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Report IDs Austin Water staff missteps that preceded Feb. boil-water notice

Wednesday, March 30, 2022 by Chad Swiatecki

The city has completed its investigation into the cause of an early February boil-water notice and concluded that staff at the Ullrich Water Treatment Plant failed to take actions to address escalating equipment problems on an overnight shift.

Through a combination of incorrect actions, misinterpreting data and alerts linked to water quality, and not communicating issues to Austin Water leadership, the three-person team managing the plant from the evening of Feb. 4 through the morning of Feb. 5 caused the turbidity (or cloudiness) of city water to increase far past safe levels.

Once managers for the utility became aware of the growing crisis shortly after 7 a.m. on Feb. 5, the plant was shut down within two hours, causing a boil-water notice to be issued that evening which stayed in effect for much of the next week. It was the utility’s third boil-water notice since late 2018.

The report substantiated the allegations made against the overnight staffers, known as the “Orange Team”: overlooking or disregarding alerts and lab results on water quality problems, and failing to notify those higher in the chain of command. The Orange Team members were lead technician Jason Perez, assistant technician Benjamin Petrush and associate technician Joseph Dooley.

Problems at the plant began earlier in the week when only two of the plant’s four centrifuges were in operation, at decreased capacity because of deterioration. Preparation for expected freezing conditions had disrupted normal operations for the utility, though a third centrifuge was brought online on Feb. 2 and processes to remove solids in the Colorado River water that create cloudiness were running as planned.

On the morning of Feb. 4, the repaired centrifuge began showing performance issues again and assemblies feeding lime into a pair of basins had frozen, with increased workload shifted to two other basins that were functioning normally. Work to address these issues continued into the evening hours, with all four basins eventually brought online, though the No. 4 centrifuge was still not operating.

As is standard at the utility, the incoming Orange night shift team was made aware electronically and in paper reports of the maintenance issues earlier in the day. Around 9:30 p.m. turbidity levels in one of the problematic basins began to climb, though no issues were reported during a 10:22 p.m. check-in call from a division manager.

By 2:30 a.m., turbidity levels in the basin climbed to levels beyond the monitoring capabilities of the plant’s equipment. By 4 a.m., filters began failing because of turbidity levels that were five times maximum regulatory limits, with no steps to address those problems taken until shift changeover at 7 a.m. on Feb. 5.

Perez, as the senior member of the team with 10 years of service at the plant, was found to have overlooked or misinterpreted signs of cascading problems with the equipment, despite receiving notification via the “pass down” that occurs from one team to the next.

Once Perez became aware of turbidity problems via sample tests taken around 10 p.m., he presumed they were due to a possible line break – with no acknowledgment of the maintenance issues earlier in the day – and directed the other members of the crew to try to locate the source of the problem, which took a combined three hours of work time. Looking for the nonexistent line break was the only corrective action the team took related to the turbidity issues.

As part of the fallout from the four-day disruption to the city’s water customers, longtime Austin Water Director Greg Meszaros offered his resignation to the city.

The findings of the report are the main agenda item for Thursday’s meeting of City Council’s Austin Water Oversight Committee.

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