Operation Failure

SCID #00115
Town of Spencer (2007)

Operator Error / Configuration Error
Date of Event/Incident: 25-Apr-2007 (Wednesday)
Date Updated: 28-Sep-2007 (Friday)
Date Updated (SCIDMARK): 14-Feb-2021 (Sunday)


BETA VERSION v0.57

Information Statement

Information contained within this site is considered ‘experimental’, and is not recommended for legal or evidentiary purposes.


NOTE: For additional reference specific to this incident, please refer to this case number as:

http://scidmark.com/scid-00115-20070425.pdf

Case Information

On April 25, 2007 (Wednesday), it was discovered early in the morning that there was a malfunction at one of the town’s water treatment facilities where a hazardous amount of sodium hydroxide (lye) was released into the town’s water supply. The official cause was a malfunction of the system due to operator error, that regulates the amount of lye released. According to local news reports, dozens of people received medical treatment for “burning sensations and skin rashes.†1

infracritical

The Massachusetts Department of Environmental Protection (MassDEP) was notified by the Spencer Water Department of an incident involving water operations on Wednesday morning, April 25, 2007. The Spencer Water Department reported an overfeed of sodium hydroxide into its water distribution system. The incident resulted in numerous transports of users to the hospital for treatment as the result of exposure to and ingestion of water with an elevated pH level.†2

The cause of the incident appeared to have been operator error, along with the failure of alarm systems to notify the operators of the problem when those operators were off-site. Based on interviews, MassDEP believes that the incident began as a result of the operators placing the sodium hydroxide feed system in “manual operation mode” as part of maintenance and repair of one of the lines. Sodium hydroxide is commonly used to treat the water to prevent the leaching of lead and copper into the drinking water from domestic plumbing. The sodium hydroxide feed is normally in automatic operation, meaning an electronic control provides the proper dose of chemical into the water distribution line. In a normal, automated operation, sodium hydroxide only flows into the system when a pump moving water out of the treatment plant is operating. The sodium hydroxide feed shuts down when the pump turns off. This ensures the proper dosage and adequate dilution of the sodium hydroxide into the water supply.†2

By placing the pump in manual mode, the feed system continued injecting sodium hydroxide into the system whether water was flowing through the distribution line or not.

The operators, making repairs to the line on Tuesday, April 24, 2007, switched the system controlling the pump to manual operation in order to make repairs to a leaking line. At the end of the day it appears that they failed to return the switch to automatic operation. This resulted in approximately 34 gallons of sodium hydroxide entering the system overnight from April 24 to April 25, 2007 – a period of approximately 12.5 hours - without proper dilution.

infracritical

On the morning of April 25th, at approximately 4:30 am local time, when the treatment plant pumps began moving water into the system, a concentrated amount of sodium hydroxide entered the distribution system.

The operators recognized the error and returned the system to automatic feed at just before 7 am local time on April 25th. The sodium hydroxide feed system was later disconnected from the clarification process completely, and remained offline pending an investigation until further notice.

The error was compounded by a failure of the alarm system to notify operators while off-site. The plant during the nighttime hours was not in operation. As indicated earlier, the pumps did not begin operating until the early morning hours.

infracritical

While the MassDEP review had indicated that the alarms were sounding in the building, no alarms were being sent to operators outside of the building. This resulted in the situation to continue unabated until the early morning hours of April 25th. MassDEP continued invesigating as to why the alarms did not notify off-site operators, and was later submitted through an After Action Report/Improvement Plan (AAR/IP)†9 report provided by the Town of Spencer through an HSEEP†10†11†12†13 post-analysis review process.

As a result of their review, MassDEP referred the operators of the system to the Board of Professional Licensure for their error in leaving the sodium hydroxide feed system on manual overnight from April 24th to April 25th.†2

    Updated 12-Feb-2021  

The U.S. Department of Homeland Security revised their suggested plan of action for local and state governments to practice in case of a chemical exposure incident. The document is utilized as part of their incident response program.†14

    Updated 14-Feb-2021  

The incident specific to the Town of Spencer has many similarities with other incident cases. One case that has several characteristics may be compared to Case #00113 - City of Oldsmar. Several of the common factors between the two incident cases have been identified. A comparison chart is provided below:

Municipality Town of Spencer (#00115) City of Oldsmar (#00113)
Incident Type Incident Incident
Incident Sub-Type Accident Attack
Incident Severity Significant Significant
Incident Dispersion Local Local
Incident Impact Significant Significant
Incident Urgency Critical Critical
Failure Method Operation Failure Operation Compromise
Failure Sub-Type Operator Error / Configuration Error External Adversary
Detection Method Human Only Human Only
Detection Type Onsite Staff Onsite Staff
Damage Localized Town of Spencer City of Oldsmar
Controls Bypassed Yes Yes
Controls Bypass Reason Manual Mode Due to Maintenance System Override
Outage Type Partial Partial
Outage Condition Damaged (Degraded) Damaged (Degraded)
Outage Repairability Repairable Repairable
Outage Time > 1 Day, < 1 Week < 1 Hour
Recovery Time < 1 Week ~ 1-2 Hours
Loss of Safety Yes No
Reduced Safety Yes (Temporarily) Yes (Temporarily)
Safety Impacted Yes (Temporarily) Yes (Temporarily)
No. Injured ~ 100-145 0
Loss of Control Yes (Partial) Yes (Partial)
Loss of Operation Yes (Partial) Yes (Partial)
Loss of Configuration Yes (Alarm System Configuration Error) Yes (Partially Due to Intruder)
Operation Type Sodium Hydroxide Injection Sodium Hydroxide Injection
Operation Affected Yes Yes
Operation Compromised Yes Yes
Operational State Manual (NaOH Feed Disabled) Automated (Remote Access Disabled)
Operational Disruption Partial Partial
Operational Impact Partial Partial
NFPA SCALE (0-4)

Health: 3 | Flammability: 0 | Physical Hazard: 1

Health Safety: Similar to other corrosive acids and alkalis, sodium hydroxide solutions can readily decompose proteins and lipids in living tissues via amide hydrolysis and ester hydrolysis, which consequently cause chemical burns and may induce permanent blindness upon contact with eyes.

Sodium hydroxide occurs naturally in water (usually) at very low levels. The chemical is added as part of the water treatment and distribution for corrosion control purposes at rates between 1 and 40 ppm levels.†2 Sodium hydroxide is commonly known by another name as 'lye', which is used in several cleaning (both industrial and consumer) as well as disinfectant products.†3†4†5†6

One cleaning product that is commonly used in practically every household is bleach.†7†8 Liquid chlorine 'bleach' is a household cleaning product that combines chlorine, sodium hypochlorite, and sodium hydroxide.

When used at safe levels, sodium hydroxide is used during water purification to raise the pH level of water supplies. Increased pH makes water less corrosive to plumbing while reducing the amounts of lead, copper and other toxic metals that can dissolve into drinking water.

Source(s):
†1  "Spencer, Massachusetts"; Wikipedia; dated 31-Jan-2021; URL: Wikipedia (alt)[alt-01]
†2  "Statement by MassDEP of Preliminary Findings Regarding the Water Supply Incident in Spencer, Massachusetts April 25-27, 2007"; MassDEP; dated 2-May-2007; URL: Massachusetts Department of Environmental Protection (alt)[alt-02]
†3  "Product No. 19539 sodium hydroxide"; Ted Pella; dated 22-May-2015; URL: Ted Pella (alt)[alt-03]
†4  "SAFETY DATA SHEET, CAUSTIC SODA LIQUID (ALL GRADES), MSDS No.: M32415, Rev. Date: 31-May-2009, Rev. Num.: 05"; OxyChem; dated 31-May-2009; URL: OxyChem (alt)[alt-04]
†5  "Material Safety Data Sheet - sodium hydroxide, solid - ACC #21300"; Fischer Scientific; URL: Fischer Scientific (alt)[alt-05]
†6  "sodium hydroxide - Safety Data Sheet"; LabChem; dated 21-Feb-2018; URL: LabChem (alt)[alt-06]
†7  "Liquid bleach"; Wikipedia; dated 19-Sep-2020; URL: Wikipedia (alt)[alt-07]
†8  "SAFETY DATA SHEET"; The Chlorox Company; dated 12-Jun-2015; URL: The Chlorox Company (alt)[alt-08]
†9  "After Action Report/Improvement Plan (AAR/IP) - Spencer Water Crisis April 25-27, 2007"; The Town of Spencer; dated c. Sep-2007; URL: The Town of Spencer (alt)[alt-09]
†10  "Homeland Security Exercise and Evaluation Program"; U.S. DHS FEMA; dated 17-Dec-2020; URL: U.S. DHS FEMA (alt)[alt-10] (alt)[alt-10a] (alt)[alt-10b]
†11  "Homeland Security Exercise and Evaluation Program (HSEEP)"; U.S. DHS FEMA; dated c. Jan-2020; URL: U.S. DHS FEMA (alt)[alt-11]
†12  "Homeland Security Exercise and Evaluation Program (HSEEP) 2020 Revision - Information Sheet"; U.S. DHS FEMA; dated c. 2020; URL: U.S. DHS FEMA (alt)[alt-12]
†13  "Homeland Security Exercise and Evaluation Program (HSEEP) - Frequently Asked Questions"; U.S. DHS FEMA; dated c. 2020; URL: U.S. DHS FEMA (alt)[alt-13]
†14  "Patient Decontamination in a Mass Chemical Exposure Incident:National Planning Guidance for Communities"; U.S. DHS; dated c. 2014; URL: U.S. DHS (alt)[alt-14]

Industry Information

Corporate Information

Spencer is a town in Worcester County, Massachusetts, United States. The population was 11,688 at the 2010 census.
Source(s):
†15  "Spencer, Massachusetts"; Wikipedia; URL: Wikipedia (alt)[alt-15]

CIP Information

Sector
Water△5
Sub-Sector
Water
Treatment
△6
Note(s):
△5  Relevant sector-specific information may referenced at "Critical Infrastructure Sectors - Water and Wastewater Systems Sector"; date unknown; URL: DHS (CISA) - Water and Wastewater Systems Sector (alt)[delta-05]
△6  Combined subordinate fields of 'Water' and 'Treatment' apply to water treatment and distribution. The term 'water treatment' refers to the clarification of water from wells into drinking water; whereas, 'distribution' refers to local transport only.

Index Information

Vector Information

  Primary Op.    Cyber Impact    Secondary Op.  
Primary Operation
Operator Maintenance
Secondary Operation
Local Equipment△7
Note(s):
△7  The term 'local equipment' refers to site-specific equipment used to manage plant process operations.

Scoring Information

90.14
IMPACT INDEX
88.57
RELIABILITY INDEX
95.68
SCID INDEX


Occurrence Information

Incident Information

Incident Type
Incident
Incident Sub-Type
Accident
Accident Method
Operation Failure
Accident Source
Operator Error / Configuration Error
Source Reliability△1
Reliable
Source Creditability△1△2
Confirmed
Source
Type   
Media
Source
Sub-Type
Website, News Media, Report
Source Name(s)
The Telegram, The New York Times, NBC News, Town of Spencer
Operation(s) Affected
Yes
Incident Severity
Level 3 (Significant)
Operation(s) Impacted
Water clarification process involving sodium hydroxide was released caused by operator error due to failure to restore automated operation of system controlling pH levels of treated water, as well as configuration error due to lack of high/low alarms for external communications.†2†9
Description of Severity
Level 3 - Significant Business Impact - Operational product features are unavailable with an acceptable workaround; however, no timeframe exists, or time to recovery anticipated longer than expected. Customer's implementation or primary business production, major applications or mission critical systems are functioning with limited capabilities or partially missing functions.
Regulation(s)
Public Health Security and Bioterrorism Preparedness and Response Act (PHSBPRA) of 2002.†16†17
Source(s):
†2  "Statement by MassDEP of Preliminary Findings Regarding the Water Supply Incident in Spencer, Massachusetts April 25-27, 2007"; MassDEP; dated 2-May-2007; URL: Massachusetts Department of Environmental Protection (alt)[alt-02]
†9  "After Action Report/Improvement Plan (AAR/IP) - Spencer Water Crisis April 25-27, 2007"; The Town of Spencer; dated c. Sep-2007; URL: The Town of Spencer (alt)[alt-09]
†16  "Public Health Security and Bioterrorism Preparedness and Response Act"; Wikipedia; dated: 15-Aug-2020; URL: Wikipedia (alt)[alt-16]
†17  "PUBLIC HEALTH SECURITY AND BIOTERRORISM PREPAREDNESS AND RESPONSE ACT OF 2002; Public Law No. 107-188"; U.S. Congressional Library, 107th U.S. Congress; dated: 12-Jun-2002; URL: U.S. Congress (alt)[alt-17]
†18  "Water Infrastructure Resilience"; U.S. EPA; dated: 11-Mar-2002; URL: U.S. EPA (alt)[alt-18] (alt)[alt-18a]
Note(s):
△1  Refer to U.S. Army FM 2-22.3, (alt)[delta-01] "HUMAN INTELLIGENCE COLLECTOR OPERATIONS", Appendix B, "Source and Information Reliability Matrix", p. B-1 (285) and B-2 (286) for further information.
△2  The term "information content" may be applied in lieu of the term "source creditability" (refer to △1).

Non-Accident/Accident Information

Accident Type
Operator Error / Configuration Error
Accident Sub-Type
Oversaturation of Sodium Hydroxide
Degree of Accident
Approximately 34 gallons of sodium hydroxide accidentally released into water supply
Incident Dispersion
Local
Incident Impact
Significant
Incident Urgency
Critical
Description of Accident to Operations
According to both the Administrative Consent Order (ACO) issued by the Massachusetts Department of Environmental Protection (MassDEP) and the Inspection of the Water Treatment Plant’s Chemical Feed System Instrumentation conducted by Weston & Sampson Services, Inc., dated May 25, 2007, the high and low pH alarms were found not to be connected to the auto dialer, nor was the auto dialer connected to an active telephone line. The consequence of this was a failure to detect abnormal pH levels at the treatment plant prior to the water being introduced into the water distribution system. Once finished water with abnormal pH levels were in the distribution system, it was consumer complaints that alerted water department employees that there was a problem.

According to testimony from the Office of Development an Inspectional Services (ODIS) Director, after the department was notified by the police dispatcher of a “chlorine bomb” (a water service term for super-chlorination of a waterline) in the water system and the department received instructions to “do not use” the water in an email from the Town Manager, there was not an understanding on the Director’s part of the gravity of the situation, and therefore a failure to take immediate action which caused a delay in the response actions to protect the public health.

The possibility that the abnormal pH level was an intentional act was ruled out early in the incident by Spencer Water Department employees with knowledge of the system, which allowed proper characterization of the threat, and the steps required to manage the consequences to be implemented very quickly.
Once Spencer Water Department field personnel were aware of the contaminated water, they began flushing the system and the advisory not to use water was initiated. Because the contaminant was known early on in the incident, additional testing was not required to confirm a contamination incident.

As indicated by the Utilities & Facilities Management Superintendent, there was a delay in immediate notification to MassDEP. According to the Public Health Security and Bioterrorism Preparedness and Response Act of 2002 (Bioterrorism Act), the Spencer Water Department was to have certified and submitted a vulnerability assessment to the EPA by June 30, 2004, and certified an emergency response plan within six months following completion of the vulnerability assessment. At the time of the Blue Ribbon Committee’s interviews with both the Utilities & Facilities Management Superintendent and the Chairman of the Board of Water Commissioners, neither the Superintendent nor the Chairman were aware of the existence of any emergency response plan for the Spencer Water Department.

Although most of the local entities involved in managing the water incident provided After Action Reports, despite numerous requests, several of the state agencies involved in the incident had not completed AARs by the time the Blue Ribbon Committee had completed its independent review. Based on testimony from the ODIS Director, there were delays in notifying both permitted and non-permitted businesses in the affected area. Initially, there was a failure to recognize the need for notification to be initiated. Once notification was begun, the records management system impeded timely notification.

Attack Information

<<  NO INFORMATION AVAILABLE FOR THIS INCIDENT  >>

Architecture Information

<<  NO INFORMATION AVAILABLE FOR THIS INCIDENT  >>

Detection Information

Detection△3△4
Human Only
Detection
Time
> 3 Hours, < 1 Day
Detection
(Human)
Staff
Detection
(Machine)
N/A
Network Detection?
No; detection appears to have been determined by staff.
Reason
No further information or details are available.
Threat Intel Detection?
No; non-applicable to this incident.
Reason
No further information or details are available.
Note(s):
△3  Refer to NIST Special Publication 800-61, Revision 2, (alt)[delta-03] "Computer Security Incident Handling Guide", Section 3, "Handling an Incident", p. 21 (30) for further information.
△4  Context with regards to embedded control devices and/or control systems may be applicable as suitable countermeasures for detection. Human decision required.

Damage Information

Damage Afflicated
Serviced equipment placed into manual operation; once servicing was complete, operators failed to reset equipment to automated operation. Additionally, as manual operation resumed at approx. 7 am local time, high/low pH level alarms sounded within the buildings, but did not notify externally due to loss of configuration and loss of availability of communication line. Approximately 145 residents suffered skin burns of irritations due to exposure to tainted water.
Damage
Localized
Yes; localized to Town of Spencer
Controls
Bypassed
Yes; manual instead of automated operation
Damage Type
Hardware
Damage Sub-Type
Operator Error / Configuration Error
Damage Cost Known
No
Damage Cost Amount
N/A
Description of Damage to Operations
Damage appeared to be isolated to the Town of Spencer only; however, as there were multiple residents affected by the tainted water, multiple fire districts were contacted to alleviate the overwhelming number of residents requiring immediate medical attention.†19 The serviced equipment suffered some damage resulting from the operator error and was replaced at an unknown date; additionally, the alarm system was remediated as well, also at an unknown date.†2<†9
Source(s):
†2  "Statement by MassDEP of Preliminary Findings Regarding the Water Supply Incident in Spencer, Massachusetts April 25-27, 2007"; MassDEP; dated 2-May-2007; URL: Massachusetts Department of Environmental Protection (alt)[alt-02]
†9  "After Action Report/Improvement Plan (AAR/IP) - Spencer Water Crisis April 25-27, 2007"; The Town of Spencer; dated c. Sep-2007; URL: The Town of Spencer (alt)[alt-09]
†19  "Incident Management: Assigning Personnel to Collect and Record Information at Mass Decontamination Sites"; U.S. DHS FEMA; dated c. Sep-2007; URL: U.S. DHS FEMA (alt)[alt-19]

Outage Information

Outage
Type
Partial
Outage
Condition
Damaged (Degraded)
Outage
Repairability
Repairable
Outage Time
> 1 Day, < 1 Week

Recovery Information

Recovery Type
Disable NaOH Pump (pending investigation)
Recovery Time
< 1 Week
Restoration Type
Fix NaOH Pump; Upgrade Alarm System, Upgrade Safety System
Restoration Sub-Type
Update ICS△10 SOPs; Regular Testing
Note(s):
△10  The abbreviation "ICS" refers to the definition "Incident Command System", which is part of the "National Incident Management" system provided by the U.S. Department of Homeland Security, Federal Emergency Management Agency.

Reference Information

Authoritative Information

DHS
(CISA)
N/A
FBI
(CYBER)
N/A
DOE
(FERC)
N/A
NRC
(NSIR)
N/A
DOD
(CYBERCOM)
N/A
NIST
(NVD)
N/A
NIST
(NISTIR)
N/A
IEEE
(IEC/ANSI)
N/A
Other
Town of Spencer, Massachusetts Department of Environmental Protection (MassDEP)†9, Supporting Local Communities△8△9
Source(s):
†9  "After Action Report/Improvement Plan (AAR/IP) - Spencer Water Crisis April 25-27, 2007"; The Town of Spencer; dated c. Sep-2007; URL: The Town of Spencer (alt)[alt-09]
Note(s):
△8  The following fire departments that responded to the emergency include: East Brookfield, Leicester, Brookfield, Upton, Grafton, Paxton, Auburn, Worchester (MDU at St. Vincent's), Oxford, Blackstone, Mendon, Millvile, Uxbridge, and Douglas
△9  The following ambulance organizations (fire departments and private sector) that responded to the emergency include: East Brookfield Fire, North Brookfield EM, Leicester EMS, Brookfield EMS, Charlton Fire, Sturbridge Fire, Oxford Fire, Eascare Ambulance, AMR Ambulance, UMASS Ambulance, Patriot Ambulance, Pathways Ambulance, South Hadley Fire, Northhampton Fire, Amherst Fire, Sherborn Fire, Foxboro Fire, East Hampton Fire, Ware Fire, Agawam Fire, Westfield Fire, Longmeadow Fire, Wilbraham Fire, Hollison Fire (chief only), Hopkinton Fire, Ashland Fire, Wayland Fire, Franklin Fire, Walpole Fire, Millis Fire, Wrentham Fire, Ayer Fire, Littleton Fire, Groton Fire, Pepperell Fire, Shirley Fire

Non-Authoritative Information

RISI
N/A
YouTube
Yes†23
Other
N/A
Source(s):
†23  "Several residents in Spencer, Mass describe the safety scare involving contaminated water in the tow; AP News; dated 31-Jul-2015; URL: AP News (alt)[alt-23]

Design Information

<<  NO INFORMATION AVAILABLE FOR THIS INCIDENT  >>

URL / Case Number Information



SCID #00115
Town of Spencer (2007)
QR Updated:
25-Apr-2007 (Wednesday)

Impact Information

Safety Information

Loss of Safety
Yes
Reduced Safety
Yes, temporarily
Safety Impacted
Yes, temporarily
Other(s) Impacted
No
Method of Safety Impacted
Both operator error from unintentionally keeping pump operations in manual mode, and configuration error preventing remote notification via high/low pH level alarms.
Safety Standard(s)
N/A
Loss of Life
No
No. of Deaths
N/A
Loss of Health
Yes
No. of Injured
~ 100 Residents†9†19
Source(s):
†9  "After Action Report/Improvement Plan (AAR/IP) - Spencer Water Crisis April 25-27, 2007"; The Town of Spencer; dated c. Sep-2007; URL: The Town of Spencer (alt)[alt-09]
†19  "Incident Management: Assigning Personnel to Collect and Record Information at Mass Decontamination Sites"; U.S. DHS FEMA; dated c. Sep-2007; URL: U.S. DHS FEMA (alt)[alt-19]
Note(s):
△11  The correct number of residents affected by this incident varies. Although the majority of the supporting documents indicate approximately 100 residents, one document from U.S. DHS FEMA†19 has indicated approximately 145 residents. No further reported numbers have been found; additionally, no confirmation may be obtained from either the Town of Spencer nor the Massachusetts Department of Environmental Protection.

Operational Information

Denial of
View
(DOV)
No
Denial of
Control
(DOC)
No
Denial of
Access
(DOA)
No
Denial of
Operation
(DOO)
No
Loss of
View
(LOV)
No
Loss of
Control
(LOC)
Yes, partial
Loss of
Access
(LOA)
No
Loss of
Operation
(LOO)
Yes, partial
Breakdown of Loss of Operational Information
>> (LOO) Both operator error from unintentionally keeping pump operations in manual mode, and configuration error preventing remote notification via high/low pH level alarms.†9†19
Operation(s)
Compromised
Yes
Operational
State
Manual
Operational
Disruption
Partial
Operational
Impact
Partial
Loss of
Recovery
No
Loss of
Restoration
No
Loss of
Backups
N/A
Backups
(F/P/I/NA)
N/A
Loss of Comm.
Yes; pH level alarm system offline remotely
Comm. Outage Time
Unknown
SCADA/HMI(s)
No
DCS(sic)
No
PLC(s)
No
RTU(s)
No
IoT/IIoT
No
Telemetry
No
Sensor(s)
No
Other
N/A
Loss of
Logging
(LOL)
Uncertain
Loss of
Log(s)
(Deleted)
Uncertain
Loss of
Log(s)
(Archive)
Uncertain
Loss of
Log(s)
(Integrity)
Uncertain
Loss of
Integrity
(LOI)
No
Loss of
Config
(LOCC)
No
Description of Impact
Increased sodium hydroxide saturation levels resulting to manual operation mode due to operator error.†1†2
Source(s):
†9  "After Action Report/Improvement Plan (AAR/IP) - Spencer Water Crisis April 25-27, 2007"; The Town of Spencer; dated c. Sep-2007; URL: The Town of Spencer (alt)[alt-09]
†19  "Incident Management: Assigning Personnel to Collect and Record Information at Mass Decontamination Sites"; U.S. DHS FEMA; dated c. Sep-2007; URL: U.S. DHS FEMA (alt)[alt-19]

Financial Information

<<  NO INFORMATION AVAILABLE FOR THIS INCIDENT  >>

Data Information

<<  NO INFORMATION AVAILABLE FOR THIS INCIDENT  >>

Timing Information

<<  NO INFORMATION AVAILABLE FOR THIS INCIDENT  >>

Unconfirmed / Speculative Information

Some information stated by public officials are either speculative or unconfirmed. This information may never be completely confirmed; however, given the nature of this incident, it has been considered as admissible evidence for this case.

Costs were never disclosed - State of Information: False - Neither the Town of Spencer nor the Massachusetts Department of Environmental Protection have indicated any rescue or recovery costs pertaining to this incident. No other information has been found indicating either estimated or actual costs for rescue or recovery operations. Additionally, no fines appear to have been levied against either the operators perform the maintenance who were found negligent, nor against the Town of Spencer for lack of up-to-date ICS△10 instructions. However, a whitepaper presented by the Journal New England Water Works Association dated c. Dec-2012†21, indicated that the Town of Spencer had applied for capital spending on a project to upgrade the existing water distribution system to a two-pressured system. Approval was received in November, 2009 by MassDEP, and the project was public bid in December, 2009 and awarded $6.17M USD. This was shy of the $6.3M USD granted by the 192nd General Court of the Commonwealth of Massachusetts on 19-Mar-2009.†22

There were safety systems in place, just not activated - State of Information: Unconfirmed - Based on several reports, there were no indications that there were any safety systems whatsoever that would have prevented the oversaturation of sodium hydroxide into the water distribution system. This would have required a safety valve to override the manual operation once the high/low pH sensors tripped the alarm system; as best as can be determined, there were no devices installed.

The number of residents affected were approx. 100 in number - State of Information: Unconfirmed - The correct number of residents affected by this incident varies. Although the majority of the supporting documents indicate approximately 100 residents, one document from U.S. DHS FEMA†19 has indicated approximately 145 residents. No further reported numbers have been found; additionally, no confirmation may be obtained from either the Town of Spencer nor the Massachusetts Department of Environmental Protection.
Source(s):
†19  "Incident Management: Assigning Personnel to Collect and Record Information at Mass Decontamination Sites"; U.S. DHS FEMA; dated c. Sep-2007; URL: U.S. DHS FEMA (alt)[alt-19] †20  "National Incident Management System"; U.S. DHS FEMA; dated 2-Feb-2021; URL: U.S. DHS FEMA (alt)[alt-20]
†21  "Town of Spencer, Massachusetts Two Zone PressureSystem Project", Vol. CXXV!, No. 4, December 2012; NEWWA; dated c. Dec-2021; URL: New England Water Works Association (NEWWA) (alt)[alt-21]
†22  "Chapter 26 - AN ACT MAKING APPROPRIATIONS FOR THE FISCAL YEAR 2009 TO PROVIDE FOR SUPPLEMENTING CERTAIN EXISTING APPROPRIATIONS AND FOR CERTAIN OTHER ACTIVITIES AND PROJECTS."; Commonwealth of Massachusetts; dated 19-Mar-2009; URL: Commonwealth of Massachusetts (alt)[alt-22] (alt)[alt-22a]
Note(s):
△10  The abbreviation "ICS" refers to the definition "Incident Command System", which is part of the "National Incident Management" system provided by the U.S. Department of Homeland Security, Federal Emergency Management Agency.