An accident can be described as an undesirable event that could have been prevented, had the contributing factors to the event been identified and action taken to prevent it: these could be human factors, organisational factors, or predisposing factors. The same can be said of the events leading to the litigation sought by the residents of Woburn, Massachusetts in the USA. Approximately 50 years ago, the residents complained continuously of foul tasting waters (due to high concentrations of manganese and iron making it undrinkable), between the years 1964 and 1979, supplied by the municipal wells. The situation was further escalated by the increased incidences of Leukaemia and eventually death of two individuals in the area supplied with contaminated water. The ensuing law suit involved the directly affected residents (eight East Woburn families) and two multi-national corporations: W.R. Grace & Co. and Beatrice Foods Inc. The plaintiffs alleged that consumption of the contaminated water due to chemicals present in both defendants’ industries - as confirmed by the findings of a test conducted in the water samples in both wells - was responsible for the severe health defects. Seven of the plaintiff’s kids contracted leukemia – five of whom died from the condition and from complications due to the condition. However, the spouse of one of the plaintiffs in the case also contracted acute myelocytic leukemia and passed away. The emotionally charged case was filed in 1982 to a Municipal court before it was moved to a federal court: which later signed a 68.2 million dollar 20-50 year plan to clean up East Woburn and its environs. Due to the complexity of the case, it was divided into four stages in the court: stage one to determine if the chemicals of said industries contaminated wells G and H during the fifteen year period in operation, which if true at the time, would proceed the court to address health effects in the following two stages before punitive damages were addressed in the final stage.
In this case study, the wells G and H were initially intended to supply water during emergencies or dry seasons. There were also other wells to the south of its location that regularly supplied water to residents. The wells to the south were located on a different aquifer compared to wells G and H; which also explained why only G and H were affected by contaminants. River Aberjona – which contributed 50% of the water in wells G and H –was alleged to convey toxic chemicals that contaminated the aquifer for wells G and H.
The failure in the system can be best analyzed using the James Reason Swiss Cheese Model. The model describes a layered sort of measure used in healthcare and other disciplines used to anticipate faults, problems or challenges that may affect a system and each security layer/measure is uniquely designed to deal with each failure of previous measure: penetration in depth. Each measure has its own strengths and weaknesses: like holes in a Swiss cheese, and like Swiss cheese, the security layers are designed in such a way that no one problem should be able to go through all the loopholes in the system – for instance, the probability of the holes in 5 Swiss cheese in a linear arrangement aligning in such a way that a rod can go through all holes is highly unlikely. The Woburn hydrology case study presents a classic case where the loopholes in the security measures (big or small) aligned leading to a failure in the system that lasted fifteen years before it was addressed.
An aquifer is basically an area under the ground bearing water that can be accessed by dropping a well to its water level. They occur in different areas and at different depths under the ground: wells G and H were on a different aquifer unlike the rest to the south, all contributing to the City’s water supply. The wells G and H were dug in the mid-60s despite objections presented to city officials by their consultant that the water was unpalatable for drinking. Chemicals dumped in proximity to wells G and H by the two multi-national corporations leaked into River Aberjona eventually collected at the bottom of both wells as Volatile Organic Compounds (VOCs) making the water undrinkable. The measure put in place to anticipate and mitigate this sort of scenario is mandated to the United States Environmental Protection Agency charged with responsibility of protecting public health. The fact that they responded to the problem after 15 years represents an organizational failure: due to a lack of technology (mass spectrometer) to test the claim. However, it’s a fact that they did not anticipate the consequences of industrial waste being dumped in proximity of domestic water supply wells.
The two multinational corporations deemed responsible for the VOCs by the court also represent a failure in the system that was alluded to in court by the litigants’ lawyer: Michael B. Keating – Grace Attorney – alluded to the fact that multi-national corporations always got away with allegations of contaminating of the environment despite the fact that people always got hurt by theirs reckless endangerment. This statement alludes to the extent of influence that multi-national organizations wield even over the judicial systems in place. Cryovac Plant, owned by W.R. Grace & Co, used TCE to clean equipment but took no proper measures to dump the material. Beatrice Foods on the other hand was sued since they were responsible for any legal liability incurred by the Tannery in question.
A precondition failure is also evident in this case study by the US EPA and the local health authorities. The City authorities only closed the wells immediately after information was provided by a health inspector that the both wells were contaminated with high concentrations of Trichloroethyline (TCE), Perchloroethyline (PCE) and some organic compounds.
The city officials therefore could not act before the intervention of local health inspectors (mass spectrometer became a standardized laboratory tool in 1979) or US EPA to validate the claims by local residents of East Woburn, Massachusetts. The health officials also could not take action a report from the US EPA advised them to do so. The US EPA in collaboration with the USGS were able to identify the some of the contaminant properties in the course of their investigations.
It would also be important to note that despite complaints by residents about the foulness of the water, no action was taken to supervise the wells – either by city officials, health officials and US EPA – to identify the basis of such claims and eradicate the causal VOCs. The residents of East Woburn complained for almost 15 years during which time, no recorded efforts were made to investigate their claims. In 1979, a resident is said to have reported pollution of the Aberjona River by unknown materials from about 180 barrels of the substance. It was this report that prompted health officials to dispatch a health inspector to investigate the report. In the course of examining samples from wells G and H that were in proximity of the alleged pollutant barrels of unknown materials, it was discovered that other severe toxic materials were present in high concentrations in wells G and H. The deponents in the case – retired and present employees of the Cryovac Plant belonging to W.R. Grace & Co.– gave factual information that about a quarter of a gallon of trichloroethylene was discarded on the grounds just behind the plant every day. Data from US EPA and USGS revealed during the trial showed TCE concentrations in shallow wells installed at the plant exceeded 8000 µg/L, while concentration in wells G and H also exhibited relatively high concentrations: TCE at 267 and 118µg/L and PCE at 21 and 18µg/L against a health standard value of 5µg/L.
Beatrice Foods also owned a tannery that shared a 400 meter long boundary with the Aberjona River. This particular parcel of land was stock full of more than 50 decaying containers filled with toxic waste.
The court was also presented with admissible evidence that detailed availability of said materials as far back as 1968. It was also discovered, by order of the court to dig shallow wells in the site, that the concentrations of TCE was present in excess of 400,000µg/L.
All available measures by use of Reason’s Swiss cheese analysis therefore failed in a manner that overlapped from one measure to the next hence a failure in the system.
References
Jones, N. (2013, December 02). Brief History. Retrieved March 14, 2016, from Woburn Hydrogeology Data: http://ce547.groups.et.byu.net/woburn/briefhistory.php
Kenndy, D. (1986). Toxic waste case is givent to the Jury. Woburn's landmark trial , 5A.
Metheny, E. S. (1999, March). A civil Action - What will be the legacy of wells G and H. Ground Water .
Metheny, M., & Bair, A. S. (2011). Lessons Learned from the Landmark ‘‘A Civil Action Trial". (H. E. David Deming, Ed.) Ground Water , 49 (5), 764-769.
Ryan, C. C. (1989). E. Woburn Clean-up to Cost $68 Million. Woburn Times Article , 1-3.
Science Education Resource Centre at Carleton College. (2008, April 23). The Woburn Toxic Trial. Retrieved March 20, 2016, from Science in the Courtroom: http://serc.carleton.edu/woburn/Case_summary.html
