And in the glare of the public spotlight, it became apparent that the Madison Water Utility has problems.

A Wisconsin State Journal analysis of the rise of the current manganese contamination in the fall of 2004 shows the utility was unprepared to handle such a pressing public health issue. The bumbled response to manganese reveals a number of operational shortcomings:

For months, utility employees were told to tell concerned residents that discolored water was safe even though contradictory health information about manganese was surfacing.

Many residents with dirty water who were interviewed for these stories said they have been disappointed with the utility's response to their problems and said they no longer trust the Madison Water Utility or the safety of the city's drinking water.

Record-keeping of complaints was almost non-existent in 2003 and 2004, two years when problems with turbid water and manganese were rising steeply. Such record- keeping is required by state law.

Administrators with the utility, entirely dependent on water sales to finance the operation of the water system, bristle at any publicity that reflects badly on the city's water. As a result they keep a tight lid on bad news - sometimes to the public's detriment.

Attempted break-in

Utility administrators insist they didn't think it was necessary to report an attempted water tower break-in to police or to the state Department of Natural Resources, which regulates the utility.

Tom Stunkard, the DNR water quality engineer who oversees the Madison Water Utility, was displeased when reporting by the Wisconsin State Journal turned up the unreported break-in at the Sprecher Road water tower in July 2003.

Workers with the utility found a lock on a door at the base of the water tower ground off. Utility General Manager David Denig-Chakroff said two other doors inside the tower remained locked and the culprit had not reached the water stored in the tower.

Because of that, Denig- Chakroff said, the incident was not reported.

"We just thought it was kids," he added.

Stunkard said that was a mistake. The incident should have been reported.

"I would have gone out there," Stunkard said. "And we would have gotten together with the Police Department to see if it was a credible threat. What if it hadn't been vandals? What if it had been credible?"

A little more than two years earlier, Stunkard had questioned the utility's handling of a bacteria problem.

In February 2001, utility officials were reluctant to comply with a boil order sought by the DNR when water samples tested positive for fecal bacteria, Stunkard said.

Fourteen samples were taken on the East Side and three came back positive for the dangerous bacteria that can sicken humans, Stunkard recalled.

He wanted to issue a broad boil order for East Side residents. Utility officials, he recalled, argued against the order covering as extensive an area as Stunkard wanted.

"They really didn't want to publish the notice I wanted them to," Stunkard said. "But I like to err on the side of public health. I think the problem with the bigger utilities like this is that they are so afraid of negative press. But you can't fool around with something like fecal bacteria."

The order was issued and subsequent tests showed no presence of the bacteria. Still, it had been an unsettling confrontation with the utility for Stunkard.

"It would have made my job a lot easier if instead of arguing about boundaries for the boil order they would have just issued it. Sometimes, I think the utility looks too much at dollar signs. But it's our job to look at public health."

Denig-Chakroff said utility officials were cooperative with the DNR and added that he had heard not complaints about the handling of the situation until recently.

Not on tax bill

Utility officials aren't used to much oversight from city officials or the public.

"They've gotten a little less attention from the mayor's office and from the City Council simply because they are not on the tax bill," Mayor Dave Cieslewicz said. "They probably have been less scrutinized."

Cieslewicz, with the approval of the City Council, appoints the five members of the Board of Water Commissioners that directly oversees the operation of the Madison Water Utility.

Jon Standridge, vice president of the Board of Water Commissioners, said utility officials have too often presented the board with what he called "canned presentations" on monthly utility data but not substantive issues.

"We don't get enough information," Standridge said. "For the responsibility we have, we need more details, more information on how decisions are made. . . . The communication needs to be freer, more open and more voluminous. Even though it is not the administration's intent to cover things up, that has been the perception."

More scrutiny, Cieslewicz agreed, might have prompted a more timely and complete response on manganese and other recent problems, better record-keeping, and a more forthcoming, transparent approach when dealing with problems such as pollutants and financial issues.

'The same message'

Officials with the water utility responded to manganese complaints in late 2004 in much the same way they have responded for years to complaints about rusty or dirty water.

They told anybody with discolored water that the water is safe and that running the faucet for a few minutes would clear up the problem.

"That's been the message for as long as forever," Denig- Chakroff said. "And it's the same message you'll hear in other utilities."

Such assurances were provided to many who called to complain about manganese in subsequent months.

Denig-Chakroff said the utility was relying on information provided by the federal Environmental Protection Agency - that manganese is primarily a nuisance that can discolor water but not cause health problems. The agency, he pointed out, sets only advisory and not legal standards for the mineral - 50 parts per billion for an aesthetic standard and 300 parts per billion as a health advisory.

Three wells in the Madison system had tested at levels beyond the aesthetic limits, including well No. 10, which serves the Nakoma area and more than 10,000 people on the West Side. It tested regularly for manganese at levels beyond the aesthetic standard.

But pipes in the system were apparently also clogged with the mineral, which reacts with chlorine and settles in the mains.

Some increases in homes in the Nakoma area were particularly alarming; a sample from one home would test at 244,000 parts per billion in March 2005.

On March 14, 2005, Denig- Chakroff sent a memo to water utility staffers warning them not to tell people that water may be unsafe.

"I can understand telling someone they may not wish to drink it for aesthetic reasons until things clear up, but we must be very careful NOT to imply that the water is unsafe for drinking," Denig-Chakroff wrote in the memo. "If you are responding to a call, you should reiterate to the caller that drinking the water is not a health hazard."

In 2005, the Madison Public Health Department, according to epidemiologist John Hausbeck, received information on at least two cases of possible manganese poisoning, including a Nakoma teenager whose pediatrician provided a letter with her diagnosis.

Throughout 2005, complaints about dirty water all across the city increased dramatically, Denig-Chakroff said.

On the East Side, Denig- Chakroff added, it is now apparent that many of the hundreds of complaints are at least partly related to high levels of manganese in well No. 29, the city's newest well, which has now been idled because of the problem. The utility is considering installing a $2 million filter.

Stephanie Stender noticed that the water in her Nakoma home was discolored in the winter of 2005.

When she first called the water utility she was told to let the water run and that, even though it was discolored, the water was safe to drink.

In January 2006, the utility tested her water. She didn't hear back on the test results and didn't find out until she attended a meeting on the issue and saw her house on a list of test results.

Her water had tested at 286 parts per billion, very near the federal advisory health standard of 300 parts per billion.

Stender was not pleased with the utility's response.

"There is a real erosion of trust," Stender said. "It's the fact that it seems like they're trying to hide something."

Tracking water quality complaints is difficult because for two years, just as the manganese issue was exploding, the utility barely kept records of water quality calls, even though state statute requires such record-keeping.

An open-records request by the Wisconsin State Journal for all water quality complaints for 2003, 2004 and 2005 turned up 19 recorded complaints in 2003, 28 in 2004, and 420 complaints in 2005.

Earlier this year, after an investigation of the utility's water quality complaint records, the Public Service Commission reported that "the utility acknowledged its utility complaint records were not as accurate or complete as they should have been."

Denig-Chakroff said that in February 2005, the utility installed a database system that records information on complaints. He added that, prior to that, especially in 2003 and 2004, record-keeping was lax because the person who had been responsible for the task had retired and not been replaced.

Even so, phones at the utility were ringing constantly.

John Marchewka, who has since left the utility, was charged for a while with taking the calls. From December 2005 through February 2006, after media reports of manganese problems, Marchewka said the calls skyrocketed and numbered sometimes as many as 30 a day.

Marchewka said he had asked earlier in the fall what he should be telling callers about the safety of their water. Administrators had told him to tell callers that, even though it was discolored, the water was safe.

Despite the utility's assurances, information was surfacing in the winter of 2005 that at least raised questions about the health effects of exposure to high levels of manganese.

Residents in Nakoma cited peer-reviewed scientific studies that showed uncertainty about the impact on infants when exposed to high levels of manganese, especially if they were drinking formula already fortified with the mineral.

Late in the winter of 2005, Cieslewicz formed a task force to study the manganese issue. One of the tasks tackled by the group was issuing appropriate health information.

And in March, the group issued a report that recommended against drinking or cooking with discolored water. The report also notes the dangers of too much manganese for infants as well as people with chronic liver disease.

Manganese, according to the report, can be dangerous at high levels because it has been shown to cause neurological problems.

"That should have been done a year earlier," Cieslewicz said of the report.

Cieslewicz said he was displeased with much of the utility's response to the manganese problems.

"I think it could have been handled better from the start," Cieslewicz said.

Officials with the Madison Water Utility said they still believe they responded adequately based on the information they had from the EPA about manganese in January 2004.

They cite the widespread testing they did in affected neighborhoods, several mailings to affected homeowners, replacement of pipes in Nakoma, and a citywide flushing program - using new technique that increases water velocity - to blast manganese from aging pipes.

"I don't think we made any mistakes," said Al Larson, the utility's principal engineer. "But from a public relations perspective, it wasn't properly handled."

With hundreds of Madison residents complaining about brown tap water, a four-day State Journal series takes a look at what's in Madison's water and what residents can do about it. To view other stories in this series, visit http://www.madison.com/wsj/spe/water/