Barrow outbreak in august 2002
Late 19th century and most of the 20th century have witnessed a sea change in the life style patterns and technological revolutions across the globe. Only in late 20th century and the beginning of the new millennium did we realize the impending ecological disasters that man has wrought on himself. One such incidence is the Legionella affair costing 7 lives and affecting more than 100 people with community acquired Pneumonia. Barrow Borough council, under the scrutiny of health and law officials had many questions to be answered and made accountable for the lacunas while providing public utility services. Forum 28 where the Eco disaster took place was devoid of technical and administrative controls due to the negligence of the manager. Ms.Beckingham was convicted under section 7 of the Health and Safety at work etc Act 1974 due to her non-compliance with operational issues concerning the water treatment in the air conditioning system, ensuring public safety. One each of the chilling and cooling system failed in Forum 28 and the automatic dosing system was not replenished at the appropriate time. The failure to deal properly with correspondence from Health and safety executive (HSE) and delay in completing written risk assessments also formed a part of the charges leveled against the firm, which could not anticipate the enormous public damage that its duty negligence has caused. Corporate accountability, as ensured by appropriate regulatory authorities, would go along way in cementing the confidence of the general public in service providers like Barrow council. We face biological threats like Legionella only when we shirk from the collective responsibility and do not keep our selves well informed about community acquired infections. Public awareness assures safer generation next.
Man is a social animal and down the ages he has strived hard to discover himself through materialism and opulence. In this process he has landed himself and the rest to mind blowing ecological disasters that questioned his pursuits for comforts. Yet man is not ready to learn from his past. I would like to bring forth an incident that, by human error, has led to 7 deaths and many getting affected in the process. Many would not accept the fact that entertainment centres offer a large variety and scope for unhygienic conditions which generally tend to get ignored, in the name of commercialization. Disease spread and its epidemeology is least understood by many, including experts, since the involvement of multitude of factors.
Outbreaks of communicable diseases associated with cooling towers, whirlpools and other water containing sources do occur off and on around the world. One such incident occurred in the arts and leisure center owned by Barrow Borough council in the town of Barrow-in-Furness in South Cumbria between 29th July and 2nd of August 2002. This was identified as Legionnaire's disease causing seven deaths and 180 people seriously infected due to faulty air conditioning unit at Forum 28.
DESCRIPTION OF THE DISEASE:
Legionnaire's disease, a form of Pneumonia caused by the bacterium Legionella pneumophila, is spread by contaminated air and results in symptoms ranging from high fever, chills, dry cough, breathing difficulties and may lead to fatality.
The bacteria is present in environment, but if they get into water systems in buildings they spread through air conditioning systems. Legionella survives in water temperatures from 0oC to 60oC.They do not multiply below 20oC and do not survive above 60oC.They remain dormant in cool water and become most virulent at 370C. The biofilms, sludge and scale would favour the growth of bacteria protecting it from temperatures and concentrations of biocides.
OCCURRENCE OF THE OUTBREAK:
Community Acquired Pneumonia (CAP) cases have been increasingly noticed by Furness General Hospital between 26th July and 29th July and two cases of Legionnare's disease which were notified by 1st of August 2002 led to the initiation of the Barrow outbreak incident.
Approximately 2500 people were known to be affected during the course of the outbreak among which 494 cases were clinically diagnosed as possible cases, 180 of which were identified as confirmed cases. Seven people died which accounts to the death rate of 3 to 5% during the acute phase of the outbreak.
After the discovery of this outbreak the Outbreak Control Team(OCT) has identified the source of infection in people so as to manage the consequences of the outbreak.Genetic fingerprinting linked the type of Legionella bacteria isolated from the patients in Barrow to that found in Forum 28 thereby the cooling towers at Forum 28 were shut down the same day.
The Forum 28 building has an air conditioning system to achieve a pleasant working environment inside the building comprising of two refrigerant plants or 'chillers', Carrier 120 HRs; two cooling towers, Baltimore VXT 85s;a chemical dosing system; three carrier interchillers. These units are also known as 'air handling units' (AHUs).
A schematic diagram of the air conditioning system servicing Forum 28
functioning normally is as follows:
Water circuit in the cooling towers provided an ideal environment with the temperatures at 280c to 390c for the proliferation and survival of Legionella bacteria.
The points of System failure depicted below:
During the outbreak some technical failures were identified as follows:
One chiller and one cooling tower gone out of service as shown in the figure above. Due to the failure of the fan scroll units the fan unit in tower 1 was isolated. The fan damper on tower 2 was reducing the volume of air that was passing up through the tower. Despite these failures, the system was still working as one chiller unit was servicing one cooling tower. The biocide drums were found empty which was the result of the failure of the chemical biocide dosing arrangement to deliver chemical into the system.
The investigation team, Health and safety executive (HSE) and the police investigated possible breaches under health and safety law. Environmental health officers from the local authorities (LA) anticipated the sources of Legionella.
The erroneous administration by the manager is one of the factors responsible for the havoc. The lack of knowledge and perhaps the commercial outlook of the manager led to faulty alternative contract in late 2000 that led to the cancellation of the contract and resignation of the manager.
The design Services Group (DSG) with its expertise and know-how in contract management that had procured the previous provider was involved in the procurement of the replacement contract. But Ms.Beckingham, the DSG manager had erred in the recording of the minutes of meeting in July 2001 where there was discussion on water treatment. "Checking /dosing to be omitted" was recorded by her. This error was acted upon while procuring the replacement contract. This was done in view of the expenditure involved, which resulted in not attending to chemical treatment, microbiological monitoring and system checks, thereby neglecting the Health and Safety law.
The chief executive at Barrow Borough council, Tom Campbell arrived at conclusion and issued a statement identifying the following four areas which directly or indirectly led to the Barrow outbreak as follows:
* the installation of the automatic dosing system and the registration of the cooling towers;
* the failure to deal properly with correspondence from HSE;
* delays in completing written risk assessments for Forum 28; and
* failure to establish proper contract documentation and contractor supervision following a
* Change of maintenance contractor in 2001.
OPERATIONAL FAILURES AND RECOMMENDATIONS:
Lack of responsibility and poor communication: Forum 28 failed in the appointment of responsible person with competence and knowledge to supervise and manage the air-conditioning system. The communication gap between Forum 28 and the leaders led to the occurrence of the outbreak.
Recommendations: An appointment of responsible person with managerial skills would have bridged the communication gap between Forum28 and leaders which would have prevented the outbreak. The responsibilities and relationships within their Health and safety policy need be defined by the organizations to avoid the ignorance of serious risks such as Legionella.
Failure to act on advice: A contractor conveyed the lack of water treatment for the cooling towers at Forum 28 but it was neglected to act immediately.
Recommendations: Active participation of workers and cooperation between all individuals should be effectively managed to reduce the risks by effective monitoring and reporting.
Failure to assess the risks: The risk assessments from Legionella had been totally neglected by Barrow Borough council at Forum28 until the outbreak in 2002.
Recommendations: Under the management of health and safety at work regulations 1999,all employers are required to assess and review the risks their workers may face in their work.
To carry out the tasks competently and safely the people must have the ability,experience,information,training so as to identify and assess the attack of Legionella bacteria.
Poor management of contractors and contract documentation. The failure by the Council to properly manage contractors was a significant factor in the cause of the outbreak. Officers in charge of procuring the new air conditioning maintenance contractor failed to request or exchange proper documentation or agree the specifics for the work. The Council did not check whether the contractor was doing the work or not as it was ought to be done.
Recommendations: Clients need to specify clearly the work at the tendering stage for the contractor to provide quote for the work so as to provide the service expected by the client. The client must be able to manage and supervise the contractors' work by arranging periodic checks on their performance.
Inadequate training and resources: The authority could not provide the resources for the risk assessments and in house monitoring. It also failed to give adequate training to ensure the management of the control of Legionella.
Recommendation: The leaders have to take effective steps to promote training facilities and take the advice from the competent organizations that deliver Legionella control training such as Legionella Control Association (LCA)
Individual failings: Ms. Beckingham was convicted under section 7 of the Health and Safety at work etc Act 1974 because of her failure of attention concerning about the water treatment in the air conditioning system.
Recommendation: Section 7 of the Health and Safety at Work etc Act 1974 places important duties on the employee, while at work, irrespective of the obligations on the employer. Employees may commit an offence if they contravene the general duties imposed by section 7 by their carelessness and non-cooperation to their management in rendering their duties towards the reduction of health risks.
This incident has given rise to the complex legal procedures. The Crown Prosecution Service (CPS) with the joint approach of the Barrow police and HSE identified the lacunae and brought Barrow Borough to justice.
In short Barrow Borough Council and its chief officer Ms.Beckingham were both accused of manslaughter. As an employee Ms.Beckingham failed in her duty which resulted in causing health hazard to the public.
Legal implication caused Barrow Borough Council to pay £125000 in fine and £90000 in legal costs and its official Ms.Beckingham had to pay £15000 in fine for the proven negligence of duty leading to manslaughter.
However, Ms.Beckingham appealed against the sentence in the higher court where she succeeded in getting the sentence set aside.
The net result in the public interest is that the HSE reengaged with Barrow Borough Council and reviewed the overall arrangements for managing Health and Safety with its positive and constructive approach in everyone's interests that the council performs well with fair and impartial intention.
As a consequence the HSE undertook national programme of work with its inspectors engaging with Local Authorities (LA) with duties under Health and Safety Law.The aim is to gain the commitment of senior officers to achieve a reduction in injuries, illhealth and sickness by taking sensible and necessary precautions.
Remedial measures resultant out of the findings on the impact of the incident:
Empowering, strengthening and activating of HSE providing hope to the entire public that with the combination of preventive measures -
L8 contents highlighting the duties, responsibilities and legal bindings of all the personnel involved and putting forward a check to their actions against the standards in L8 whether they are complying with the provisions of L8; Provision of guidance through video checklists and periodical trainings to all the employees of Local Authorities.Management of spa pools activating HSE's biological agents unit with training courses for HSE inspectors establishing a Legionella working Group and closely associating with Legionella control association thereby maintaining effective lines of communication both internal and external stakeholders of the organization through their inspection programmes thereby ensuring the control of the risks associated with Legionella risk systems.
ROLE OF REGULATORY BODIES:
The laws to control and prevent outbreaks of Legionnaire's disease ensure that the operating systems such as cooling towers and other industrial hot water systems are managed properly so as to prevent the risk of exposure to Legionella bacteria. Approved Code of Practice and guidance, commonly referred to as L8, describes the legal duties and provides practical guidance on how to comply with the law. Assessment of risks of Legionnaire's disease, Preparation of plans or schemes to control the risks, managerial oversight and to put the plan into action are the criteria of L8.Programmes like inspection, maintenance involving regular cleaning and disinfection dosed with a biocide which acts as an effective chemical to prevent the growth of Legionella bacteria are included in the schemes of L8.
Maintenance of records with safety operations of the cooling tower and the practical advices on the legal obligations are provided by L8.
Health and Safety at Work etc Act 1974
Objectives of the Act are to secure the health, safety and welfare of people at work and to manage risks that arise from work activities.
Section 2 (1) states: "It shall be the duty of every employer to ensure, so far as is reasonably practicable, the health safety and welfare at work of all his employees."
Section 3(1) states: "It shall be the duty of every employer to conduct his undertaking in such a way as to ensure, so far as is reasonably practicable, that persons not in his employment who may be affected thereby are not thereby exposed to risks to their health or safety."
Management of Health and Safety at Work Regulations 1999(MHSWR)
MHSWR draws a well defined plan of action of the employees in understanding and dealing with the situations to be faced at the time of outbreaks of health hazards like Legionnaire's disease at their work place. First of all, guidelines are provided to all the personnel involved whether employees and employers or a set of self-employed personnel who put in their combined efforts as a unified force. Sufficient training and directions are given how to communicate and exchange information regarding health risks within the individuals of the group at work and also with the managerial personnel connected to their work-officials and representatives of the council who are all collectively responsible in taking care of their own personal health and also striving to take care of the concerns of the public to whom they owe their responsibility in implementing the health and safety law in handling to reduce health risks.In this process communication gaps leading to failures in controlling health and safety at work are totally closed through effective guidelines provided for communication process and checks for fixing the responsibilities and hierarchical supervisions.This ensures application of all the provisions of health and safety law.
Control of Substances Hazardous to Health Regulations 1999(COSHH)
COSHH ensures scientific analysis identifying the risks from hazardous substances as well as biological agents.
Notification of Cooling Towers and Evaporative Condensers Regulations 1992
Under these regulations stress is laid on the consumers or occupiers towards their duty and responsibility with respect to the local authority. Rendering their duty implies to notify in writing the details on cooling towers and evaporative condensers containing water and leading to exposure to air and also the failures in provision of required water or electrical power connection. It is evident that the appropriate authority is there to enforce regulations for the premises with the notifiable devices. Inspite of that the occupiers also are required to notify the local authority inorder to assist in the investigations of outbreaks.
Health and Safety (Enforcing Authority) Regulations 1998
The Health and Safety (Enforcing Authority) Regulations 1998 allocated to HSE and LAs the responsibility for enforcing the Health and Safety at Work etc Act 1974 and the relevant statutory provisions, subject to specific exceptions, in different premises, depending on the main activity. Local Authorities do enforce the health and safety measures in their offices, business centres and service places controlled and managed by the local authority. With regard to the places of public interest or the centres of work forces like factories, mines etc., HSE owes the responsibility in regulating the health and safety laws.
Tragic outbreaks - are preventable. If suitable and sufficient risk assessments had been carried out on the air conditioning system, it is almost certain that the 7 fatalities would have been avoided. These assessments would have identified the 6 major failings. Since the outbreak, Forum 28 operates "quite successfully" without air conditioning, removing the hazard altogether. The council also now has a 20-strong group drawn from all parts of the authority, reviewing new risk assessments and calling in existing ones to check their utility value.
The wider outcome of the disaster management completely and successfully removing the hazard altogether at Forum 28 is the awakening of the public through propagation of awareness through various agencies. All the local authorities and corporate bodies, business houses, private work force centres and also self employed work places and in general consumers or occupiers of public places got alerted about the health risks involved in utilizing air-conditioning systems. With the lessons from the occurrence of outbreak at Forum 28 and findings thereafter and also successful operations in arresting the causes of the outbreak, the HSE has been empowered, reorganized and regulated to ensure the unified efforts of the technical, managerial and all the administrative agencies of it.The stages of initiation,notification,the follow up measures in translating into action without any communication lapses from among the employers and also the employees within themselves and also to the public to whom they owe the responsibility has been leading to ensure the reduction of health risks.
Legionnaires' disease. The control of legionella bacteria in water systems. Approved Code of Practice and guidance L8 (Third edition) HSE Books 2000 ISBN 978 0 7176 1772 2
Health and Safety at Work etc Act 1974 (c.37) The Stationery Office 1974
ISBN 978 0 10 543774 1
Management of health and safety at work. Management of Health and Safety at Work Regulations 1999. Approved Code of Practice and guidance L21 (Second edition) HSE Books 2000 ISBN 978 0 7176 2488 1
Managing health and safety in construction. Construction (Design and Management) Regulations 2007. Approved Code of Practice L144 HSE Books 2007 ISBN 978 0 7176 6223 4
Managing health and safety: Five steps to success Leaflet INDG275 HSE Books 1998(ISBN 978 0 7176 2170 5)
Web version: www.hse.gov.uk/pubns/indg275.pdf
Directors' responsibilities for health and safety Leaflet INDG343 HSE Books 2001
(ISBN 978 0 7176 2080 7)
Web version: www.hse.gov.uk/pubns/indg343.pdf
2003,An introduction to health and safety: Health and safety in small businesses Leaflet INDG259 (rev1) HSE Books
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ISBN 0 7176 6179 2
Practical advice on workplace health and safety at www.workplacehealthconnect.co.uk
Five steps to risk assessment Leaflet INDG163(rev2) HSE Books 2006
( ISBN 978 0 7176 6189 3)
Web version: www.hse.gov.uk/pubns/indg163.pdf
Managing contractors: A guide for employers. An open learning booklet HSG159
HSE Books 1997 ISBN 978 0 7176 1196 6
Control of substances hazardous to health (Fifth edition). The Control of Substances Hazardous to Health Regulations 2002 (as amended). Approved Code of Practice and guidance L5 (Fifth edition) HSE Books 2005 ISBN 978 0 7176 2981 7
The Notification of Cooling Towers and Evaporative Condensers Regulations 1992 SI1992/2225 The Stationery Office 1992 ISBN 0 11 025225 X
The Health and Safety (Enforcing Authority) Regulations 1998 SI1998/494
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