Recent news about the Flint water crisis highlights the role of risk management in protecting human health and drinking water supplies. Public health, safety and well-being is a precious commodity. The development of safe public water supplies creates major benefits by improving living standards, quality of life, and protecting against disease and sickness. The successful implementation of a safe public water supply hinges on many factors, and a key one is rigorous risk management. How could a sound risk management process have helped to protect public health in Flint?
Flint is a city in Michigan with a population of about 100,000. It was the birthplace of General Motors, but in recent years with the relocation of car manufacturing jobs, it went through an economic slump, culminating in difficulty balancing its local government budget. In 2011, with Flint facing a $15 million debt, a state of financial emergency was declared and an Emergency Manager appointed to manage the city. In an attempt to reduce drinking water costs in the face of rising prices from the water supply provided by Detroit Water and Sewerage Department; the Flint City Council and the Emergency Manager chose to proceed with a new water supply scheme from Lake Huron, the Karegnondi Water Authority (KWA). This would replace the water supply from Detroit and was projected to save Flint around $2 million a year. This prompted Detroit to terminate its contract to supply water to Flint with 12 months’ notice, leaving a gap of about two years until the KWA supply came online. To meet the shortfall, Flint chose to use the water supply from Flint River, which went live in April 2014. And that’s when the problems began.
Immediately after the changeover, residents complained about the taste, colour and odour of the water. In August 2014, E. Coli bacteria were detected and the city issued a boil water notice. Then trihalomethane (THM) levels exceeded safe limits and the Michigan Department of Environmental Quality (DEQ) issued a violation notice. THMs are a chlorine disinfection by-product linked to cancer and other diseases.
In October 2014 the General Motors plant in Flint stopped using water from the Flint River supply because it was corroding motor parts. It was known that the raw water was corrosive and that the water supply infrastructure included aging cast-iron pipes and solder that contain lead. The records of the pipes’ location, age and condition are generally not digitised, but instead recorded on 4500 cards, some dating back a century. Corrosive water can leach lead toxins from these old pipes. Lead exposure can cause long-term physical, cognitive and nervous system damage.
Flint City, Michigan DEQ, and EPA had been locked in a debate over the need for corrosion control treatment, and compliance with the Lead and Copper Rule (LCR). Lead levels far exceeding acceptable standards were first detected in January 2015, and follow-up testing showed levels of 13,200 ppb, although the federal safe level is 15. But authorities were slow to act. The option to implement corrosion control treatment to minimise leaching was not put in place. It was not until 18 months later, in September 2015, when Virginia Tech published report findings that Flint water was very corrosive and causing lead contamination in homes, and a concerned doctor released a study, confirming that the percentage of Flint children with elevated blood-lead levels had doubled since the implementation of the Flint River water supply, that the supply was turned off. In October 2016 Flint was reconnected to the Detroit water system.
To review how a comprehensive risk management process could have contributed towards better decision making and produced a safer water supply that protected public health, we need to understand the five-step risk management process:
1. Identify -> 2. Analyse -> 3. Evaluate -> 4. Treat -> 5. Monitor and Review
- The Identification Phase involves identifying events that can give rise to risks.
It is apparent that the economic risk was clearly identified – the current situation was unaffordable to the city and its residents.
The risk factors of corrosive water, and the city’s aging water pipelines containing lead, were also identified. However, it is possible that the connection was not made between the corrosive water and old cast-iron pipes triggering lead leaching.
How could robust risk identification have helped to capture these risks and their implications?
Effective risk identification uses tools and techniques to achieve balance during the identification phase, and:
- focuses on stakeholders and end-users needs – what is important to them and what will affect their overall well-being?
- uses divergent and convergent thinking,
- involves the whole team – gets team members to identify risks independently, as well as collectively,
- uses risk categories,– this helps to identify all risks by a) grouping the risks into categories in an ordered, structured way, and, b) making the team consider all aspects of the situation rather than just focusing on areas they know already,
- uses mind mapping to display risks visually.
It’s easy to identify your pet risks, and risks that are important to the hierarchy in which you work. But it’s important to be open, keep a fresh perspective, and get input from the entire team, so that you extract the maximum value when identifying risks. If this exercise isn’t completed effectively, project risks easily slip through the net.
- The Analysis Phase involves assigning a likelihood and consequence to each of the risks identified in Step 1. Using the example of Flint, we have a raw water that is very corrosive combined with ageing pipes which contain lead. The likelihood of lead leaching from the pipes would be ‘almost certain,’ and the consequence, if it did occur, would be ‘catastrophic’ to human health and well-being. It seems at this stage, the link was still not made between corrosive water, lead leaching, and harm to human health.
Running counter to this was the economic risk of staying with the Detroit water supply, which was financially unaffordable to a city in severe budget deficit, with no immediate source of alternative funding. Let’s assume that the likelihood of ongoing budget deficit due to the high cost of Detroit water is ‘almost certain,’ and the consequence is ‘major,’ because the City would become bankrupt.
- The Evaluation Phase is when we rank and prioritise the magnitude of the risk. The magnitude of the risk is a combination of the likelihood and consequence identified in Step 2. This is illustrated in the colour-coded qualitative Magnitude of Risk matrix. The likelihood is presented in the columns to the left of the matrix and the consequence is presented in the rows at the top of the matrix. When we combine the almost certain likelihood of occurrence with the major and catastrophic consequences we can see that both the economic risk and the public health risk have an extreme magnitude of risk.
This was a problem at Flint. Because the human health risks were severely under-estimated, economic well-being was given inappropriate priority over physical well-being and human health and safety. If a standardised matrix like this is used and the risk assignment is open to input from the full range of team members, then the process is transparent and structured, and the likelihood of risk magnitudes being allocated logically and correctly is significantly enhanced.
- The Treatment Phase involves working out how to treat our most serious risks, which have been identified in Steps 1 to 3. Extreme risks are considered to be unacceptable in their current form and require further treatment to reduce the residual risk to acceptable or tolerable levels. In the case of Flint water supply – how could we go about treating these two risks to reduce them to acceptable levels?
Corrosion control treatment, would have cost in the order of $80 – $100 per day. This would have avoided the lead poisoning, and had the concurrent benefit of mitigating the economic risk, because by providing a safe alternative to Detroit water the required cost savings would have been made.
- The Monitor and Review Phase is when we monitor and track risks and associated treatment strategies. Over the nearly two years that Flint River was used there were a number of incidents that should have alerted authorities to the problem; such as water monitoring showing that safe lead levels were far exceeded.
These alerts are more likely to be captured and addressed if a formal Risk Register is maintained and updated at regular intervals and whenever new information is available. Every risk has a ‘risk owner’ who takes primary responsibility for managing that risk and putting the agreed preventative and contingency plans in place when required. This leads to feedback to other parts of the risk management process and allows us to review progress and make sure that we remember to address all risks. It is also a transparent communication tool that informs team members and stakeholders what is going on.
At Flint, the risks were either not identified, or if they were identified their magnitude was under estimated, leading to risk treatment not being adequately implemented, and risk monitoring and review falling well short of the mark.
So how could a sound risk management process have helped? It could have helped by:
- Identifying all the events that could give rise to risk by: focusing on stakeholder needs, assigning risk categories, and involving the entire team in identifying the risks to ensure they are all captured.
- Analysing all risks within a standardised system of assigning likelihood and consequence. This enforces consistency and minimises the opportunity for personal preference to dominate.
- Evaluating risks within a consistent framework so that the risk magnitude is ranked in a rational manner. This means the most serious risks are clearly identified. In the case of the Flint water supply it appears that the public health risk due to leaching of toxic metals was severely under-estimated.
- Treating the extreme risks so that the residual risk is reduced to within acceptable or tolerable levels.
- Containing all risk information in a comprehensive risk register which is reviewed as new information becomes available. There were a number of feedback loops that should have alerted the water providers and regulators that there was a problem, and resulted in a review to the process and intervention to mitigate the risk. These alerts were missed or dismissed, wasting opportunities to mitigate the risk before it reached such serious levels.
It is not the purpose of this article to point the finger. People make mistakes. The challenge is to capture those mistakes and deal with them before they reach the end-users hands. This is crucial when human health, safety, and well-being are at stake. There were a number of complex, inter-related and overlapping factors at Flint and using a risk management process that is standardised, robust, structured, transparent, and focused on stakeholders and end-users, is a basic building block to prevent situations like this from occurring again.
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