Understanding the causes for water system failure

Transcription

1 Oxenford & Williams E Understanding the causes for water system failure JEFF L. OXENFORD AND SHARON I. WILLIAMS Oxenford Consulting LLC, Golden, Colo. City of Westminster, Colo. To understand the causes for water system failure and to better direct limited assistance resources, the Colorado Safe Drinking Water Program in conducted an analysis of public water system data. The goal was to use data that are routinely collected by the program to determine the root causes for system failure. Three data sets were analyzed: data tracked by the program s Acute Team, data collected during sanitary surveys, and self-reported compliance data. The results from this study clearly pointed to a number of issues that most frequently lead to critical system failure. The data are being used by the program to focus assistance resources and conduct additional investigations. Keywords: chlorine residual, compliance, cross-connections, disinfection, distribution, distribution system, regulations, sanitary survey, significant and minor deficiencies, violations, water treatment Public water systems have the responsibility of maintaining physical and human infrastructure to supply safe drinking water to the public and to comply with state and federal regulations that govern drinking water. Colorado is home to more than, public water systems, and the Colorado Safe Drinking Water Program (SDWP) is responsible for maintaining the state s regulatory infrastructure and monitoring and enforcing compliance with regulations. In addition to conducting regulatory enforcement activities, program staff routinely assist public water systems in understanding their roles and responsibilities. Staff also provide capacity-building support through training, technical assistance, and management support services. This project was conducted with the Capacity Building Unit of the Colorado Department of Public Health and Environment (CDPHE) to identify and illustrate the most common failures observed by community water systems within Colorado. Failures were defined as the inability to meet maximum contaminant levels (MCLs), reporting requirements, or other requirements of the Colorado Primary Drinking Water Regulations (CDPHE, ), identification of significant and minor deficiencies during sanitary surveys, or events that were brought to the attention of CDHPE that had the potential for acute health effects. Failure as defined for this project does not necessarily equate with a measured public health outcome. However, if these failures were not addressed they had the potential to lead to public health problems. For example, failing to monitor does not mean that there is contamination in the system, only that if there was contamination it would go undetected; identification of a cross-connection does not mean that backflow has occurred, only that it could occur. Data in this study also included the waterborne outbreak of salmonella that occurred in Alamosa, Colo. (Falco & Williams, ). It was hoped that by identifying and illustrating the most common failures, significant improvements could be made in public water system operations, regulatory compliance rates, and overall public health. Also, the unit could focus limited resources on the most critical issues facing public water systems in Colorado. APPROACH This project was initiated in September 8 and concluded in June. The project used a modified Pareto analysis to evaluate water system failures. The Pareto principle, commonly referred to as the 8/ rule, has been applied in a variety of industries to quickly set priorities and focus on the activities that would have the highest return on investment. The concept is that 8% of the benefit can be generated through % of the effort. To address the remaining % of the benefit would require 8% of the effort. By applying the Pareto principle, resources could be targeted to address the most significant issues that cause system failures and to most effectively use limited resources. For this study, the Pareto approach was modified such that a strict adherence to demarcating 8% of all the failures was not a requirement of the analysis. Instead, the rate of failure was graphed and the top categories were identified and prioritized. This simpler approach appeared well-suited for the dataset and resulted in more focused recommendations. This approach was used to prioritize resources of the program as a whole. Failures in the % area would still be addressed on a case-by-case basis. DATA SOURCES Data analyzed in this study were from a three-year period, fiscal years 6 8 (July, June, 8). All data JOURNAL AWWA American Water Works Association JANUARY 6:

2 Oxenford & Williams E came from existing programs within CDPHE and were used as provided by the program. The first data source was from the program s Acute Team tracking system. The Colorado Drinking Water Program s Acute Team comprises key staff members who respond to water system issues that could pose an acute risk to the public and therefore need an immediate response from the state. The Acute Team becomes involved when monitoring data show an acute health risk, when certain deficiencies are identified in a sanitary survey, when a public water system asks for help in an emergency, or when the program learns of an acute risk through other means. Data from all Acute Team actions were collected and stored in a spreadsheet that was maintained by the program. The second set of data consists of significant and minor deficiencies identified by CDPHE inspectors during sanitary surveys. These deficiencies have been defined by the US Environmental Protection Agency (USEPA): Significant deficiency means any situation, practice, or condition in a public water system with respect to design, operation, maintenance, or administration that the state determines may result in or have the potential to result in the production of finished drinking water that poses an unacceptable risk to the health and welfare of the public served by the water system. Minor deficiencies do not pose an immediate risk to human health but if left unaddressed for a long period of time, could get worse and cause an adverse health effect. These are often related to system management and planning. A sanitary survey is an onsite review of a public water system s water source, facilities, equipment, operation, and maintenance. Eight areas within a water system are evaluated: water sources; treatment; distribution systems; finished water storage; pumps, pump facilities, and controls; monitoring, reporting, and data verification; water system management and operations; and operator compliance with state requirements. Sanitary surveys are required by the Safe Drinking Water Act (SDWA) to be conducted a minimum of every three years for community surface water systems and every five years for community groundwater systems and noncommunity systems. (This study was conducted with regulations at the time [ 8] and does not account for changes in the Total Coliform Rule, Ground Water Rule, Surface Water Treatment Rule, and others.) In Colorado, however, many small noncommunity groundwater systems are inspected more frequently (as often as every year) by local health departments and SDWP staff. Data are stored in the Safe Drinking Water Information (SDWIS) a national database administered by USEPA where individual states are required to collect and input data (SDWIS/ State). Data are categorized by 8 deficiency codes that are assigned by the inspector. Until 8, data collected by local health departments were not routinely entered in the SDWIS/State database. Therefore, sanitary survey data from small noncommunity groundwater systems are limited in this study. The final set of data used consisted of compliance data. These data are routinely submitted to CDPHE by water systems at frequencies specified in the regulations. Data on violations and enforcement action related to the SDWA Regulations are stored in the SDWIS database. APPROACH The approach for this project consisted of three tasks. Task Data collection. Data were extracted from the SDWIS database and Acute Teams spreadsheets from state fiscal years 6 8 (July, June, 8). At the time this study was conducted, this represented the latest complete years of data for analysis. Spreadsheets were prepared for the different data sources and included Acute Team reporting history, major deficiencies identified in sanitary surveys, minor deficiencies identified in sanitary surveys, and compliance history. Task Data analysis. The second major task was to analyze the data to identify the most frequent failures and the highest-risk failures in water systems. The data were compiled in graphs and tables using Pareto analysis techniques, with frequency of failure graphed against failure type. The classification of the failures came directly from the data sources. This information was then visually assessed to determine categories of failures that contribute most significantly to compliance rates, sanitary survey deficiencies, and Acute Team responses. Task Recommendations. The final task was to use the results of the analysis to develop a set of recommendations for future program efforts to promote improvements in water system operations and management. Building recommendations based on the Pareto analysis were designed to reflect a certain transparency in decision-making so that interested stakeholders and internal staff have a clear understanding of why and how future program priorities and operations will be established. RESULTS In general, Colorado has a strong history of compliance with health-based standards, as indicated in annual reports prepared by the SDWP. This study went beyond compliance rates to include both health-based and nonhealth-based violations and data collected about operational failures and system deficiencies. The goal was to identify types of failures that could potentially lead to more significant issues in the future. Events reported in the Acute Team tracking database. The Acute Team tracking database included 6 acute events reported during the three-year study period (6 8). Acute events were organized according to frequency and the category of failures observed and then compared with the type of response action warranted by the failure (Figure ), type of public water system affected, and the duration of the event response (Figure ). The acute events reported in the Acute Team database were organized into the following categories: Distribution Deficiency, Treatment Deficiency, Surface Water (SW), Bacteriological (bacti)/microscopic particulate analysis (MPA) Results Causing Acute Situation, Treatment Deficiency, Groundwater (GW), Untreated Groundwater (GW) Intended for Drinking, Untreated Surface Water (SW) Intended for Drinking, Tampering/Security, Source Water Supply Disruption. JOURNAL AWWA American Water Works Association JANUARY 6:

3 Oxenford & Williams E FIGURE Failure classification by response action Boil water order = 7 Bottled water order = Other public notice = No further action = 6 Acute Team Incidents* number Distribution Deficiency 6 Treatment Deficiency, SW Bacti/MPA Results Causing Acute Situation Treatment Deficiency, GW Untreated GW Intended for Drinking 6 Untreated SW Intended for Drinking Tampering/ Security Source Water Supply Disruption Failure Classifacation Bacti/MPA bacteriological/microscopic particulate analysis, GW groundwater, SW surface water *Total = 6 (These categories align in general with failure classifications used by the Centers for Disease Control and Prevention when reporting on the underlying causes of waterborne disease and outbreaks associated with drinking water in biennial surveillance reports.) In Figure, the number and categories of failures observed were compared with their response actions. This chart illustrates the utility of a Pareto analysis. Although the Acute Team responds to a variety of events, this analysis shows that the top two failures requiring a response were Distribution Deficiency (such as pipe breaks, leaks, and power outages) and Treatment Deficiency (such as turbidity spikes, chlorinator failures, and positive coliform results). Together, these two categories comprised more than half of all Acute Team responses. By focusing resources on preventing distribution system and surface water treatment deficiencies, the SDWP has the potential to reduce internal resource demands and produce a significant and measurable overall benefit to public water systems in Colorado. Figure provides a comparison among the categories of failures observed and the duration of the response as of October, 8. As shown, systems with untreated groundwater or surface water intended for drinking had the longest order durations in response to acute events. The average duration of most bottled water orders was less than days, whereas the average duration of bottled water orders for untreated groundwater or surface water was and 6 days, respectively. This was probably because of the long lead time to design and construct infrastructure improvements to provide proper treatment where none existed. In addition to the data analysis just provided, several observations and insights were noted regarding the Acute Team tracking database and the nature of acute responses. The observations and insights listed subsequently show the effect of acute response events and the usefulness of compliance data in flagging areas of concern. JOURNAL AWWA American Water Works Association JANUARY 6:

4 Oxenford & Williams E FIGURE Failure classification by order duration Boil water order Bottled water order Acute Team Incidents days 6 8 Distribution Deficiency Treatment Deficiency, SW 8 Bacti/MPA Results Causing Acute Situation 6 Treatment Deficiency, GW Untreated GW Intended for Drinking Untreated SW Intended for Drinking Tampering/ Security Source Water Supply Disruption Failure Classifacation Bacti/MPA bacteriological/microscopic particulate analysis, GW groundwater, SW surface water Data compiled on Oct., 8, for the period of record of July, June, 8 One hundred twelve (7%) of all 6 acute responses required Tier public notification, which involves notifying the public of the condition as soon as practical but no later than hours after the system operators learn of the condition. Ninety nine (6%) of all 6 acute responses required a boil or bottled water order. Nearly 6, people were affected by boil or bottle water orders. The spring 8 salmonella outbreak in Alamosa, Colo., which affected, people, was the largest boil or bottled water event during this period. Thirteen (68%) of the systems that reported bacti/mpa acute failures had at least one violation before the acute event (not necessarily a Total Coliform Rule [TCR] violation). Four (%) of the systems that reported bacti/mpa acute failures had TCR monitoring and reporting violations following the event. Six (%) of the systems that had an acute response to turbidity spikes had reported turbidity violations before acute violations. Four of these systems were using bag filters. Seventy percent of all distribution system deficiencies were caused by loss of system pressure from main breaks, loss of power, or other infrastructure failures. Sanitary survey deficiencies. The SDWIS/State included data for a total of, sanitary surveys conducted during the three-year study period (6 8). Sanitary surveys may have identified multiple significant or minor deficiencies, and the data was organized into eight categories. These categories were based on the eight components of a sanitary survey provided in the Colorado Primary Drinking Water Regulations as follows. Treatment Distribution Monitoring, Reporting, and Data Verification Source Finished Water Storage Management and Operation Pump/Pumping Facility and Control Operator Compliance with State Regulations Within each category, violation codes were assigned by inspectors. There are more than 8 potential violation codes. Significant deficiencies. During the three-year study period, significant deficiencies were found during 8 (%) of the, sanitary surveys reported in SDWIS. In these systems, there were separate significant deficiency observations, or an average of nearly two significant deficiencies per deficient JOURNAL AWWA American Water Works Association JANUARY 6:

5 Oxenford & Williams E FIGURE Sanitary survey significant deficiencies by system type Community = Transient noncommunity = Nonpublic = Nontransient, noncommunity = 6 7 Significant Deficiencies* number Treatment Distribution Operator Compliance With State Requirements Monitoring and Reporting and Data Verification Source Finished Water Storage Management and Operation Area of Deficiency Data compiled on Oct., 8, for the period of record of July, June, 8 *Total = system. Most of the systems that had significant deficiencies also had minor deficiencies. For this project, the data on significant and minor deficiencies were evaluated using a Pareto analysis to identify specific issues that could be prioritized for maximum potential benefit from the use of resources. First, an analysis was conducted to determine the top 8 (8%) of all significant deficiencies identified during the study period (before grouping by category). The most common significant deficiency codes were associated with a lack of a certified operator, failure to obtain design approval, deficient disinfection equipment, and inadequate disinfection residual in the distribution system. (Improvements with operator certification requirements and enforcement were already under way during the period of this study. These activities have greatly improved compliance with operator certification requirements. Thus, operator certification itself was not further addressed in depth in this work.) In Figure the significant deficiencies were grouped by category, and then the number and categories of deficiencies were compared with the type of public water system where the deficiencies were observed. As shown, the most common significant deficiencies were associated with treatment processes ( or %), distributions systems ( or %), operator compliance with the regulations ( or %), and monitoring, reporting, and data verification (8 or %). The majority of significant deficiencies occurred in community water systems; however, this may have been in part an artifact of the data-collection process. Sanitary surveys are conducted a minimum of every three years for community surface water systems and every five years for community groundwater systems and noncommunity systems. In addition, although small noncommunity groundwater systems are inspected more frequently (as often as every year) by the SDWP in partnership with local health departments, the results of those surveys were not routinely entered into SDWIS/State during the majority of the study period. As of 8, these data were being entered into SDWIS/State; however, a skew in the data toward community systems still existed for the study period. JOURNAL AWWA American Water Works Association JANUARY 6:

6 Oxenford & Williams E6 FIGURE Sanitary survey deficiency classification by source type Groundwater under the influence of surface water = Groundwater = Surface water = Purchased surface water = Significant Deficiencies* number Treatment Distribution Operator Compliance With State Requirements 7 Monitoring and Reporting and Data Verification Source Finished Water Storage Management and Operation Deficiency Classification *Total = Overall, approximately 7% of public water systems in Colorado are groundwater systems and the remaining percentage is surface water or groundwater under the direct influence of surface water (GWUDI). Figure provides a comparison between the number and categories of significant deficiencies and the source of the drinking water for the system where the deficiency was observed. As shown, (%) of all significant deficiencies were associated with groundwater systems, 6 of which were treatment-related deficiencies. Given that treatment deficiencies were the most common type of significant deficiency observed (Figures and ), the nature of treatment deficiencies was further evaluated. In Figure, all observed treatment deficiencies ( total) were evaluated based on unique treatment-related deficiency codes. As shown, the most common treatment deficiencies were a lack of or inoperable disinfection equipment ( or 6%) followed by cross-connection issues (7 or %). s with these deficiencies are at a greater risk of a waterborne disease outbreak. Because distribution system deficiencies ranked second highest in the total number of significant deficiencies observed (Figures and ), the nature of distribution system deficiencies was also further evaluated. In Figure 6 all observed distribution system deficiencies ( total) were shown based on their deficiency codes. The most common distribution system deficiencies were a failure to maintain disinfection residuals (7 or %), followed by crossconnection issues ( or %), and raw or untreated water service (6 or %). These deficiencies have a very high potential for a significant effect on public health. Monitoring, reporting, and data verification deficiencies ranked fourth highest in the total number of significant deficiencies observed (Figures and ), and therefore the nature of these deficiencies was further evaluated. In Figure 7 all monitoring, reporting, and data verification deficiencies (8 total) are illustrated based on their deficiency codes. As shown, the most frequent monitoring, reporting, and data verification deficiency was failure to obtain plans and specifications approval for the system or renovations to the system ( or 6%). Anecdotal information suggests that many water systems, their operators, and their design engineers did not understand the design criteria or failed to understand the significance of JOURNAL AWWA American Water Works Association JANUARY 6:

7 Oxenford & Williams E7 FIGURE Sanitary survey significant deficiencies for treatment Significant Deficiencies* number 7 T T T T T T T T6 T T T T T T T T6 Deficiency Code CPDWR Colorado Primary Drinking Water Regulations *Total = No disinfection equipment present or equipment not operating. CPDWR 7.. (a),(b) & 7.6.(b);S (CDPHE, ). has an uncontrolled cross-connection that allows contamination to enter drinking water that will cause an immediate sanitary risk. CPDWR. (a);s (CDPHE, ). many of the provisions in the criteria. Failure to obtain proper approval can lead to other failures at a later date. Minor deficiencies. Minor deficiencies were found during 77 (%) of the, sanitary surveys reported in SDWIS/State during the three-year study period. In these systems, there were,86 separate minor deficiency observations. The top, (8%) of all the minor deficiencies identified during the study period (before grouping by category) corresponded to a lack of or inadequate planning for cross-connection control, bacti sample-siting, monitoring, and emergency response. In Figure 8 the minor deficiencies were grouped by category, and then the number and categories of deficiencies were compared with the types of public water system where the deficiencies were observed. As shown, the most common minor deficiencies were associated with monitoring, reporting, and data verification ( or %) and system management and operation (8 or 6%). Because monitoring, reporting, and data verification de - ficiencies were the most common minor deficiencies observed, the nature of these deficiencies was further evaluated. In Figure, all observed monitoring, reporting, and data verification deficiencies ( total) are shown based on their deficiency codes. The most common monitoring, reporting, and data verification deficiency codes were a lack of or inadequate bacti sample-siting plan ( or %), a lack of or inadequate general monitoring plan ( or 8%), and inadequate record keeping or document retention (6 or 8%). Regulatory violations. Reports from SDWIS/State included more than 6, violations (largely associated with monitoring and reporting) during the three-year study period. Of the, public water systems in Colorado, a total of,86 (approximately 6%) reported at least one violation. These water systems collectively provide water to 7% of the population served by all public water systems. A total of water systems (% of all systems in Colorado) reported at least one violation in the high-priority categories of MCL or treatment technique violations; these violations do indicate an increased public health risk. This information is summarized in Table. In Figure, all violations reported in SDWIS for the threeyear study period were grouped according to the violation categories shown in Table for Colorado drinking water JOURNAL AWWA American Water Works Association JANUARY 6:

8 Oxenford & Williams E8 FIGURE 6 Sanitary survey significant deficiencies for distribution systems Significant Deficiencies* number 7 6 D D D D7 D6 D8 D Deficiency Code CPDWR Colorado Primary Drinking Water Regulations *Total = is not maintaining the required disinfection residuals in the distribution system. CPDWR 7..(c)()(i) & 7.6.(c);S (CDPHE, ). has an uncontrolled cross-connection that allows contamination to enter drinking water that will cause an immediate sanitary risk. CPDWR. (a);s (CDPHE, ) has customer service connections that serve untreated drinking water. CPDWR 7..(c) & 7.6.(b);S (CDPHE, ). rules. These groupings were then plotted to show the types (i.e., category and rule) of violations most commonly reported by public water systems. The drinking water regulations used in this evaluation pertain to inorganic contaminants (IOC), radionuclides, synthetic organic chemicals (SOC), volatile organic chemicals (VOC), consumer confidence reports, disinfection by-products (DBPs), Lead and Copper Rule, public notification, Surface Water Treatment Rule, and TCR. As shown in Figure, the largest number of monitoring and reporting violations occurred with the VOC, SOC, and IOC regulations. However, each of these contains a suite of contaminants that must be monitored at the same time, and therefore any single failure to sample/report may result in multiple violations, one for each contaminant in the suite. No public water systems reported MCL violations for VOCs and SOCs; 6 MCL violations were reported for IOCs. Figure compares the number and categories of violations with the number of public water systems in which the violations were reported. As shown, the greatest number of individual public water systems reported monitoring and reporting violations of the TCR (7 or 6% of all systems with violations), followed by the IOC violations (8 or 7% of all systems), and the Disinfection/Disinfectants Byproducts Rule ( or 6% of all systems with violations). MCL violations were most frequently associated with the TCR ( or % of all systems with violations), followed by the JOURNAL AWWA American Water Works Association JANUARY 6:

9 Oxenford & Williams E FIGURE 7 Sanitary survey significant deficiencies for monitoring, reporting, and data verification Significant Deficiencies* number 6 R R7 R R R R7 R R Deficiency Code CPDWR Colorado Primary Drinking Water Regulations *Total = 8 has not received plans and specifications approval for the system or for renovations to the system, including the addition of new sources, changes in treatment or changes in the distribution system. CPDWR..;S (CDPHE, ). Radionuclide Rule ( or % of the systems with violations), and IOC violations ( or % of the systems). KEY FINDINGS A modified Pareto analysis of the failure data for a threeyear study period (ending June, 8) from the division s Acute Team tracking database and the SDWIS/State database showed important trends in compliance failures at public water systems in Colorado. The following are key findings from analysis of this data. Acute Team data show that approximately 8% of the system failures resulting in a response were associated with o distribution system deficiencies and o bacteriologic result indicating an acute health concern (such as an Escherichia coli positive sample). The majority of acute responses occurred at community water systems, although this may be the result of transient and nontransient water systems failing to report to the Acute Team during the study period. s with failures associated with untreated groundwater and surface water intended for drinking resulted in the longest duration of boil or bottled water orders. Although the full extent of the public health effect is unclear, more than 6, people were affected by boil or bottled water orders during acute events during the three-year study period. SDWIS/State data from sanitary surveys showed that individual significant deficiencies were most commonly associated with the lack of a certified operator, failure to obtain design approval, deficient disinfection equipment, and failure to maintain an adequate disinfection residual in the distribution system. When grouped into categories, significant deficiencies were most commonly associated with o treatment (primarily inadequate disinfection equipment) and o distribution systems (primarily failure to maintain disinfection residuals and cross-connection control). SDWIS/State data showed that minor deficiencies were most commonly associated with nonexistent or inadequate cross- JOURNAL AWWA American Water Works Association JANUARY 6:

10 Oxenford & Williams E FIGURE 8 Sanitary survey minor deficiency classification by public water system type Community water system = 8 Transient noncommunity = Nonpublic = Nontransient, noncommunity = 78 Minor Deficiencies* number Treatment Distribution Operator Compliance With State Requirements Monitoring and Reporting and Data Verification 6 6 Source Finished Water Storage Management and Operation Pump/ Pumping Facility and Control Deficiency Classification *Total =,86 connection control plan, bacti sample siting plan, or monitoring plan. When grouped into categories, minor deficiencies were most commonly associated with o monitoring, reporting, and data verification (primarily lack of or inadequate bacti sample siting plan and general monitoring plan) and o system management and operation (primarily failure to maintain cross-connection control). SDWIS/State compliance data also showed that although 6% of all systems in Colorado reported at least one violation during the study period, the majority of violations were monitoring and reporting violations, which are not necessarily associated with an increased public health risk. About % of the systems reported at least one violation in the high-priority category of MCL violations, which do indicate an increased public health risk. MCL violations were most frequently associated with the TCR, followed by the radionuclide and inorganic contaminant violations. In summary, the data collected over the three-year period suggested the following primary reasons for observed failures in public water systems: Disinfection o Failure to maintain disinfection residuals o Inadequate disinfection equipment o Positive total coliform samples Cross-connection control o Presence of cross-connections o Lack of cross-connection control planning Distribution system operations o Failure resulting in loss of system pressure o Failure to maintain disinfection residuals o Failure to maintain cross-connection control Failure to plan o Lack of or inadequate bacti sample siting plan o Lack of or inadequate general monitoring plan JOURNAL AWWA American Water Works Association JANUARY 6:

11 Oxenford & Williams E FIGURE Minor deficiencies for monitoring, reporting, and data verification Minor Deficiencies* number R R R R R R R7 R R6 R7 R R6 R R R8 R R7 R R R R R R R Deficiency Code CPDWR Colorado Primary Drinking Water Regulations *Total = lacks a properly designed bacteriological sampling plan; plan is inadequate for the system. Not having a bacteriological sampling plan is an alleged violation of the CPDWR..(e),..(a);M (CDPHE, ). lacks a monitoring plan detailing the system s background information, sources, treatment, and distribution system or plan has not been properly maintained. CPDWR.;M (CDPHE, ). does not maintain records according to the minimum requirements, including five years bacteriological analysis, including turbidity, years chemical analysis, years sanitary surveys. CPDWR.6.;M (CDPHE, ). o Failure to obtain design approval Management and operation o Operator compliance with state requirements o Failure to monitor and report water quality in compliance with regulations o Failure to obtain design approval before construction The sanitary survey results indicated a lack of adequate planning, and compliance data in turn reflected a failure to execute planned or required activities. Minor deficiencies were most frequently related to lack of or inadequate plans for monitoring cross-connection control. A lack of planning can create the conditions that lead to treatment upsets, distribution failures, and contaminated water. RECOMMENDATIONS The recommendations from the modified Pareto analysis described in this article provided the basis for the Capacity Building Unit of the Colorado SDWP to effectively target resources to address the most common failures of public water systems. The key recommendations from this project follow. Focus training, technical assistance, and management support services on the key weaknesses and compliance failures identified in this study. The failures identified can be used to prioritize and target training, technical assistance, and other support activities. Develop programs to further assess the root cause of monitoring violations and to reduce them. The most common failure among public water systems is failure to comply with monitoring JOURNAL AWWA American Water Works Association JANUARY 6:

12 Oxenford & Williams E TABLE Summary of violations data Violation Category Population Affected by Violations Population Affected by Violations % Population Unaffected by Violations % Number of Water s Affected by Violations Water s Affected by Violations % Water s Unaffected by Violations % All,6,6 6.., MON,,..7,8..78 RPT, MCL 6, TT 8, PN....8 SS MCL maximum contaminant level, MON monitoring, PN public notice, RPT reporting, SS sanitary survey, TT treatment technique FIGURE Violation classification by rule, MCL violations = 6 TT violations = M&R violations =,7 CCR+PN violations = 6,,6,,,,8 Violations number,,,,,, IOC RAD SOC VOC CCR DBP LCR PN SWTR TCR Rule or Regulation CCR consumer confidence reports, DBP disinfection by-products, IOC inorganic contaminants, LCR Lead and Copper Rule, MCL maximum contaminant level, M&R monitoring and reporting, PN public notification, RAD radionuclides, SOC synthetic organic chemical, SWTR Surface Water Treatment Rule, TCR total coliform rule, TT treatment technique, VOC volatile organic chemical JOURNAL AWWA American Water Works Association JANUARY 6:

13 Oxenford & Williams E FIGURE Number of PWSs with violations classified by rule 8 MCL systems TT systems M&R systems CCR+PN systems PWS number IOC RAD SOC VOC CCR DBP LCR PN SWTR TCR Rule or Regulation CCR consumer confidence reports, DBP disinfection by-products, IOC inorganic contaminants, LCR Lead and Copper Rule, MCL maximum contaminant level, M&R monitoring and reporting, PN public notification, RAD radionuclides, SOC synthetic organic chemical, SWTR Surface Water Treatment Rule, TCR total coliform rule, TT treatment technique, VOC volatile organic chemical and reporting regulations. Although the health effects of inadequate monitoring are difficult to quantify, monitoring is clearly key to ensuring safe water. Although this study shows that failure to monitor is an important issue, it does not identify the root cause for these failures. Additional studies may be needed. Continue improving data consistency and use the resulting data to develop benchmarks for improvement. This study was made possible by the extensive database within the program. Improving data consistency and availability is an ongoing effort, and should continue. Benchmarks should be established to track and assess improvements in public water system performance and to evaluate the effectiveness of capacity-building services and other programs. Use these and future report results to promote and enhance communication with stakeholders. The project results provide a foundation for improved communication with stakeholders and for focused development of capacity-building services. The results provide a certain transparency in decision-making so that interested stakeholders as well as internal staff have a clear understanding of why and how program priorities and operations are established. The program has already addressed many of the recommendations of this study. These have included an increased emphasis on improving disinfection practices, working with systems to develop monitoring plans, and incorporating the results of this analysis into training content statewide. The program is actively engaged with the AWWA Rocky Mountain Section and other training providers in the state to develop a statewide training strategy. Through analysis such as this study and continual data quality improvements, Colorado has an opportunity to continue being one of the leaders in the nation in providing safe water. ACKNOWLEDGMENT The authors would like to acknowledge Dean Vlachos, Jon DeBoer, Dave Rogers, Richard Summerville, and Margo Griffin for their assistance on this project. JOURNAL AWWA American Water Works Association JANUARY 6:

14 Oxenford & Williams E ABOUT THE AUTHORS Jeff Oxenford is principal of Oxenford Consulting LLC, Washington Ave., Golden, CO 8 USA; joxenford@comcast.net. He is currently leading training of operators on a wide range of topics that include distribution system water quality, main location, leak detection, and board and council training. Oxenford has worked for the New Jersey Department of Environmental Protection, Awwa Research Foundation, and Stratus Consulting. He received his bachelor s degree in chemistry and environmental management from Warren Wilson College in Swannanoa, N.C., and his master s degree in environmental engineering from the University of North Carolina at Charlotte. Sharon I. Williams is the water resources engineering coordinator for the city of Westminster, Colo. PEER REVIEW Date of submission: // Date of acceptance: // REFERENCES CDPHE (Colorado Department of Public Health and Environment),. Colorado Primary Drinking Water Regulations. CCR -. Water Quality Control Commission, CDPHE, Denver. Falco, R. & Williams, S.I.,. Waterborne Salmonella Outbreak in Alamosa, Colorado March and April 8. Safe Drinking Water Program, Water Quality Control Division, CDPHE. obheadername=content-disposition&blobheadername=content-type&blo bheadervalue=inline%b+filename%d%alamosa+outbreak+investigati on+report+.pdf%&blobheadervalue=application%fpdf&blobkey=id& blobtable=mungoblobs&blobwhere=8777&ssbinary=true (accessed November ). Oxenford, J.L. & Williams, S.I.,. Failure and Root Cause Analysis Project Report. Capacity Building Unit, Colorado Safe Drinking Water Program, CDPHE. =Content-Disposition&blobheadername=Content-Type&blobheadervalue= inline%b+filename%d%failure+and+root+cause+analysis+project+re port+.pdf%&blobheadervalue=application%fpdf&blobkey=id&blobtable =MungoBlobs&blobwhere=8768&ssbinary=true (accessed November ) USEPA (US Environmental Protection Agency),. Sanitary Survey. Office of Water, Washington. (accessed November ). JOURNAL AWWA American Water Works Association JANUARY 6: