An expert report into the fluoride overdosing incident in Brisbane in May this year has highlighted a series of problems with equipment and monitoring systems, as well as inadequate training, communication failures and poor management systems that collectively contributed to the incident. The report, by the International WaterCentre (IWC) in Brisbane, was commissioned by the Queensland state government and reviewed the following aspects of the event:
- the design and operation including the control systems of the fluoridation system at North Pine Water Treatment Plant;
- monitoring programs undertaken by various relevant agencies, including review of data collected;
- the communication and notification systems that are in place and their effectiveness;
- emergency response plans and their effectiveness;
- other fluoridation systems in operation in South East Queensland;
- national and international experience in fluoridation systems, particularly any insights in relation to best practice in systems and operations.
As reported in Health Stream Issue 54, the overdosing occurred after fluoride dosing equipment continued to operate during a scheduled maintenance shutdown of the plant. It was initially believed that a large volume of highly fluoridated water had flowed into the distribution system when the plant was restarted, possibly exposing up to 4000 households to elevated fluoride levels (initially reported as over 30 mg/L but later revised to 20 mg/L) for several hours. However subsequent investigations revealed that most of the affected water had been used for backwashing filters at the plant, and the potential for public exposure was much less than originally thought. The main findings of the IWC report are summarised here…
*Read original Public Health Newsletter of Water Quality Research Australia at http://fluoridealert.org/wp-content/uploads/australia.brisbane.overdosing.sept_.2009.pdf
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