RICHMOND, Va. (WRIC) — The Richmond water crisis that sent shockwaves through the city and surrounding counties in January was the result of decades of negligence, according to a newly-released report from the Virginia Department of Health (VDH).

For six days in early January, many area residents did not have any water after a power outage at Richmond’s water treatment plant . Those who did had minimal pressure and needed to boil that water before use. Though the crisis’ source was the city, localities connected to that water service — Henrico , Hanover and Goochland counties — were also affected.

The VDH has repeatedly stated its belief that the water crisis “should never have happened” and said it would launch an investigation into the factors that led up to the chaos. In the resulting report, released on Wednesday, April 16, it reiterated that belief, saying that the crisis was “completely avoidable” based on that investigation’s findings.

“Specifically, the failure at the Richmond plant was not the result of a ‘day of’ disaster, but rather, the result of years’ long neglect,” the VDH said in a letter to Gov. Glenn Youngkin and Richmond Mayor Danny Avula, which was attached to the report.

VDH added that it was not just “faulty components,” but also a “faulty culture” within the plant and the city’s Department of Utilities (DPU) that contributed to the crisis.

The investigation was conducted by VDH’s Office of Drinking Water (ODW) and engineering firm Short Elliott Hendrickson, Inc. (SEH). It is broken into two parts: a root cause analysis and a needs assessment with future recommendations.

Part one: What caused the water crisis?

Engineers assessed five key factors contributing to the crisis: issues of manpower, machines, materials, methods and measurements.

Manpower: Not enough trained staff

Regarding manpower, the report pointed out a “lack of qualified electrical staff on the night shift.”

The VDH detailed that the DPU allowed the plant to be overly reliant on manual operation, and without having an electrician or enough trained staff at the water treatment plant (WTP) during a severe weather event .

Machinery: Critical infrastructure was neglected

The VDH then highlighted faults in machinery, primarily in the plant’s back-up system.

“The Uninterrupted Power Supply (UPS) battery back-up systems were not properly maintained and were past their design life,” the VDH said.

The VDH said that, if the UPS battery back-ups were properly tested, maintained and replaced every three to five years, the water crisis would not have happened.

Additionally, the automatic power transfer, called the “bus tie,” failed. If it had been functional, it would have prevented the power outage and the resulting flooding. The VDH said that, because underground equipment rooms were flooded, the water disruption was extended.

Materials: Flooding could have been prevented

In the area of materials, the investigation found that the WTP lacked sufficient overflow pipes to prevent flooding.

“DPU has known for decades that flooding was a risk; yet the Department did not take appropriate actions,” the VDH letter to Avula and Youngkin reads.

Methods: Cost prioritized over preventing service disruption

At the time of the water crisis, DPU was operating the plant in “Winter Mode”, meaning the WTP was relying solely on the main power feed without the secondary feed backing it up.

The alternative, “Summer Mode,” would have provided power from both the main and secondary feeds.

This was identified as one of the three primary errors that caused the crisis, with the VDH noting that the city was operating in Winter Mode “as a cost-saving measure.”

“Winter, when the threat of a power outage from a snow/ice event is greatest, was the exact wrong season to take the underground main power feed offline,” the VDH said.

DPU has since stopped operating in Winter Mode.

Additionally, the VDH affirmed the findings of the city’s own after-action report , which stated that staff were not at all trained or prepared for emergency situations.

Measurements: Important controls failed to work

The investigation found that the electrical switchgear alarms did not alarm the control room when the plant began to flood.

The VDH also stated that the UPS valve controls failed to close the plant’s filter effluent valves, which control the rate of water flowing through the filter. If these valves had been closed, the flooding would not have occurred.

Part two: VDH’s conclusions, recommendations

The report states that unaddressed systemic issues over decades, including a “complacent and reactive organizational culture,” caused the water crisis.

“DPU allowed situations to exist that increased the risk of a water crisis,” the VDH said in its letter.

According to the VDH, inspectors learned that equipment at the plant would break and it would not be fixed for “unnecessarily long periods of time.”

This was reportedly commonplace due to a “managerial environment where WTP staff works with known issues that increase risk of WTP failures,” wherein DPU fostered “general acceptance and normalization of critical unacceptable issues.”

The investigation identified that about $64 million of infrastructure upgrades are needed over the coming years to address the issues discovered by VDH.

However, the city will not need to find that full $64 million in new funding, as several upgrades identified by SEH are already included in Richmond’s capital improvement plan.

The VDH highlighted that funding from the City’s PILOT (Payment in Lieu of Taxes) program could be leveraged to generate at least $80 million for recommended infrastructure upgrades. Since 2006, the city has reportedly diverted PILOT program funding away from the water treatment plant and to its general fund.

Moving forward, the VDH said DPU’s management team is changing the organizational structure to improve communication among its staff, specifically maintenance and operations.

“Culture and organizational complacency are being replaced with active management and an emergency preparedness mentality,” the VDH said.

While the VDH has already identified multiple alleged code violations from the city, it said that, following this report, the city should expect a second Notice of Alleged Violations (NOAV) with additional infractions.

The VDH is also requiring a corrective action plan from Richmond and it will monitor the city’s compliance.