According to a pair of independent reports, a freak set of circumstances led to the formation of a cloud of noxious vapor that sickened five swimmers – including two minors – at the Evolutions Fitness and Wellness Center in Tulare last month.
The reports were made public on Thursday, July 13 at a special meeting of the Tulare Local Health Care District (TLHCD), which owns the facility. Both reports are available at the TLHCD website.
CEO Describes What Happened
TLHCD CEO Randy Dodd said the focus of the district’s leadership is now assuring no similar incident occurs in the future.
“Five people did go to the hospital, and that is taken very seriously by this board and our staff,” he said. “And we’re obviously looking at ways in which we can obviously prevent anything like that happening again.”
According to Dodd, the pool at Evolutions was closed on Sunday, June 25 so maintenance techs could repair a cracked filter. The repair was completed the next day at about 4 p.m.
“The water was flipped back on, which begins the process of balancing chemicals and filtering water,” Dodd said. “And from that time until the pool was reopened the following day the water should have turned over about three times through the filtering process.”
On the day of the poisoning incident – Tuesday, June 27 – the district’s pool maintenance technician checked the pool, initially finding it within normal chemical reading limits.
“Our certified pool guy came in and tested the water at 8 a.m. and found that the chemicals were all within normal ranges at that time,” Dodd said. “The alkalinity was a little bit low, so they did add some sodium bicarbonate to help bring those levels up, and the heater, which had been off because there was no need for it, was turned on that morning as well.”
The pool was reopened to members at 10 a.m.
“At or about 10:40, the chemicals were tested again in the pool, and they were also again found to be within normal ranges,” Dodd said.
About an hour later, the tech noticed pH levels were dropping.
“It wasn’t out of the normal range, but it was at the low end, which is not a usual circumstance, so he was keeping his eye on that to make sure that nothing else changed, and nothing else did change on that particular sensor before.”
Minutes later, Evolutions staff were notified swimmers were having trouble breathing.
The staff, Dodd said, responded swiftly.
“So, immediately the pool was shut down. People were pulled out of the pool,” he said. “The management was notified about a minute later, who then notified 911 and pulled the fire alarm, and the building was evacuated as quickly as possible. We think that happened within six to eight minutes to get everybody out of that space.”
Firefighters used fans to increase circulation and opened the pool area to outside air as much as possible to clear it of lingering vapors. With the help of Evolutions staff, firefighters added additional bicarbonate sodium to the pool to further adjust the pH and “to calm [the pool] down,” Dodd said.
The five people who suffered difficulty breathing while in the pool were taken by ambulance to local hospitals.
“At least one report indicated that they were there for about five or six hours before they were released with respiratory issues that involved oxygen treatments as well as in some cases steroids to help open airways and so forth,” Dodd said.
Paul Olson, the father of one of the victims who is a competitive swimmer at the University of Nevada Las Vegas, said his daughter was experiencing lasting effects from the exposure as much as 10 days afterwards. Olson could not be reached for an update on his daughter’s health.
Slow Response from TLHCD
Olson took the district to task for its slow response in releasing information about the chemicals his daughter and the others injured were exposed to. Prior to the independent investigations, muriatic acid was speculated to be the agent responsible for the injuries to the swimmers.
On the day of the poisoning, Firefighters were told the pool is treated with chlorine, muriatic acid and sodium bicarbonate.
“I believe at that point they [firefighters] believed that muriatic acid could have been the culprit in this, and that narrative started at that point in time,” Dodd said. “It’s what the hospital was given to help with their process and that rumor, if you will, started at about that time.”
Chloramines Caused Poisoning
Two independent pool inspection services were contracted to review the incident and provide reports on their findings. Both investigators blame chloramine, a byproduct of the chlorine used to sanitize the pool combining with ammonia compounds introduced to the pool by users.
“Chloramines are formed when chlorine combines with ammonia and organic amines, usually
from swimmers’ body waste (urine, fecal incidents, sweat), and can build up to very unsafe
levels for swimmers and people in the pool area over time if not treated,” wrote Timothy Petsch, director of TMI Sustainable Aquatics, who reviewed data about the incident for TLHCD.
Knorr Systems International, which also investigated the incident, agreed chloramines were the causal agent in the poisoning. Ammonia compounds, its report said, are introduced to pools by such vectors as “body sweat, oils, lotion and in many cases urination.”
When chloramine gasses are allowed to remain in an area with an indoor pool, they can be forced back into solution in the pool water.
“This off-gas typically disperses to the atmosphere, however because the pool is enclosed the off-gas is trapped and unable to escape, and rather than dispersing into the air, it is forced back into the pool water. When this happens the residual of chloramine levels in the pool will rise, causing irritable odors at risk of being ingested by swimmers using the pool,” the Knorr report stated.
Dodd summarized what happened on June 27 in lay terms.
“We had a situation: The pool is down a couple of days, the water’s not being stirred up, the air’s not being moved, those chloramines drop down, sit on top of the pool, and then you introduce people, contaminants, other things that have a reaction with whatever the chemicals are, and this is conjecture, which is not a great place to be, but at that point whatever that level reached, it off-gassed,” Dodd said.
A cloud in the pool noticed by swimmers before the incident is also indicative of chloramines in the water.
Dodd was adamant the cause of the respiratory distress was not muriatic acid, as was previously assumed.
“I asked one of the guys: Could this have been muriatic acid? And his comment to me was you’d have to have someone standing over the pool just dumping gallons of muriatic acid into the pool,” Dodd said. “It doesn’t seem like that’s the issue here.”
It was concern about providing misleading information that led the district to wait before presenting more definitive information about the contaminant. The lack of official word led to a rumor that muriatic acid was responsible for the poisonings.
“It’s unfortunate this is the narrative that started early in the process, but the truth is we didn’t have all of this understanding of how this pool chemistry works until the last few days, frankly, as these reports came to our attention,” Dodd said.
Board Regrets Lack of Sympathy
TLHCD Board President Kevin Northcraft addressed how the board initially responded to news of the incident at the Evolutions pool. Comments issued via social media took the board to task for its lack of forthrightness regarding the incident.
“In hindsight, at our last meeting we could have expressed more sympathy to the injured people from this issue,” Norfthcraft said. “I think we all felt that. We didn’t probably verbalize that as well as we could have.”
Northcraft extended the board’s well-wishes to those injured.
“We hope they’re doing much better, and we certainly didn’t want to convey anything but best wishes for them and hope they’ll resume their membership in the gym and continue to enjoy the health benefits of that membership,” he said.
Northcraft emphasized the amount of work and money the district had put into maintaining Evolutions.
“In the past couple of years, the board has committed to keeping Evolutions and rehabbing it and having a long-term asset for our community,” he said. “We’ve either spent or committed millions of dollars for floor and solar, air conditioning, little upgrades in trying to get Evolutions … to improve it and make sure it’s there for many years to come.”
The incident at Evolutions is a matter of the best of intentions gone unintentionally wrong, Northcraft said. The board’s efforts to keep Evolutions open and up to date, he said, are intended to improve the overall quality of life for Tularians.
“That’s to keep an asset to help our 88,000 people have access to something that will improve their health. Being a healthcare district, it seems consistent with that,” he said. “Unfortunately, having people injured at that gym is the opposite of what we’re having the gym for, so we certainly have concerns.”
CEO Calls District Response Flawed
CEO Dodd said the district’s less-than-adequate response was, at least in part, his fault. He blames the fog of information that often surrounds emergencies in their immediate aftermath.
“This was a failure on my part to adequately notify all board members,” he said during the July 13 special meeting. “I did notify our board chair, and two other board members that were present got partial communication, as well as our attorney, but we were really in mode at that point of trying to figure out what happened.”
All eyes at the district are now on the same page, he said.
The pool, which remained closed as of July 13, has been deemed safe to reopen. However, means of preventing a similar incident in the future are being explored and pursued.
“We’re going to have to look at everything and see what the options are,” Dodd said. “This is an unfortunate accident, but it’s hard to pinpoint anything that would have said, ‘If we’d have done this, it might have been different.’”
There were, Dodd said, no clear warning signs something was wrong.
“The thing that’s strange about this one is that nothing was really extraordinary in terms of level [of pool chemicals], so no action was called for,” he said.
Preventing Another Toxic Cloud
There are some steps the staff at Evolutions can take to prevent another cloud of chloramine gasses forming above the indoor pool.
The source of the ammonia compounds in the pool water is likely the swimmers who use it. This form of contamination is a regular occurrence in most pools.
“That’s going to off-gas into chloramine, and if the chloramine levels, as I understand it, gets to a certain level it does this off-gassing process, which in an outdoor pool is not a big issue,” Dodd said. “In an indoor pool it’s a big issue.”
The pool area at Evolutions is equipped with ventilation equipment, and the board has ordered a review of it to ensure it is adequate and to improve it if needed. At the recommendation of the two experts hired to review the incident, a UV filtration system will be added to reduce chloramine buildup.
And getting bathers to shower before entering the pool would also help.
“Better enforcement of the showering before swimming rule would help, but it’s difficult to get compliance,” Dodd said. “We do have signs up to that effect, but you can’t get everybody to do that either.”