History of transgressions
● In July 1998, Havelock North had an outbreak of campylobacteriosis, which in many respects mirrored last year's outbreak.
It was attributed to unusually heavy rainfall causing flooding of water contaminated with sheep faeces into a leaking bore chamber and then via loose gland seals in the bore heads.
At the time an independent report by Stu Clark (the Clark report) raised concerns about the security of the water source and whether the aquifer was confined.
"Regrettably, while the two outbreaks shared remarkable similarities, it appears nothing was learned from the July 1998 outbreak. The district council, as the water supplier, did not take the 1998 outbreak seriously enough and implement enduring, systemic changes. Memory of the earlier outbreak simply faded," the inquiry found.
● In 2002 health protection officer Mr Inkson wrote to the both the regional and district councils alerting them to an insecure bore situated in a sheep paddock approximately 45 metres from bore 2. Neither the district nor regional council had any record of their responses (if any) to this complaint and the inquiry was left with no significant evidence other than the email itself.
● In mid-July 2013 there was a serious E. coli contamination at the Anderson Park sporting complex in Havelock North. It was determined this came from a water connection with no back-flow protection.
No illnesses resulted but suspicions that rainfall and earthworks being carried out by Te Mata Mushrooms should have been investigated further by the district council, the inquiry report said.
● In October 2015 a potentially serious contamination was discovered at Brookvale Bore 3, but the district and regional councils, as well as Drinking Water Assessors failed to respond with the level of care and concern required.
● In December 2015 high readings of E. coli were found in the regional council test bore 10496, located 230m away from bore 3 and next door to Te Mata Mushrooms. The district council commissioned Tonkin & Taylor to undertake an investigation of the 2013 and 2015 contamination events, but this happened at a slow pace with a draft only produced after the outbreak last year.
● Additional transgressions occurred in March 2007, February 2010, December 2011, January, February and July 2012, July 2013, September 2015, and January and May 2016. Each was considered to be a problem in the distribution infrastructure or reticulation.
In 2014 the ESR (Institute of Environmental Science and Research) raised concerns about the high number of transgressions, said to be on average the highest in the country for a large supply.
"The inquiry considers it unfortunate that ESR's concerns in 2014 at the number of transgressions, apparently shared by the DWAs, were not pursued in a probing and effective manner by the DWAs, the district council, or Dr Jones [Hawke's Bay DHB Medical Officer of Health Dr Nick Jones]."
In addition the ESR raised doubt about the security of the ground water source "but it seems the district council drinking water management did nothing about this important question. Continuing transgressions in the first half of 2016 still failed to provoke more extensive investigation".
HDC responds: The inquiry highlights the 1998 gastro outbreak and the fact that there was no institutional memory or learning from this event. This criticism is fair. The matter at the time was handled within the East Water business unit and it appears that it was never reported to council. It also appears that some recommendations from the Clark Report at the time were not implemented. Records of that event are scarce in council files.
Council should have been more responsive in 1998 and should have ensured that lessons from the event were kept at the forefront of water operations activities.
Separate from 1998, the inquiry highlighted a number of transgressions from 2007 onward. These were all recorded and dealt with in line with the Drinking Water Standards. However, the inquiry is signalling that HDC and the wider water industry need to be more curious and have a higher standard of care in relation to water safety and investigating transgressions. They have made it clear they view the drinking water standards as a minimum standard rather than a target.
Staff management/competence issues
The inquiry found the district council's internal staff failings applied especially to its mid-level managers, who delegated tasks but did not adequately supervise or ensure their implementation. This caused unacceptable delays to the preparation of a Water Safety Plan, which was fundamental in addressing the risks of an outbreak of this nature.
The council's water safety plan inadequately identified potential risks to the safety of the drinking water supply. It had no adequate general risk assessment system for the catchment area surrounding the Brookvale Rd bores and failed to liaise with the regional council in relation to aquifer and catchment risks that might affect its water supply.
In relation to August's event, some managers at the district council seemed to have little or no knowledge about protozoan pathogens and the significant risks associated with them.
HDC responds: Council accepts many of the criticisms made in terms of information exchange, escalation of issues, supervision and record keeping. Council is undertaking a full review of its drinking water operations which will address these issues. Actions to correct all deficiencies highlighted by the inquiry and review will be taken once completed. The review will be reported to council within the next month.
There has been a complete review and rewrite of the Water Safety Plan and the risks. This is now under review by the Drinking Water Assessors and will then be formally assessed as part of the implementation of the Drinking Water Plan. Further work on aquifer assessment and risk management needs to be undertaken in conjunction with the regional council.
Poor bore maintenance
The district council did not properly manage the maintenance of plant equipment or keep records of that work; and it carried out little or no supervision of necessary follow-up work. Specifically, it was slow to get a report on bore head security, a key plank in source water security, and it did not promptly carry out recommended improvements.
The inquiry found that the district council was also negligent in not raising the bore heads in Brookvale Rd bores 1 and 2 above ground. While this was not a method of sealing per se, it was a measure that would have substantially reduced the risk of water reaching the bore heads.
HDC responds: This criticism is largely fair. While some maintenance and inspection took place, they were not rigorous enough and record keeping was very poor. There is now a programme and system in place which schedules and monitors work and maintenance.
Lack of contingency planning
The district council had no contingency plan (referred to in various contexts also as
an Emergency Response Plan), draft boil water notices, or communications plans at the ready.
In addition there were no comprehensive contact lists prepared to alert vulnerable customers, including aged care facilities, and some schools.
HDC responds: This criticism is accepted. A full Emergency Response Plan with a Boil Water and other notices and tools is in place. It has already been used in response to transgressions at Waimarama and Eskdale.
Dysfunctional relationship with regional council
The inquiry found the district and regional councils did not work effectively and constructively together to the point the relationship was dysfunctional. The lack of collaboration and information sharing resulted in a number of missed opportunities that may have prevented the outbreak. Things deteriorated further with the regional council's prosecution of the Hastings council that was subsequently dropped.
HDC responds: The council accepts this. The quality of relationship at officer level varied from time to time and given this there was no obvious recognition that the relationship was dysfunctional or in a poor state. There was no formal reporting to councils.
Council staff, led by the chief executive, are committed to putting in place effective working relationships on water safety. The Joint Working Group on drinking water is already operational and is a very good first step to this process. In addition staff from both the regional council and the Hawke's Bay DHB have had input into the council's review of water operations.