10.4.1 Instructional Design Case Study

Project Quality: Case Study

High quality is achieved by planning for it rather than by reacting to problems after they are identified. Standards are chosen and processes are put in place to achieve those standards, and ongoing action is required to ensure that they are maintained.

On May 18, 2000, schools in Walkerton, ON reported 57 ill or absent students. By the next day, a retirement home reported an outbreak of gastroenteritis among residents, and the local hospital had dozens of emergency room patients suffering from the same illness. Hundreds more people called the hospital, describing similar symptoms.

Walkerton is located in an agricultural area, and one of the three wells supplying the town’s water had become contaminated by E. coli due to rainwater runoff. The well water had been improperly treated and resulted in virtually everyone in the town of 5,000 being exposed to unsafe drinking water. By the time the cause of the outbreak was tracked down and contained, 2,300 people had become sick and seven were dead.1

In the aftermath of this public health disaster, a coroner’s inquest, a police investigation, and a provincial public inquiry were held. The outcome of the inquiry, the Walkerton Report, identified a series of systemic failures and human errors. Brothers Stan and Frank Koebel were the supervisors of the Public Utilities Commission at the time, with certification as water distribution operators received through a grandfathering of the licensing process, and not through actual formal education. They were both charged following a criminal investigation that revealed falsified reports and drinking on the job. The inquiry also revealed many improper operating procedures, including incorrect sample collection, poor system monitoring, and insufficient chlorination. The Public Utilities Commissioners in charge of oversight had inadequate knowledge and no review processes in place. When contamination was identified, this information was not disseminated to public health officials quickly enough or with enough emphasis on the dangers that the situation posed.2

Some critics laid blame for this tragedy on the various levels of government for cutbacks and too much emphasis on budgetary matters at the expense of public safety. Others argued that this tragedy would have been entirely avoidable had processes been enforced and maintained through a quality management system for water suppliers, attention to benchmarks, and adequate training and supervision for operators and managers. Were the Koebel brothers truly responsible, or were they scapegoats? How can elected officials, civil servants, and ultimately, all project managers ensure a balance between controlling costs while still maintaining quality? In what ways does planning influence a quality end product?

[1] Salvadori, M. I., Sontrop, J. M., Garg, A. X., Moist, L. M., Suri, R. S., & Clark, W. F. (2009). Factors that led to the Walkerton tragedy. Kidney International, 75, S33–S34. https://doi.org/10.1038/ki.2008.616

[2] Walkerton E. coli outbreak. (2021). In Wikipedia. https://en.wikipedia.org/w/index.php?title=Walkerton_E._coli_outbreak&oldid=1000236910