A recent report from the Virginia Department of Health highlights long-term staff complacency as a factor in the January water treatment plant failure that left much of the Richmond region without running water for days.

The report, published last week, is the result of an independent investigation by VDH and engineering firm Short Elliott Henderson to evaluate the plant and its operations.

Like previous independent reports, the timeline of events in VDH’s report points to a power outage as the critical point of the crisis, leading to flooding and mechanical failures.

However, the new report goes further, citing mechanical, systemic and personnel issues that it attributes to a culture of institutional complacency. The report states that culture allowed inadequate operations and unresolved problems to become normalized.

Examples include poor housekeeping that led to plant overflow during the crisis, failure to maintain critical systems and oversights in the chlorine contact basins and alarm system. These failures were compounded by previously identified issues such as insufficient staff training, unaddressed improvement plans and deteriorating equipment.

“The city’s Department of Public Utilities (DPU) leadership, in our view, allowed a complacent and reactive culture whereby problems and known risks were not addressed,” said Dwayne Roadcap, director of VDH’s Office of Drinking Water, during a briefing on the report last week. “That added additional risk for a water crisis to occur.”

The release of the VDH report came with multiple recommendations, including improvements totaling almost $35 million for the plant and almost $32 million for pump stations and tanks.

Roadcap also said a cultural shift is needed at DPU to prevent future crises and improve operations. He expressed confidence in the ongoing efforts of DPU Director Scott Morris and other department leaders.

Following the report’s release, a notice of alleged violation will be issued to the City of Richmond in the coming weeks. The department also will request a corrective action plan and timeline to address 12 significant deficiencies identified in the investigation.

The City of Richmond will have 45 days to respond once the notice is issued.

“VDH’s report overlaps with the independent investigation conducted by HNTB for the City of Richmond,” Mayor Danny Avula said in a statement after the report’s release. “We’ll of course review it and think through the best ways to integrate its recommendations into our work moving forward.”