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Title: The Dark side: Critical Cases on the Downside of Business

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The story behind the water in
Walkerton, Ontario
Elizabeth A. McLeod and Jean Helms Mills

In May 2000, seven people lost their lives and over 2,300 became ill after drinking water
contaminated with Escherictiia coli Oi57:H7 and Campylobacter jejuni bacteria from
manure spread on a farm near Well 5 in Walkerton, Ontario. Schools, daycare centres
and businesses were shut down. The sports arena was converted Into a depot where
volunteers handed out bottled water and bleach, which It was necessary for them to
add to the water in Walkerton before using It to wash their hands. Helicopters flew
overhead transporting sick patients in air ambulances from local hospitals to a special-
ized hospital in London, Ontario.
Justice Dennis O'Connor concluded: "The most serious case of water contamina-
tion in Canadian history could have been prevented by proper chlorinatlon of drink-
ing water, according to a judicial inquiry report about Walkerton, Ontario's fatal £. coli
outbreak". His report also "points to the region's public utilities managers and Ontario
government cutbacks as contributors to the tragedy".
The pedagogical note presents options for discussing the case in the classroom.
Accompanying the case are questions and answers, and links to audlos and videos
available online which Include Interviews with:

Stan Koebel, manager of the Public Utility Commission (PUC) at the time of
the tragedy in May 2000
Frank Koebel, water foreman
Dr Murray McQuigge, Medical Officer of Health for the Grey Bruce region of
Ontario
180 THE DARK SIDE: CRITICAL CASES ON THE DOWNSIDE OF BUSINESS

Subject area
T o i l l u s t r a t e a n d p r o v o k e d i s c u s s i o n a b o u t t o p i c s taught i n u n d e r g r a d u a t e o r
M B A management courses, including organizational behaviour, organizational
theory, and business ethics.

Key issues
• To teach critical thinking skills

• To enhance problem-solving skills

• T o d e m o n s t r a t e t h e a p p l i c a b i l i t y of m a n a g e m e n t c o n c e p t s , s u c h as
decision-making, power, politics, communications, organizational cul-
t u r e a n d s t r u c t u r e t o a i d o u r u n d e r s t a n d i n g of h o w o r g a n i z a t i o n a l dis-
asters o c c u r

• T o m a k e s t u d e n t s a w a r e of t h e link b e t w e e n b u s i n e s s e t h i c s a n d c o r p o -
rate s o c i a l r e s p o n s i b i l i t y a n d t h e a c t i o n s of o r g a n i z a t i o n a l m e m b e r s

Case description
In M a y 2000 s e v e n p e o p l e lost t h e i r lives a n d o v e r 2,300 b e c a m e s i c k f r o m d r i n k -
i n g w a t e r c o n t a m i n a t e d w i t h Escherichia coli 0 1 5 7 : H 7 a n d Campylobacter jejuni
b a c t e r i a f r o m m a n u r e s p r e a d o n a f a r m near W e l l 5 i n W a l k e r t o n , Ontario.^
S c h o o l s , d a y c a r e s a n d b u s i n e s s e s w e r e s h u t d o w n . T h e s p o r t s arena w a s c o n -
v e r t e d Into a d e p o t w h e r e v o l u n t e e r s h a n d e d o u t b o t t l e d w a t e r a n d b l e a c h ,
w h i c h w a s n e c e s s a r y t o a d d t o t h e w a t e r i n W a l k e r t o n before u s i n g it t o w a s h
t h e i r h a n d s . H e l i c o p t e r s flew o v e r h e a d t r a n s p o r t i n g s i c k patients i n a i r a m b u -
lances from local hospitals t o a specialized hospital i n L o n d o n , Ontario.
A c c o r d i n g t o a j u d i c i a l i n q u i r y r e p o r t a b o u t W a l k e r t o n , O n t a r i o ' s fatal E. coli
outbreak b y Justice Dennis O'Connor:

The most serious case of water contamination in Canadian history

could have been prevented by proper chlorination of drinking water.^

1 "Wallcerton report higlilights," CBC News Online, January 2002 (www.cbc.ca/news/baclc-

ground/walkerton/walkerton_report.html, 23 October 2006)
2 Ibid.
 3.2 THE STORY BEHIND THE WATER IN WALKERTON, ONTARIO McLeod and Helms Mills 181

J u s t i c e O ' C o n n o r ' s r e p o r t a l s o " p o i n t s t o t h e region's p u b l i c utilities m a n a g -

ers a n d O n t a r i o g o v e r n m e n t c u t b a c k s as c o n t r i b u t o r s t o the tragedy."^
A c c o m p a n y i n g the c a s e are a t i m e l i n e of the W a l k e r t o n t r a g e d y a n d a c o m p r e -
h e n s i v e b i b l i o g r a p h y that i n c l u d e s l i n k s t o a u d i o s a n d v i d e o s of b r o a d c a s t s b y
the C a n a d i a n B r o a d c a s t i n g C o r p o r a t i o n ( C B C ) . T h e s e i n c l u d e i n t e r v i e w s w i t h :

• Stan K o e b e l , m a n a g e r of t h e P u b l i c U t i l i t y C o m m i s s i o n ( P U C ) at t h e
t i m e of the t r a g e d y i n M a y 2000

• Frank Koebel, water foreman

• Dr. M u r r a y M c Q u i g g e , M e d i c a l Officer of H e a l t h for G r e y - B r u c e

Introduction
It was 3 M a y 2000 a n d Stan K o e b e l , the m a n a g e r of t h e P u b l i c U t i l i t y C o m m i s s i o n
in W a l k e r t o n , w a s p r e p a r i n g t o leave for a c o n f e r e n c e in W i n d s o r , O n t a r i o .
L i t t l e d i d t h e r e s i d e n t s of t h e s m a l l f a r m i n g c o m m u n i t y k n o w that, o v e r t h e
next few d a y s , a series of faulty d e c i s i o n s that h a d b e e n m a d e b y Stan a n d h i s
b r o t h e r o v e r a l o n g p e r i o d of t i m e w o u l d c u l m i n a t e i n t h e d e a t h of s e v e n p e o p l e ,
i n c l u d i n g a t w o - y e a r - o l d c h i l d , a n d that n e a r l y half of W a l k e r t o n ' s p o p u l a t i o n of
4,800 w o u l d b e c o m e s i c k f r o m E. coli.
T h e s u b s e q u e n t i n q u i r y i n t o t h e w o r s t c a s e of c o n t a m i n a t e d d r i n k i n g w a t e r
i n N o r t h A m e r i c a w o u l d r e v e a l that, a l t h o u g h officials k n e w W a l k e r t o n ' s w a t e r
s y s t e m h a d b e e n foul f r o m 1995 t o 1998, w a r n i n g s f r o m t h e M i n i s t r y of E n v i r o n -
ment t o t h e P U C w e r e largely Ignored b y Stan K o e b e l , r e c o r d s of w a t e r t e s t i n g
h a d b e e n c o n t i n u a l l y falsified b y b o t h b r o t h e r s o v e r a l o n g p e r i o d of t i m e , a n d
i m p o r t a n t i n f o r m a t i o n was b e i n g w i t h h e l d .
H o w c o u l d this h a p p e n i n C a n a d a — a c o u n t r y that p a r t i c i p a t e s i n t h e d e v e l -
o p m e n t of W o r l d H e a l t h O r g a n i z a t i o n ( W H O ) g u i d e l i n e s f o r d r i n k i n g water?
W h a t factors c o n t r i b u t e d t o the final tragic o u t c o m e a n d w h y w a s n ' t s o m e t h i n g
d o n e s o o n e r ? T h e s i m p l e a n s w e r m i g h t b e t o l a y t h e b l a m e s o l e l y o n the K o e b e l
b r o t h e r s , b u t o t h e r s h a v e s u g g e s t e d that t h e c a u s e is m u c h m o r e c o m p l e x a n d
i n v o l v e s a s e q u e n c e a n d c h a n g e of events that c u l m i n a t e d i n t h e d i s a s t r o u s out-
come.

3 Ibid.
182 THE DARK SIDE: CRITICAL CASES ON THE DOWNSIDE OF BUSINESS

The Public Utilities Commission and the Koebel brothers

Stan K o e b e l p u t h i s feet u p o n t h e d e s k a n d c l o s e d h i s eyes f o r a f e w minutes
w h i l e he w a i t e d f o r h i s b r o t h e r F r a n k t o s h o w u p . F r a n k w a s t h e w a t e r foreman
for t h e P U C a n d w o u l d b e i n charge of t h e w a t e r u t i l i t y w h i l e Stan w a s a w a y at
the c o n f e r e n c e . T h e p r e v i o u s d a y t h e r e h a d b e e n a p r o b l e m w i t h o n e of the
three w e l l s that s u p p l i e d w a t e r t o t h e t o w n a n d Stan n e e d e d t o t e l l Frank what
had to be done.
A s t h e r a i n beat h a r d against the w i n d o w , Stan reflected o n h o w different this
j o b w a s n o w f r o m w h e n h e a n d Frank h a d s t a r t e d w i t h t h e P U C i n t h e early
1970s. J o b s i n t h i s s m a l l t o w n w e r e s c a r c e a n d b o t h b r o t h e r s c o n s i d e r e d t h e m -
selves l u c k y t o get j o b s w i t h t h e w a t e r utility. T h e i r father, F r a n k Sr., w a s already
w o r k i n g t h e r e as a f o r e m a n , s o h e w a s a b l e t o k e e p h i s e y e o n b o t h b o y s . Stan,
i n p a r t i c u l a r , h a d d o n e w e l l for himself, d e s p i t e not h a v i n g taken a n y c o u r s e s o r
w r i t t e n t h e e x a m s for c e r t i f i c a t i o n i n w a t e r m a n a g e m e n t . Yes, it w a s a l o n g w a y
f r o m h i s first j o b as a g e n e r a l l a b o u r e r , a n d l u c k i l y for Stan, a v o l u n t a r y "grand-
parenting" scheme, w h i c h was not u n c o m m o n for long-term utility employees,
meant that h e r e c e i v e d c e r t i f i c a t i o n b a s e d o n h i s on-the-job e x p e r i e n c e . Now,
at t h e age of 47, Stan w a s t h e m a n a g e r of t h e P U C i n W a l k e r t o n a n d h i s b r o t h e r
Frank, w h o h a d n ' t d o n e b a d l y either, was t h e w a t e r f o r e m a n .
A s h e l o o k e d d o w n at t h e m e s s of p a p e r s a n d files o n h i s d e s k , Stan r e m e m -
b e r e d that t h e r e h a d b e e n a t i m e w h e n t h e j o b h a d b e e n m u c h s i m p l e r . N o w ,
not o n l y w a s h e r e s p o n s i b l e for the w a t e r utility, but for a l l utilities a n d projects
that t h e P U C m a n a g e d . T h i s m e a n t that h e w a s s p e n d i n g less t i m e l o o k i n g after
t h e w a t e r u t i l i t y a n d m o r e t i m e t r y i n g t o s t a y o n t o p of t h e m a n a g e m e n t of o t h e r
p r o j e c t s , s o m e t h i n g h e f o u n d i n c r e a s i n g l y difficult. In fact, l a t e l y h e felt h e w a s
o n l y g i v i n g a b o u t 5% of h i s t i m e t o t h e w a t e r utility, w h i l e h e w a s s t r u g g l i n g to
k e e p abreast w i t h a l l t h e p r o j e c t s that he w a s n o w i n c h a r g e of m a n a g i n g .
Stan c o u l d n ' t h e l p b u t t h i n k that, s i n c e t h e C o n s e r v a t i v e g o v e r n m e n t h a d
c o m e t o p o w e r i n O n t a r i o i n 1995, t h e P U C h e n o w w o r k e d f o r h a d c h a n g e d
d r a m a t i c a l l y f r o m t h e c o m p a n y he h a d k n o w n i n t h e 1970s. A t first t h e change
w a s i m p e r c e p t i b l e , but w h e n t h e t o w n of W a l k e r t o n w a s a m a l g a m a t e d w i t h t w o
o t h e r m u n i c i p a l i t i e s , n o t o n l y d i d Stan's w o r k l o a d a n d r e s p o n s i b i l i t i e s increase
b u t , b e c a u s e t h e r e w e r e s o m a n y n e w e m p l o y e e s , t h e W a l k e r t o n P U C n o longer
h a d t h e s a m e feel of family.
If that h a d n ' t b e e n b a d e n o u g h , w h e n t h e budget for t h e M i n i s t r y of the E n v i -
r o n m e n t w a s c u t b y a l m o s t half d u r i n g t h e first t h r e e y e a r s of P r e m i e r H a r r i s '
t e r m , t h e w a y t h i n g s w e r e d o w n at t h e w a t e r u t i l i t y r e a l l y s t a r t e d t o change.
F i r s t , t h e staff r e s p o n s i b l e for safe d r i n k i n g w a t e r w a s c u t f r o m 161 t o 43, w h i c h
l e d t o a d e c r e a s e i n t h e n u m b e r of tests i n water, i n c l u d i n g t e s t i n g for E. coli
in w a t e r p l a n t s like W a l k e r t o n . F u r t h e r m o r e , i n a n a t t e m p t t o find n e w w a y s to
generate f u n d s , t h e g o v e r n m e n t h a d d e c i d e d t o c h a r g e m u n i c i p a l i t i e s a fee for
w a t e r tests that h a d p r e v i o u s l y b e e n d o n e for free. T h i s r e s u l t e d i n m u n i c i p a l i -
ties s w i t c h i n g t o less e x p e n s i v e p r i v a t e labs a n d the e v e n t u a l c l o s u r e altogether
 3.2 THE STORY BEHIND THE WATER IN WALKERTON, ONTARIO McLeod and Helms Mills 183

of t h e m i n i s t r y l a b s . A t this stage, Stan r e c a l l e d , e v e n W a l k e r t o n h a d n o c h o i c e

but t o hire a l a b o r a t o r y c a l l e d G A P E n v i r o M i c r o b i a l t o c o n d u c t its w a t e r tests.
A k n o c k o n t h e d o o r a w a k e n e d Stan f r o m h i s d a y d r e a m i n g . A s F r a n k s e t t l e d
into the c h a i r a c r o s s f r o m h i m , Stan w a s t e d n o t i m e i n filling F r a n k i n o n a p r o b -
lem t h e y w e r e h a v i n g w i t h W e l l 7, w h i c h w a s c u r r e n t l y t h e p r i m a r y s o u r c e of
water f o r t h e t o w n . A l t h o u g h t h e r e w e r e o t h e r w e l l s s u p p l y i n g t h e area, o n l y
three (Wells 5, 6, a n d 7) r e m a i n e d i n u s e b u t , b e c a u s e Wells 5 a n d 6 w e r e m u c h
shallower. Well 7 was the preferred source. Even though Well 7 h a d been acti-
v a t e d t h e p r e v i o u s day, t h e c h l o r i n a t o r , w h i c h d i s p e r s e d the c h l o r i n e n e e d e d t o
purify t h e water, w a s n o t b e i n g a d d e d t o W e l l 7. A l t h o u g h Stan a n d F r a n k w e r e
b o t h of t h e o p i n i o n that n o n - c h l o r i n a t e d w a t e r t a s t e d better, a n e w c h l o r i n a t o r
h a d b e e n o r d e r e d a n d Stan w a n t e d F r a n k t o i n s t a l l it w h e n it a r r i v e d . A s s u r i n g
h i m that he w o u l d l o o k after t h i n g s , Stan went h o m e confident that h e w o u l d
have o n e less t h i n g t o w o r r y a b o u t .

A tragic chain of events

A s h e w a s d r i v i n g a l o n g t h e h i g h w a y o n t h e o u t s k i r t s of W a l k e r t o n , F r a n k w o n -
d e r e d if t h e r a i n w a s ever going t o e n d . It w a s T u e s d a y a n d it s e e m e d like it
h a d b e e n r a i n i n g forever. Stan h a d b e e n a w a y f o r three d a y s a n d F r a n k s t i l l
hadn't gotten a r o u n d t o i n s t a l l i n g the n e w c h l o r i n a t o r for W e l l 7. Instead, he h a d
d e c i d e d t o d e a c t i v a t e W e l l 7 as t h e w a t e r s o u r c e a n d w a s just c o m i n g f r o m a c t i -
v a t i n g W e l l 5, a s h a l l o w e r w e l l but o n e w i t h a w o r k i n g c h l o r i n a t o r , as t h e p r i m a r y
source, w h i c h he knew wouldn't be a p r o b l e m , given the heavy rains.
A s F r a n k p a s s e d b y D a v i d Biesentha's f a r m , a b o u t a half a k i l o m e t r e f r o m W e l l
5, he c o u l d s m e l l t h e cattle m a n u r e D a v i d B i e s e n t h a h a d s p r e a d o v e r t h e field
of h i s Stonegate f a r m . D a v e h a d o w n e d t h e farm s i n c e 1969 a n d h e d i d w h a t h e
c o u l d t o p r o t e c t the e n v i r o n m e n t a n d his cattle. I n c l u d i n g fencing t h e w a t e r w a y s
on his p r o p e r t y t o keep his cattle out. T o p r e v e n t runoff, he put eaves t r o u g h s o n
his b a r n t o d i r e c t the r a i n w a t e r a w a y f r o m t h e m a n u r e p i l e , w h i c h w a s s t o r e d o n
a c e m e n t p a d . So w h e n he h a d s p r e a d 70 t o n n e s of cattle m a n u r e o n h i s field i n
A p r i l , h e w a s careful t o f o l l o w p r o p e r p r a c t i c e s b u t there w a s n o d i s g u i s i n g t h e
s t e n c h of t h e m a n u r e .
O n Saturday, Frank set o u t t o p e r f o r m a r o u t i n e c h e c k of t h e o p e r a t i n g w e l l s .
T u r n i n g o n t h e r a d i o , he w a s just in t i m e to hear a r e p o r t that t h e p r e v i o u s
day's rainfall h a d b e e n 69.85 m m (2.75 i n c h e s ) a n d that, f r o m M a y 8 t o M a y 15,
a r e c o r d of 133.35 m m (5.25 i n c h e s ) h a d fallen! A l t h o u g h this m a d e f o r lots of
m u d a n d flooding, it a l s o meant that the w e l l s w o u l d b e full. D r i v i n g a l o n g F r a n k
was t h i n k i n g h o w n i c e it w o u l d b e t o get h o m e , sit d o w n a n d h a v e a beer o r t w o ,
e s p e c i a l l y n o w that t h e w e a t h e r h a d i m p r o v e d . A l t h o u g h he k n e w h e h a d a bat-
tle w i t h t h e b o t t l e , it h a d b e e n a l o n g week, s o w h a t h a r m c o u l d there b e i n a
c o u p l e of d r i n k s o n a S a t u r d a y afternoon? H e t h o u g h t a b o u t s t o p p i n g at W e l l 5
IS** THE DARK SIDE: CRITICAL CASES ON THE DOWNSIDE OF BUSINESS

but w h y b o t h e r ? N o b o d y e v e r r e a l l y c h e c k e d t h e s e t h i n g s . B e s i d e s , h e h a d been
falsifying t h e r e c o r d s for y e a r s a n d n o t h i n g b a d h a d e v e r y h a p p e n e d . A l l he h a d
to d o w a s fill u p t h e s a m p l e b o t t l e w i t h t a p water, r e c o r d a n a c c e p t a b l e status
for t h e c h l o r i n a t i o n i n t h e l o g b o o k a n d n o b o d y w o u l d b e t h e w i s e r a n d h e c o u l d
go h o m e a n d e n j o y the rest of t h e day.
B y M o n d a y , Stan w a s b a c k f r o m t h e c o n f e r e n c e a n d h a d met b r i e f l y w i t h Frank,
w h o gave h i m a n u p d a t e of the events of t h e p r e v i o u s w e e k , i n c l u d i n g t h e infor-
m a t i o n that W e l l 5 h a d b e e n t h e p r i m a r y s o u r c e of w a t e r for W a l k e r t o n s i n c e the
p r e v i o u s T u e s d a y . After F r a n k left his office, Stan d e c i d e d that, e v e n t h o u g h Well
7 w a s s t i l l w i t h o u t a c h l o r i n a t o r , he w o u l d r e a c t i v a t e it, s w i t c h t h e s u p p l y back
to Well 7 a n d s h u t d o w n W e l l 5. H e a l s o h a d t o m a k e s u r e that w a t e r s a m p l e s
were c o l l e c t e d f r o m the w e l l s , s o t h e y c o u l d b e sent off for r o u t i n e tests the next
d a y t o A & L C a n a d a L a b o r a t o r i e s , t h e firm that h a d t a k e n o v e r W a l k e r t o n ' s water
testing w h e n G A P d r o p p e d the contract.
T h i n k i n g n o t h i n g m o r e of i t , Stan w a s n o t t o t a l l y s u r p r i s e d t o r e c e i v e a tel-
e p h o n e c a l l f r o m A & L L a b o r a t o r i e s o n W e d n e s d a y m o r n i n g i n f o r m i n g h i m that
t h e w a t e r s a m p l e that t h e y t e s t e d w a s c o n t a m i n a t e d . T h i s w a s n ' t t h e first time
t h e r e h a d b e e n p r o b l e m s w i t h the w a t e r s y s t e m i n W a l k e r t o n . A M i n i s t r y of E n v i -
r o n m e n t i n s p e c t o r h a d d i s c o v e r e d that W a l k e r t o n h a d t a i n t e d w a t e r between
1995 a n d 1998, a n d h a d m a d e r e c o m m e n d a t i o n s t o test m o r e f r e q u e n t l y a n d
to i n c r e a s e t h e c h l o r i n e levels i n t h e w a t e r s u p p l y . A l t h o u g h Stan h a d v o w e d
to c o m p l y w i t h t h e r e c o m m e n d a t i o n s , h e h a d n ' t d o n e a n y t h i n g . W h y b o t h e r t o
m a k e m o r e w o r k for himself? B e s i d e s , t h e w a t e r t a s t e d b e t t e r w i t h o u t c h l o r i n e .
N o t h i n g h a p p e n e d before, s o it w a s u n l i k e l y that t h i s s i t u a t i o n w a s a n y more
s e r i o u s . Stan k n e w that t h e r e p o r t i n g g u i d e l i n e s , w h i c h h a d b e e n c h a n g e d i n
1997, m e a n t that t h e results w o u l d n ' t go a n y f u r t h e r u n l e s s h e c h o s e t o reveal
t h e m . In t h e o l d d a y s , t h e M i n i s t r y of H e a l t h w o u l d h a v e t o h a v e b e e n i n f o r m e d
of a n y i r r e g u l a r i t i e s , b u t , w i t h n e w p r i v a c y r u l e s , t h e results of t h e w a t e r were
sent d i r e c t l y t o t h e c u s t o m e r , i n t h i s c a s e the P U C , a n d c o u l d o n l y b e p a s s e d o n
to t h e M e d i c a l Officer if t h e c u s t o m e r gave p e r m i s s i o n . S o Stan d e c i d e d t o d o
n o t h i n g , d e s p i t e a f o l l o w - u p fax o n T h u r s d a y b y A & L L a b o r a t o r i e s e m p h a s i z i n g
that W a l k e r t o n ' s entire s y s t e m w a s c o n t a m i n a t e d w i t h E. coli.

Serious medical impact

S u d d e n l y d u r i n g t h e t h i r d w e e k of M a y t h e r e s i d e n t s of W a l k e r t o n , e s p e c i a l l y
c h i l d r e n , s e e m e d t o be getting m o r e i l l t h a n n o r m a l . O n F r i d a y M a y 19, Dr. M u r -
r a y M c Q u i g g e , M e d i c a l Officer of H e a l t h for G r e y - B r u c e , w a s w o r k i n g at his desk
at h o m e w h e n h e r e c e i v e d a c a l l f r o m Dr. K r i s t e n H a l l e t t , a p e d i a t r i c i a n from
O w e n S o u n d . She w a n t e d t o r e p o r t t w o s u s p i c i o u s cases that s h e h a d referred t o
her from the Walkerton area. One was a seven-year-old girl with b l o o d y diarrhea,
a n d t h e s e c o n d w a s a n eleven-year-old b o y w i t h a b d o m i n a l p a i n a n d a fever w h o
 3.2 THE STORY BEHIND THE WATER IN WALKERTON, ONTARIO McLeod and Helms Mills 185

d e v e l o p e d b l o o d y d i a r r h e a later that e v e n i n g . Dr. Hallett w a s c o n c e r n e d b e c a u s e

s h e felt that things weren't r i g h t , that "there m u s t b e s o m e t h i n g g o i n g o n . "
Dr. M c Q u i g g e s p r a n g i n t o a c t i o n a n d i m m e d i a t e l y c o n t a c t e d Stan K o e b e l at
the P U C a b o u t a n y i r r e g u l a r i t i e s i n t e s t i n g . R e a s s u r e d b y Stan that the w a t e r w a s
p e r f e c t l y safe to d r i n k a n d w a s f r e q u e n t l y t e s t e d . Dr. M c Q u i g g e d e c i d e d t o l o o k
at f o o d p o i s o n i n g as a p o s s i b l e c a u s e of t h e i l l n e s s e s .
It was p r e t t y c l e a r that t h i s w a s a p r o b l e m that w a s n ' t g o i n g away. B y S a t u r d a y
o v e r 40 p e o p l e h a d b e e n a d m i t t e d t o t h e l o c a l h o s p i t a l w i t h b l o o d y d i a r r h e a
a n d e x c r u c i a t i n g s t o m a c h c r a m p s , head-fogging n a u s e a , fever a n d c h i l l s , a n d
s w e a t s , a n d m a n y o t h e r W a l k e r t o n r e s i d e n t s a n d v i s i t o r s w e r e b e g i n n i n g t o suf-
fer s i m i l a r b u t less s e v e r e s y m p t o m s . W h a t e v e r t h e s o u r c e , t h e s y m p t o m s of
t h e s e i l l n e s s e s l o o k e d like t h e result of E. coli, a t y p e of b a c t e r i a c o m m o n l y
f o u n d i n t h e intestines of a n i m a l s a n d h u m a n s a n d g e n e r a t e d f r o m h u m a n a n d
a n i m a l w a s t e . A l t h o u g h E. coli c a n b e w a s h e d i n t o c r e e k s , r i v e r s , s t r e a m s , lakes,
o r g r o u n d w a t e r d u r i n g p r e c i p i t a t i o n a n d e n d u p i n d r i n k i n g w a t e r that is i n a d -
e q u a t e l y t r e a t e d ( w h i c h w a s w h y Dr. M c Q u i g g e at first s u s p e c t e d t h e w a t e r s u p -
p l y ) , it c o u l d a l s o t u r n u p i n p o o r l y p r e p a r e d f o o d . W o r r i e d a b o u t t h e effects
o n t h e y o u n g . Dr. M c Q u i g g e a s k e d h i s staff t o p e r s o n a l l y c o n t a c t t h e p a r e n t s of
c h i l d r e n u n d e r five a n d give t h e m i n s t r u c t i o n s for p u r i f y i n g water.

The whisteblower
O n S a t u r d a y e v e n i n g B o b M c K a y w a s feeling t e n s e . H e d e c i d e d he c o u l d s t a n d
it n o longer. H i s n e i g h b o u r s o n b o t h s i d e s h a d c o m e d o w n w i t h t h e m y s t e r i o u s
illness a n d w h o k n e w w h e n it w o u l d end? A s a long-time e m p l o y e e at t h e P U C ,
B o b k n e w that w h a t h e w a s a b o u t t o d o w o u l d m o s t l i k e l y j e o p a r d i z e his career
but w h a t c h o i c e d i d he have? H e h a d s e e n t h e fax f r o m A & L L a b o r a t o r i e s that
h a d a r r i v e d at t h e P U C t h e p r e v i o u s T h u r s d a y a n d n o w h e k n e w he h a d t o d o
something.
P i c k i n g u p the p h o n e . B o b s l o w l y d i a l e d t h e n u m b e r for the E n v i r o n m e n t a l
E m e r g e n c y C e n t r e . W h e n t h e o p e r a t o r a n s w e r e d , he t o l d h e r that he w a n t e d t o
r e m a i n a n o n y m o u s b u t he h a d i n f o r m a t i o n o n t h e c a u s e of t h e s i c k n e s s e s that
w e r e s p r e a d i n g t h r o u g h t h e c o m m u n i t y . B o b t h e m p r o c e e d e d t o t e l l t h e m that
the P U C h a d r e c e i v e d a fax f r o m A & L L a b o r a t o r i e s o n M a y 18 w a r n i n g it that t h e
w a t e r s a m p l e s c o n t a i n e d t h e d e a d l y E. coli b a c t e r i a .
T h e o p e r a t o r i m m e d i a t e l y n o t i f i e d Dr. M c Q u i g g e , w h o w a s u p s e t w i t h t h e
P U C ' s s l o w r e s p o n s e b e c a u s e it h a d w a s t e d v a l u a b l e t i m e as m e d i c a l officials
c o n t i n u e d t o l o o k for f o o d s o u r c e s for t h e o u t b r e a k of E. coli. H e d e c i d e d t o c a l l
Stan K o e b e l , t h e manager i n c h a r g e of t h e w a t e r u t i l i t y at t h e P U C . B u t , first, h e
c o n t a c t e d his s e c r e t a r y t o i s s u e a n i m m e d i a t e " b o i l w a t e r a d v i s o r y . "
186 THE DARK SIDE: CRITICAL CASES ON THE DOWNSIDE OF BUSINESS

The PUC cover-up

O v e r at t h e P U C , Stan w a s w o r k i n g late, e v e n t h o u g h it w a s a S u n d a y night. He
h a d just gotten off t h e p h o n e w i t h t h e H e a l t h U n i t a n d t h e y w e r e a s k i n g a w k w a r d
q u e s t i o n s . T h e y h a d r e c e i v e d a n a n o n y m o u s t i p a b o u t t h e fax f r o m A & L Labo-
r a t o r i e s a n d Stan s u s p e c t e d it w a s o n e of h i s e m p l o y e e s . Stan t h o u g h t he h a d
s t a l l e d t h e m b y m i s l e a d i n g t h e m a b o u t t h e s o u r c e s of t h e p o s i t i v e s a m p l e s , but
he k n e w that t h e y w o u l d b e b a c k a n d w a n t i n g t o see t h e r e c o r d s of c h l o r i n a t i o n
a n d w a t e r s a m p l i n g . Stan c a l l e d F r a n k a n d t o l d h i m he n e e d e d t o see h i m right
away.
W h e n F r a n k a r r i v e d , Stan c l o s e d t h e d o o r t o his office a n d t o l d h i m w h a t was
h a p p e n i n g . E v e n t h o u g h n e i t h e r b r o t h e r b e l i e v e d that t a i n t e d w a t e r w a s the
s o u r c e of t h e i l l n e s s e s , t h e y b o t h k n e w that if t h e H e a l t h U n i t s t a r t e d t o poke
a r o u n d t h e files t h e y w o u l d s h o w that t h e c h l o r i n a t o r h a d n o t b e e n r e p l a c e d in
W e l l 7. N o t o n l y w a s Stan t a k i n g t h e heat for d e l a y i n g t h e r e p o r t f r o m the l a b , but
w h e n h e h a d m e t t h e E n v i r o n m e n t a l M i n i s t r y t h e m o n t h before, he h a d p r o m -
i s e d t o b e m o r e v i g i l a n t o v e r t h e w a t e r s a m p l i n g a n d c h l o r i n a t i o n . T h e y a l l knew
that it w a s l i k e l y that t h e H e a l t h U n i t w o u l d w a n t t o s e e e v i d e n c e of c h l o r i n e
levels, e s p e c i a l l y i n W e l l s 5 a n d 7.
C o n c e r n e d , Stan a s k e d F r a n k t o c h a n g e t h e l o g b o o k t o c o n c e a l t h e s e facts o n
W e l l 7. H e w a s a l s o w o r r i e d a b o u t t h e w a t e r s a m p l e e n t r i e s for c h l o r i n e levels,
e s p e c i a l l y s i n c e t w o of t h e s h a l l o w e r w e l l s (5 a n d 6) w e r e l o c a t e d v e r y c l o s e to
a g r i c u l t u r a l l a n d s a n d h e a v y r a i n s m i g h t h a v e a l l o w e d s u r f a c e w a t e r t o seep
i n t o t h e w a t e r s u p p l y . T r o u b l e i n t h e past w i t h n o n - c o m p l i a n c e w i t h M i n i s t r y
of E n v i r o n m e n t d i r e c t i v e s for m o r e frequent t e s t i n g a n d i n c r e a s e d c h l o r i n a t i o n
m a d e Stan w a r y that t h e y w o u l d b e p a r t i c u l a r l y o n t h e l o o k o u t for a c c u r a t e and
up-to-date r e c o r d s .
F r a n k s a i d h e w o u l d c h a n g e t h e l o g b o o k e n t r y for W e l l 7's c h l o r i n a t o r a n d
t o l d Stan that there w a s also n o n e e d t o w o r r y a b o u t t h e w a t e r s a m p l e s from
t h e w e l l s b e c a u s e , w h i l e Stan h a d b e e n away, F r a n k h a d t a k e n care of it b y fill-
i n g i n s o m e b l a n k s o n t h e t e s t i n g sheet, i n d i c a t i n g c h l o r i n e r e s i d u a l l e v e l s , even
t h o u g h t h e c h l o r i n a t o r w a s b r o k e n at W e l l 7 a n d t h e r e wasn't a n y c h l o r i n e in
t h e w a t e r t o r e c o r d . H e t h e n forged Stan's s i g n a t u r e , s o e v e r y t h i n g w o u l d m a t c h
u p . Stan w a s r e l i e v e d that his b r o t h e r h a d h a d t h e foresight t o take care of t h i s .
It w a s o n e less t h i n g t o w o r r y a b o u t at a t i m e w h e n t h e y n e e d e d t o m a k e sure
all t h e d e t a i l s m a t c h e d . B o t h Stan a n d F r a n k w e n t h o m e , t h i n k i n g t h e w o r s t was
over.

The epidemic
Stan slept w e l l S u n d a y night, b e l i e v i n g that he a n d F r a n k h a d the s i t u a t i o n u n d e r
c o n t r o l . B u t , w h e n h e a w o k e M o n d a y m o r n i n g a n d t u r n e d t h e r a d i o o n , t h e news
 3.2 THE STORY BEHIND THE WATER IN WALKERTON, ONTARIO McLeod and Helms Mills 187

wasn't g o o d . T h e d e a t h of L e n o r e A l w a s b e i n g r e p o r t e d a n d t h e c a u s e w a s
b l a m e d o n c o n t a m i n a t e d water. T h e s e c o n d b i t of b a d n e w s f o r Stan w a s that
the M i n i s t r y of E n v i r o n m e n t w a s o p e n i n g a n i n v e s t i g a t i o n i n t o t h e town's w a t e r
p r o b l e m s . O n T u e s d a y , w h e n t h e M e d i c a l H e a l t h Office finally h a d c o n f i r m a t i o n
that t h e w a t e r s u p p l y w a s c o n t a m i n a t e d , Stan r e a l i z e d that h e h a d t o c o n f e s s t o
r e c e i v i n g t h e fax a n d a l s o that t h e c h l o r i n a t o r i n W e l l 7 h a d n o t b e e n w o r k i n g
a n d h a d not b e e n r e p l a c e d .
B y T h u r s d a y there h a d b e e n t w o m o r e d e a t h s . O n Friday, w h e n it w a s
a n n o u n c e d that a c r i m i n a l i n v e s t i g a t i o n w a s b e i n g l a u n c h e d b y t h e O n t a r i o P r o -
v i n c i a l P o l i c e , Stan a n d F r a n k b o t h k n e w it w a s o n l y a m a t t e r of t i m e before t h e i r
falsification of r e c o r d s w a s d i s c o v e r e d . T h e o n l y q u e s t i o n n o w w a s w h e n .
E v e n t h o u g h t h e s o u r c e of t h e o u t b r e a k w a s b e g i n n i n g t o b e u n d e r c o n t r o l ,
the E m e r g e n c y H e a l t h U n i t w a s t r y i n g t o s t e m t h e s p r e a d of t h e c o n t a m i n a t i o n
b y h a n d i n g out b o t t l e d w a t e r a n d b l e a c h f r o m t h e s p o r t s a r e n a , w h i c h h a d b e e n
t u r n e d into a t e m p o r a r y d e p o t . M o r e t h a n 40% of W a l k e r t o n ' s p o p u l a t i o n h a d
b e e n affected b y t h e b a c t e r i a a n d t h e v e r y i l l patients w e r e b e i n g airlifted t o
a s p e c i a l i z e d unit i n t h e bigger h o s p i t a l i n L o n d o n , O n t a r i o , b e c a u s e t h e l o c a l
hospitals were being stretched beyond their capacity.
T h e final c o u n t w o u l d b e that at least 2,300 p e o p l e b e c a m e i l l . T h e final d e a t h
t o l l i n c l u d e d s e v e n p e o p l e w h o d i e d d i r e c t l y f r o m E. coli, w h i l e c o m p l i c a t i o n s
from E. coli w e r e g i v e n as t h e c a u s e of d e a t h for a n o t h e r 14 e l d e r l y p e o p l e .

The Walkerton inquiry

A public inquiry led b y the Honourable Dennis O'Connor w a s established b y
the O n t a r i o g o v e r n m e n t after t h e tragedy. It l a s t e d nine m o n t h s a n d h e a r d t h e
t e s t i m o n y of o v e r 114 w i t n e s s e s .
E v i d e n c e r e v e a l e d that there w e r e " m o r e t h a n 20 y e a r s of lies, c o v e r - u p s , a n d
d e c e p t i o n , " as Stan K o e b e l testified that he h a d falsified w a t e r s a m p l e s , faked
c h l o r i n e r e c o r d s , a n d , after h e a v y flooding t h e p r e v i o u s M a y , h a d r u n o n e of
the t o w n w e l l s w i t h o u t a c h l o r i n a t o r . W h e n h i s l a w y e r a s k e d if he s h o u l d h a v e
been t h e manager of t h e P U C , Stan K o e b e l r e p l i e d , " L o o k i n g b a c k o n it now, n o .
1 d i d n ' t h a v e e n o u g h e d u c a t i o n a l b a c k g r o u n d o r e x p e r i e n c e . " In a r e p o r t p u t
out b y t h e C a n a d i a n B r o a d c a s t i n g C o r p o r a t i o n ( C B C ) , Stan b l a m e d h i s p r e v i -
ous b o s s at t h e P U C for h i s a c t i o n s . Stan s a i d that he l e a r n e d h o w t o fake tests
and d i s r e g a r d g o v e r n m e n t r e g u l a t i o n s f r o m h i s s u p e r v i s o r , a n d that t h e s e w e r e
n o r m a l p r a c t i c e s at the P U C b e c a u s e of c o m p l a c e n c y . W h e n h e b e c a m e t h e m a n -
ager h e also e n c o u r a g e d t h o s e u n d e r h i m t o d o t h e s a m e t h i n g .
T h e c a u s e of t h e c o n t a m i n a t i o n of t h e w e l l w a t e r w a s s t r a i g h t f o r w a r d . T h e
u n u s u a l l y h e a v y rains c r e a t e d a n o v e r f l o w of s u r p l u s water, w h i c h d r a i n e d f r o m
the m a n u r e t r e a t e d fields i n t o t h e s h a l l o w u n c h l o r i n a t e d w e l l s . D e s p i t e t h e pre-
cautions D a v i d B i e s e n t h a t o o k t o m a i n t a i n e n v i r o n m e n t a l s t a n d a r d s , h i s cattle
188 THE DARK SIDE: CRITICAL CASES ON THE DOWNSIDE OF BUSINESS

w e r e , at t h e t i m e , c a r r i e r s of E. coli a n d t h e i r m a n u r e c a r r i e d the d e a d l y b a c t e r i a
s t r a i g h t Into the u n t r e a t e d w a t e r s u p p l y .
T h e I n q u i r y f o u n d t h a t i l l n e s s e s c o u l d h a v e b e e n p r e v e n t e d if S t a n K o e b e l h a d
m o n i t o r e d c h l o r i n e l e v e l s i n t h e d r i n k i n g w a t e r a n d i n s t a l l e d a c h l o r i n a t o r . B u t it
a l s o b l a m e d d e r e g u l a t i o n of w a t e r t e s t i n g a n d c u t s t o t h e E n v i r o n m e n t M i n i s t r y
b y t h e O n t a r i o g o v e r n m e n t as c o n t r i b u t i n g f a c t o r s t o t h e t r a g e d y . T h e bigger
q u e s t i o n is h o w w a s t h i s a b l e t o h a p p e n ?

Epilogue
O n M a r c h 25, 2003, S t a n a n d F r a n k K o e b e l w e r e " c h a r g e d w i t h p u b l i c n u i s a n c e ,
u t t e r i n g a n d f o r g e r y a n d b r e a c h of p u b l i c d u t y . " T h e b r o t h e r s p l e a d e d g u i l t y o n
N o v e m b e r 30, 2004, a n d w e r e s e n t e n c e d t o i m p r i s o n m e n t ; S t a n w a s s e n t e n c e d
t o o n e y e a r i n j a i l a n d F r a n k w a s s e n t e n c e d t o n i n e m o n t h s h o u s e a r r e s t . Stan
K o e b e l w a s r e l e a s e d after s e r v i n g o n l y f o u r m o n t h s .

Timeline of the Walkerton tragedy

1995: The Ontario government closes down all four publicly run water-testing laboratories.

1997: Walkerton—always responsible for its own water—has no set methods for certifying labo-
ratories, or a legal requirement to test water or report results.

June 18,1998: Walkerton Town Council complains to Ontario's conservative government about
cutbacks and the closing of labs, calling on the Ministry of Energy and the Environment to
ensure basic, healthy water standards for all Ontarians.
1999: Walkerton and two other local municipalities were amalgamated into Brockton.

April 22, 2000: Dave Biesentha follows proper practices and spreads 70 tonnes of cattle manure
over the field of his Stonegate farm, close to Walkerton's Well 5.
May 2, 2000: Activated Well 7 without installed operating chlorinator.

May 3, 2000: Stan Koebel instructs Frank Koebel to install the new chlorinator while he is
away.

May 5, 2000: Stan Koebel leaves for a water conference in Windsor, Ontario.

May 8-15, 2000: Heavy rains, totaling 133 mm (5.25 inches).

Tuesday May 9, 2000: Deactivated Well 7.

May 9-15: Well 5, a very shallow well, was the primary source of water for Walkerton.

Friday, May 12, 2000: Excessive rainfall swept southern Ontario, 70 mm (2.75 inches).

May 12, 2000 or shortly after: E. coli 0157:H7 and Campylobacter jejuni contaminants enter the
Walkerton system through Well 5.
 3.2 THE STORY BEHIND THE WATER IN WALKERTON, ONTARIO McLeob and Helms Mills 189

Within a week: Walkerton residents and visitors begin to suffer symptoms of bloody diarrhea
and excruciating stomach cramps, head-fogging nausea, fever and chills, and sweats. Doc-
tors advise patients to drink lots of water

Saturday, May 13, 2000: Frank Koebel does not check chlorine residual at Well 5 during routine
check, falsifies the readings.

Sunday, May 14, 2000: Stan Koebel returns from conference to find that brother Frank has falsi-
fied records on status of Well 5.

Monday, May \5, 2000: Stan Koebel turns Well 7 on without chlorination at 1.15 pm.

Tuesday, May 16, 2000: Water samples received by A&L Canada Laboratories.

Wednesday, May 17, 2000; Patients start being treated for symptoms of cramps, fever, bloody
diarrhea, and vomiting. A&L Laboratories telephone Stan Koebel to inform him that the
water is contaminated.

Thursday, May 18, 2000: Stan Koebel receives a fax from A&L water testing lab stating that the
entire system was contaminated with E. coli. Koebel does not report the findings and tells
the mayor that the problem is not serious.

Friday, May 19, 2000: Dr McQuigge, Medical Officer of Health at the Bruce-Grey-Owen Sound
Public Health Unit, is notified by Dr Kristen Hallett, a pediatrician, of two cases of bloody
diarrhea referred from the Walkerton Hospital to Owen Sound Hospital.

May 19, 2000: Stan Koebel assures the Public Health Unit that the water is fine. The Public
Health Unit starts looking for a possible food source to explain the documented illnesses.
New chlorinator is installed on Well 7 and Stan begins flushing and superchlorinating the
system.

Saturday, May 20, 2000: The Health Unit's Environmental Emergency Center, Spills Action Cen-
tre (SAC), is informed of failed lab test results in the Walkerton water system taken from
a construction site by an anonymous call placed by Robert (Bob) McKay, an employee of
the PUC.

May 20, 2000: Forty more people report to hospital with bloody diarrhea and test positive for
E co/( 0157:H7.

May 20, 2000: PUC reassures the Public Healtfi Unit that Walkerton's water supply is safe.
Sunday, May 21, 2000: The Health Unit contacts Stan Koebel who assures them that the positive
samples were only from the construction site. Nonetheless, Dr McQuigge decides to issue a
"boil water advisory" to the people of Walkerton telling them not to drink the water

Monday, May 22, 2000: John Earle, a Senior Environmental Officer with the Ministry of the Envi-
ronment, Owen Sound District, is assigned to investigate the water problems in Walkerton.

May 22, 2000: Lenore Al, 66, is the first person to die from the contaminated water.

Tuesday, May 23, 2000: The Medical Health Office (MHO) laboratory confirms positive test
results for E. coli in the water. Stan Koebel finally tells MHO about the fax on May 18 and
admits that the machine that puts the chlorine in the town's drinking water supply did
not work for some time. Stan instructs Frank to clean up the operating log sheets for May
2000.

May 23, 2000: Edith Pearson, 83, and Mary Rose Raymond, 2, die.

Wednesday May 24, 2000: Vera Coe, 75, dies.

Thursday, May 25, 2000: Drinking water system taken over by Ontario's Clean Water Agency.

Friday, May 26, 2000: Ontario Provincial Police launch a criminal investigation in Walkerton.

Monday, May 29, 2000: Laura Rowe, 84, dies.

190 THE DARK SIDE: CRITICAL CASES ON THE DOWNSIDE OF BUSINESS

Tuesday, May 30, 2000: Betty Trushinski, 56, dies.

Wednesday, May 31, 2000: Conservative Premier, Mike Harris, reverses iiis earlier position and
calls a public inquiry. James Bolden, former mayor of Walkerton, visits local hospital with
symptoms. He reports that "while crowded, everything is running efficiently, including
flights to London Health Sciences Centre, which now holds 11 patients (ten of them chil-
dren)."

By June 1, 2000: Death toll has reached 11 with a further 784 treated for symptoms, including
90 who were hospitalized.

June 9, 2000: Ministry of Environment issues an Order requiring that Well 5 remain closed and
disconnected.

June 15, 2000: Death toll upgraded to 14. Seven more cases investigated by the coroner. There
are estimates that half of the population of Walkerton had got sick from the water contami-
nation.

July 25, 2000: Evelyn Hussey, 84, dies of kidney failure as a result of the E. coli poisoning.

December 5, 2000: Boil order lifted.

December 20, 2004: Stan Koebel sentenced to one year in jail. Frank Koebel sentenced to nine
months of house arrest.

April 2005: Stan Koebel granted parole and released from prison after serving less than four
months of his sentence.

Bibliography

Canadian Broadcasting Corporation (CBC) news archives

CBC (2000a) "Words cannot begin to express how sorry I am" (CBC Digital Archives, broadcast
19 December 2000; archives.cbc.ca/lDC-l-70-1672-11521/disasters_tragedies/walkerton/
clipl,26 October 2006).
CBC (2000b) "London hospitals treat Walkerton citizens" (CBC Digital Archives, broadcast 24
May 2000; archives.cbc.ca/lDC-l-70-1672-11533/disasters_tragedies/walkerton/clipl, 23
October 2006).
CBC (2000c) "The hunt for E coli 0157:H7" (CBC Digital Archives, broadcast 2 June 2000;
archives.cbc.ca/lDC-l-70-1672-11517/disasters_tragedies/walkerton/clipl, 29 October
2006).
CBC (2000d) "Town epidemic" (CBC Digital Archives, broadcast 2 June 2000; archives.cbc.ca/
lDC-l-70-1672-11515/disasters_tragedies/walkerton/clipl, 26 October 2006).
CBC (2000e) "What is £. c o « 0157:H7?" (CBC Digital Archives, broadcast 27 May 2000; archives.
cbc.ca/IDC-l-70-1672-11519/disasters_tragedies/walkerton/clipl, 11 September 2006).
CBC (20000 "Deadly water: the lessons of Walkerton. A Tragic Flaw?" (News in Review, Septem-
ber 2000; www.cbc.ca/newsinreview/Sep2000/walkerton/tragic.htm, 12 August 2006).
CBC (2001) "Walkerton was a wake-up call for all of us" (CBC Digital Archives, broadcast 29 June
2001; archives.cbc.ca/IDC-l-70-1672-11541/disasters_tragedies/walkerton/clipl, 26 October
2006).
CBC (2002a) "Is Canada's drinking water safer?" (CBC Digital Archives, broadcast 18 January
2002; archives.cbc.ca/lDC-l-70-1672-11530/disasters_tragedies/walkerton/clipl, 26 October
2006).
 3.2 THE STORY BEHIND THE WATER IN WALKERTON, ONTARIO McLeod and Helms Mills 191

CBC (2002b) "Indepth: Inside Wallierton. Key figures in Wallcerton's water crisis" (CBC News
Online, January 2002; www.cbc.ca/news/baclcground/waIkerton/players.html, 26 October
2006).
CBC (2002c) "Indepth: Inside Walkerton. Walkerton report highlights" {CBC News Online, Janu-
ary 2002; www.cbc.ca/news/background/walkerton/walkerton_report.html, 23 October
2006).
CBC (2003) "A nightmare that won't end" (CBC Digital Archives, broadcast 26 May 2000; archives.
cbc.ca/IDC-l-70-1672-11531/disasters_tragedies/walkerton/clipl, 27 October 2006).
CBC (2004a) "Sentencing the Koebels" (CBC Digital Archives, broadcast 17 December 2004;
archives.cbc.ca/lDC-1-70-1672-11529/disasters_tragedies/walkerton/clipl, 27 October
2006).
CBC (2004b) "Indepth: Health. E. coli. FAQs" (C8C News Online, 23 June 2004; www.cbc.ca/
news/background/health/ecoli.html, 26 October 2006).
CBC (2004c) "Indictment in the Superior Court of Justice: Her Majesty the Queen against
Stan Koebel and Frank Koebel" {CBC News Online, November 2004; www.cbc.ca/news/
background/walkerton/gfx/koebel.pdf, 24 October 2006).
CBC (2004d) "Indepth: Inside Walkerton. Canada's worst ever E. coli contamination" {CBC News
Online, 20 December 2004; www.cbc.ca/news/background/walkerton, 23 October 2006).
CBC (2004e) "Indepth: Inside Walkerton. Timeline" {CBC News Online, 20 December 2004; www.
cbc.ca/news/background/walkerton/timeline.html, 26 October 2006).
CBC (2005a) "Fake records, forged signatures, disastrous cover-up" (CBC Digital Archives,
broadcast 7 December 2000; archives.cbc.ca/environment/pollution/topics/1672-11537, 12
September 2006).
CBC (2006) "Indepth: Health Timeline: E. coli contamination in Canada" {CBC News Online,
26 September 2006; www.cbc.ca/news/background/health/ecoli-timeline.html, 26 October
2006).

Official sources
Health Canada (2006) "Drinking Water Environmental & Workplace Health" (www.hc-sc.gc.ca/
ewh-semt/water-eau/drink-potab/index_e.html, 23 October 2006).
Health Canada (2008) Guidelines for Canadian Drinking Water Quality—Summary Table (Ottawa:
Health Canada; www.hc-sc.gc.ca/ewh-semt/alt_formats/hecs-sesc/pdf/pubs/water-eau/
sum_guide-res_recom/summary-sommaire-eng.pdf, 21 August 2008).
O'Connor, D.R. (2002a) Part One: A Summary Report of the Walkerton Commission of Inquiry: The
Events of May 2000 and Related Issues (Ottawa: Ontario Ministry of the Attorney General;
www.attorneygeneral.jus.gov.on.ca/english/about/pubs/walkerton/partl/WI_Summary.pdf,
29 October 2006).
O'Connor, D.R. (2002b) Part Two: Report of the Walkerton Inquiry: A Strategy for Safe Drink-
ing Water (Ottawa: Ontario Ministry of the Attorney General; www.attorneygeneral.jus.gov.
on.ca/english/about/pubs/walkerton/part2/Front_material_web.pdf, 30 October 2006).
Ontario Ministry of the Attorney General (2002) "Report of the Walkerton Inquiry" (www.
attorneygeneral.jus.gov.on.ca/english/about/pubs/walkerton, 29 October 2006)
Ontario Ministry of the Environment (2006) "Frequently asked questions about water and its
usage" (www.ene.gov.on.ca/envision/water/waterFAQ.htm, 11 September 2006).
Regional Niagara (2002) "Water and Land Use Planning. Walkerton Inquiry Report. Planning Act
and Official Plans" (DPD 118-2002; Regional Municipality of Niagara; www.regional.niagara.
on.ca/news/publications/pdf/DPD%20118-2002.pdf, accessed 22 October 2006).
192 THE DARK SIDE: CRITICAL CASES ON THE DOWNSIDE OF BUSINESS

Books and journal articles

Jones, G., A.J. Mills, T.G. Weatherbee, and J. Helms Mills (2006) Organizational Theory, Design,
and Change (Toronto: Pearson; Canadian edn).
Lee Burke, B. (2001) Don't Drink the Water: The Walkerton Tragedy (Victoria, BC: Trafford).
Mullen, J., N. Vladie and A.J. Mills (2006) "Making Sense of the Walkerton Crisis," Culture and
Organization 12.3: 207-20.
Pelley, J. (2000) "Deadly E. coli outbreak focuses Canadian privatization debate," Environmental
Science and Technology 34.15: A336.
Schreier, H., and L.M. Lavkulich (2002) "Safe Drinking Water—a Local Example of a Global Chal-
lenge," Journal of Business Administration and Policy Analysis 30.31: 265.

Other sources
"Case Study: The Walkerton Experience, The Events of May 2000" (Microsoft® PowerPoint®
presentation; www.glrcap.org/image_upload/File/Walkerton%20ccise%20study%20ppt%20J
MV.ppt, 13 September 2006).
Cheng, T.Y. (2002) "What Happened In Walkerton? A Tragedy Made Sense", honours' thesis.
Mount Allison University, Sackville, New Brunswick.
"Enteropathogenic Escherichia coli in Walkerton, Ontario" (wvlc.uwaterloo.ca/biology447/
modules/module4/enteropathogenic.htm, 30 December 2006).
Walkerton and District Chamber of Commerce (2006) "Map of Walkerton, Brockton, Bruce
County, Midwestern Ontario and Ontario" (town.walkerton.on.ca/Chamber/Maps.html, 29
October 2006).
"Walkerton Tragedy" (Wikipedia; en.wikipedia.org/wiki/Walkerton_Tragedy 26 October 2006).

Discussion questions
1. W h a t r o l e d i d s t r e s s p l a y i n c o n t r i b u t i n g t o S t a n K o e b e l ' s a c t i o n s ? D i s -
c u s s t h e t y p e s of s t r e s s o r s that a f f e c t e d h i m .

2. W h a t c o m m u n i c a t i o n t a c t i c s d i d S t a n a n d F r a n k use t o d e l a y the flow of

i n f o r m a t i o n a n d w h a t effects d i d t h e y h a v e ?

3. D e s c r i b e t h e o r g a n i z a t i o n a l c u l t u r e at t h e P u b l i c U t i l i t y C o m m i s s i o n
(PUC). H o w d i d the culture influence Stan and Frank Koebel's actions?

't. U s i n g t h e d e c i s i o n - m a k i n g m o d e l as a g u i d e , e x p l a i n w h y y o u t h i n k Stan
m a d e t h e d e c i s i o n t o h i d e t h e fax f r o m t h e H e a l t h U n i t d o c t o r .

5. U s i n g the p r i n c i p l e s of b u r e a u c r a c y d e s c r i b e h o w the P U C failed the

municipality.

6. W h a t effects d i d t h e g o v e r n m e n t c u t b a c k h a v e o n t h e r e s t r u c t u r i n g of
t h e P U C a n d h o w d i d t h e s e c h a n g e s c o n t r i b u t e t o the t a i n t e d w a t e r ?
 3.2 THE STORY BEHIND THE WATER IN WALKERTON, ONTARIO McLeod and Helms Mills 193

7. W a s t h e r e a n y a t t e m p t at e t h i c a l b e h a v i o u r b y t h e P U C ? D e s c r i b e
Stan a n d F r a n k K o e b e l ' s a c t i o n s f r o m a n e t h i c a l p e r s p e c t i v e ; a n d B o b
M c K a y ' s a c t i o n s as a w h i s t l e b l o w e r .

8. D i s c u s s p o w e r a n d p o l i t i c s as t h e y relates t o t h i s c a s e .

9. U s i n g E x p e c t a n c y T h e o r y , d i s c u s s h o w Stan K o e b e l ' s j o b w a s n o t m o t i -
v a t i n g a n d w h a t c o u l d b e d o n e t o e n s u r e that h i s s u c c e s s o r d o e s n ' t
take t h e s a m e s h o r t c u t s .

10. C o u l d t h i s d i s a s t e r h a v e b e e n p r e v e n t e d ? H o w c a n O B / O T h e l p u s
understand w h y this was allowed to happen and what c o u l d have been
d o n e differently?

Teaching notes for this case are available from

Greenleaf Publishing. These are free of charge
and available only to teaching staff. They can be
requested by going to:
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