When a Sandy City employee realized that a fluoridation pump had malfunctioned, contaminating a portion of the municipality’s drinking water, she frantically sent a text to her boss.
“OMG,” she wrote. “We overdosed them.”
It would be another week before the city widely notified residents that they could be drinking possibly tainted water.
These are but a few of the details outlined in a new investigative report released Thursday into Sandy City’s response to the water crisis. The 103-page report — which provides a day-by-day account of the decisions made by city officials and the miscommunications that kept residents in the dark — concludes the city violated technical notice rules and should have warned affected households sooner.
“A notice not to drink the water until residents had completely flushed their home systems delivered to a larger notification area at an earlier time would have alleviated many of the harmful impacts,” the report found. "The stated rationale that City employees wanted to avoid a 'panic’ was not warranted.”
While experts say fluoride is beneficial in small doses, unsafe levels can cause a number of health issues. Several residents said they had to take time off work, some for as long as a week, after experiencing gastrointestinal problems and stomach pains from the contaminated water.
The city released the report in a news release on Thursday, noting that although investigators had “found many areas of improvement,” they had deemed Sandy’s operational response “generally within normal industry standards” and found officials “did not hide information from the public.”
“While it is a painful exercise to go through an independent investigation, it is absolutely vital to make improvements in the future,” Mayor Kurt Bradburn said Thursday in a statement accompanying the report. “During an emergency it’s difficult to understand all of the moving parts that led to how decisions were made. This report provides a clear outline of what exactly happened and when.”
The report, dated May 23, was conducted by the Parsons Behle & Latimer law firm and investigated the city’s operational and regulatory response to the fluoride event from Feb. 5, when the pump malfunctioned, to Feb. 20, when Public Utilities Director Tom Ward was placed on paid administrative leave.
The city produced thousands of documents and text messages as part of the investigation, as well as lab reports, public notices, maps and other documents. Investigators also reviewed social media posts and news conferences related to the event.
Following the release of the report, Bradburn announced Thursday that he had reinstated Ward.
“The report clearly states that mistakes in communication were made but his department’s prompt response to the fluoride overfeed mitigated the impact on residents," Bradburn wrote of Ward. "It is easy to look back at an event with hindsight and want to make different decisions but I believe Tom made the best choices with the information he had at the time. The report confirms to me that public health and transparency were at the foremost of his decision-making process.”
Ward said in a statement that he was “looking forward” to getting back to work and had learned “a lot of lessons” as a result of the event.
The report states that the day after discovering the fluoride event on Feb. 7, Ward went backcountry skiing — a decision the investigators questioned, despite their finding that it had not impacted his response to the events.
“We do not fault a public employee for taking time off for personal recreation, particularly one who apparently works well beyond a ‘nine-to-five’ workday on a regular basis,” investigators wrote. “Nonetheless, we think it showed bad judgment on the part of Ward to go skiing when faced with a potential ‘super major disaster,’ the scope of which was yet to be determined.”
Sandy also misstepped in its timing getting notifications out to the affected households for a “Do Not Ingest warning,” the report states.
Once those notifications did go out — to a smaller area than was likely affected — Sandy officials removed the “Drinking Water Warning” and “Do Not Ingest Warning” language in favor of a header that read “Notice of Recent Drinking Water Quality Event.” Furthermore, no personal contact was made at 17 homes where the notice was left at the door.
The report states that backing up notifications with a widespread media announcement would have been the most effective way to ensure residents were not drinking contaminated water and could have dispelled concerns about a lack of transparency. But such notification appears to have been stymied by concern such a move would trigger “panic beyond the impacted area.”
“In sum, concerns about an overreaction by the public to a media announcement likely did not outweigh the importance, from both a public health and communications standpoint, of assuring all relevant information about the water contamination event was provided to the public as soon as practical via a media announcement,” the report concludes.
Early into the incident, Ward was contacted by a KSL reporter who asked about going to the pump station, the report states. Ward checked with city administration for approval, but by the time he responded, the journalist had lost interest in touring the station.
“My delay worked out, the [sic] moved to a prop 3 story and said they’re not running our story now and would call if they change mind,” Ward wrote in a text message exchange between he, Bradburn and others soon afterward.
“Well done!” Bradburn responded.
Ward explained to investigators that he wasn’t delaying on purpose and would not “do tongue-in-cheek" in texts anymore.
The report provides several recommendations to Sandy for dealing with future emergencies, including involving media in a public notification earlier on; establishing a comprehensive public notification system; centralizing reporting of water, taste, odor or illness complaints; and updating the public utilities emergency response plan to include more specific direction about notice of a water contamination event and communications related to noncompliance issues.