At least four failures in the past year involving chlorination of Madison's drinking water have prompted Mayor Dave Cieslewicz to order an investigation.

The first of the mistakes was the target of a major investigation. Cieslewicz said he wants to know why the troubled Madison Water Utility can't resolve the problems.

"I am frustrated by the way these chlorine issues have been handled," Cieslewicz said. "Clearly, it indicates we have a ways to go at the utility."

Cieslewicz has asked Larry Nelson, city engineer; Paul Nehm, with the Madison Metropolitan Sewerage District; and George Meyer, a member of the Board of Water Commissioners, to investigate the chlorination failures and how utility employees responded to them.

The Madison Water Utility uses chlorine to treat drinking water for bacteria, viruses and other contaminants. Although the state Department of Natural Resources does not require such treatment, it does set standards for the contaminants the chlorine is meant to control. The utility sets its own standards for levels of chlorine, and in all four incidents chlorine levels were either above or below those standards, according to the utility.

Too little chlorine means water may not be properly protected against contaminants. Too much chlorine could pose potential health problems. None of the incidents in the past year resulted in any reported illnesses.

The four failures

The first of the four chlorine incidents happened in August when Well No. 29 on the Far East Side was left untreated for six weeks. In the second failure, which happened in late March at well No. 8, near Olbrich Park, too much chlorine was pumped into the system. The third problem, which resulted in inadequately treated water, happened in late April and involved Well No. 16, near Memorial High School on the West Side. A final incident happened last week when water with too little chlorine was pumped from Well No. 8 for about 3 hours Tuesday.

Meyer, who was appointed to the water board by the mayor last year after numerous problems with the utility's operation surfaced, said his greatest concern is that the initial failure in August did not result in improvements that might have prevented the other chlorine incidents.

"One incident you can understand," said Meyer. "Bad things happen. But multiple bad things should not happen . . . There has to be a sense of urgency about this. There's a public credibility issue. This can't continue to happen."

After the August chlorine bungle, an investigation ordered by Cieslewicz found that disabled alarms and other inoperative equipment, poor internal communication and a string of errors by operators and supervisors at the Madison Water Utility resulted in a failure to fix a problem with the chlorine treatment system, which resulted in untreated water being pumped into some East Side homes between Aug. 24 and Oct. 5.

The investigation showed that "rounders," the utility workers who make daily checks on the wells, raised questions several times about apparent problems with the treatment system. That prompted maintenance workers to visit the well and notify operators that the well should be shut down until the treatment system was repaired.

But operation of the well continued. The inquiry showed that even Al Larson, the utility's principal engineer, reviewed records that showed low chemical usage but failed to pick up on the problem immediately.

Investigators recommended steps to help avoid similar breakdowns. These included hiring a water supply engineer to directly oversee workers responsible for operating the wells, better training, improvements in internal communication and an assessment of chlorine equipment at city wells. Larson was put in charge of making most of those changes, including the important job of hiring a water supply engineer by the end of October 2006.

While some of the changes were made, others were not.

Difficult position to fill

The utility still has not hired the supervisory engineer.

David Denig-Chakroff, the utility's general manager, said hiring an engineer has been "very difficult." When the position was advertised, six applications were received and three individuals were interviewed but none were had the appropriate qualifications for the job, according to utility records. The position is being readvertised.

Denig-Chakroff said most of the recommendations were followed. Asked why subsequent chlorine failures happened when the problems were supposed to have been fixed, he said the incidents were all different.

"Each one is not the same," Denig-Chakroff said of the breakdowns. "Each incident had its own particular issue, things that went wrong. . . . I'm very concerned about them. But like any breakdown in the system, it's an opportunity to fix things." Specific causes of the failures are still under investigation, Denig-Chakroff said.

George Twigg, a spokesperson for Cieslewicz, said utility officials updated him on the progress being made, but not as often as was requested. The investigation recommendations ordered the utility to "report to the mayor on the progress of the corrective plan on a monthly basis."

The investigation report was released in October 2006 and since then, according to Twigg, the mayor's office received only two updates. "We did not get as frequent of updates as were called for," Twigg said.

Water board member Jon Standridge said the board was provided with the results of the investigation last year but he doesn't remember ever hearing regular follow-ups on whether the recommendations were carried out. Such communication failures - whether between the utility and the board, utility officials and their employees, or the utility and the public - are troubling, Standridge said.

Communication problems

An investigation of the utility by the Wisconsin State Journal last year found numerous problems with communication and a reluctance on the part of utility officials to provide the public with information on any drinking water problems that might reflect badly on the agency. Subsequent inquiries, including a months-long study by a utility consultant, also found extensive communication problems within the utility.

Cieslewicz said he was dismayed when it became apparent the utility had failed to notify his office, the public, or board members about the March incident involving Well No. 8.

"We found out about it from the press," Cieslewicz said. "We should have known about it." He added that when utility officials were asked about why the incident wasn't made public immediately, "we didn't get a satisfactory answer."

Internal communication appears to continue to be as big a problem. Standridge said he receives regular calls from utility employees who complain to him about conditions within the utility.

"They tell me that communication between employees and management is non- existent," Standridge said.

Meyer, a former secretary of the state Department of Natural Resources, said he has been shocked at some of the communication issues he has seen within the utility since he took his seat on the water board. He said he was especially surprised when utility employees showed up at water board meetings to ask questions of their bosses.

"There's something wrong with that kind of relationship," Meyer said. "In my opinion that's a sign of something."

Denig-Chakroff said there have been improvements at the utility in the past year on a number of issues, including communication. In the case of the chlorine failures, especially the August problem with Well No. 29, there were internal communication breakdowns.

"The mechanic thought things had been fixed," Denig- Chakroff said. "The operator thought things had been fixed. At some point, that didn't happen. There should have been better communication."

Cieslewicz, as well as Standridge and Meyer, said there have been positive changes at the utility. They praised the utility's efforts to work more with the public on such issues as the replacement of contaminated Well No. 3, increased investment, the development of more wellhead protection plans, the hiring of water quality manager Joe Grande, and the aggressive testing and flushing program to address manganese in the water.

But Cieslewicz said the chlorine snafus have shown that change is coming too slowly, especially when it comes to some of the most important issues, such as openness and communication.

Others are also frustrated. Some City Council members say they are hearing more frequently from members of the public about their lack of faith in the water utility. Satya Rhodes-Conway, who was elected to the 12th District seat on the council this spring and whose constituents rely on Well No. 3, was the cosponsor of a resolution introduced last week that called for expanding the water board to seven members, adding a second council member to the board, and requiring more reports by the water utility to the council.

"I am obviously concerned," said Rhodes-Conway of the chlorine incidents and the operating and communication problems. "Fundamentally, the most important thing the water utility does is provide us with safe water. And, as for the chlorine, well that is something that, theoretically, is completely within their control."