designing socio-technical systems that protect, not threaten, public health. This applies to all critical safety systems, not just drinking water," says Vicente. "The problems are only going to get more severe as technological systems become more complex. We should all be concerned about this because these issues can threaten our collective quality of life."
The study was funded by the Jerome Clarke Hunsaker Distinguished Visiting Professorship, the Natural Sciences and Engineering Research Council of Canada and the Premier's Research Excellence Award program.

Kim Vicente
Department of Mechanical and Industrial Engineering (Currently at MIT)

Nicolle Wahl
U of T Public Affairs

University of Toronto

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