Robert Schwartz and Do crises help remedy regulatory Allan

Do crises help remedy regulatoryfailure A comparative study of theWalkerton water and Jerusalembanquet hall disasters

Robert Schwartz andAllan McConnell

Abstract This study explores whether and how policy changes in the aftermath of acrisis The authors ask why pre-existing regulatory regimes that are identified as con-tributory factors to lsquolsquofailurersquorsquo are not necessarily reformed in the wake of a crisis Theinvestigation adds to the literature that addresses the classic tension between reform-ism and conservatism in post-crisis periods Regulatory failure is identified as beinglargely responsible for two crises ndash the tainted drinking-water tragedy in WalkertonCanada and the collapse of a banquet hall in Jerusalem Israel Despite similarities inthe nature of media coverage institutional procedures for investigation and commis-sion findings these two tragedies differ dramatically in policy change outcomes Apolicy streams prism is used to identify characterize and analyse reasons for verydifferent policy responses to crises associated with regulatory failure

Sommaire Cette etude examine si et comment les politiques changent a la suite drsquounecrise Les auteurs se posent la question de savoir pourquoi des regimes dereglementation preexistants qui sont identifies comme etant des facteurs contribuanta lrsquo szlig echec ne sont pas necessairement reformes a la suite drsquoune crise Lrsquoenqueteapporte des elements a la documentation portant sur la tension classique qui existeentre le reformisme et le conservatisme au cours des periodes posterieures a unecrise Lrsquoechec de la reglementation est identifie comme etant largement responsablede deux crises la tragedie de lrsquoeau potable contaminee a Walkerton au Canada etlrsquoeffondrement drsquoune salle de reception a Jerusalem en Israel Malgre des similaritesdans la nature de la couverture mediatique dans les procedures institutionnellesde lrsquoenquete et les resultats des commissions ces deux tragedies different radicale-ment dans les resultats des modifications de politiques Un prisme des courantsde politiques est utilise pour identifier caracteriser et analyser les raisons des reac-tions tres differentes en matiere de politiques a des crises associees a lrsquoechec de lareglementation

Robert Schwartz is associate professor Department of Public Health Sciences University of To-ronto and Allan McConnell is associate professor Department of Government and InternationalRelations University of Sydney They acknowledge with gratitude the helpful comments madeby the Journalrsquos anonymous reviewers

CANADIAN PUBLIC ADMINISTRATION ADMINISTRATION P UBLIQUE DU CA NADA

V OLUM E 52 NO 1 (MARCH MARS 20 09) P P 91ndash 112

r The Institute of Public Administration of CanadaLrsquoInstitut drsquoadministration publique du Canada 2009

When regulatory failures are significant and precipitate crisis and disasterone might expect subsequent reform of these regulatory systems to reducethe risk of further fatal episodes The democratic logic of this assumption isquite straightforward As Christopher Hood Henry Rothstein and RobertBaldwin suggest risk regulation is lsquolsquogovernmental interference with marketor social processes to control potential adverse consequences to healthrsquorsquo(2001 3) Therefore the greatest damage to a regulatory regime is likely to bewhen its weaknesses lead to death and disaster We might reasonably expectthat the ensuing loss of political and public confidence coupled with inquiryfindings that demonstrate that operational systems are not capable of per-forming the public safety functions for which they were designed will leadto lessons and regulatory reform In fact given the prominence and scrutinygiven to public health issues by the media citizensrsquo groups opposition par-ties and others it may be difficult to conceive of a situation where there areno post-crisisdisaster moves to restore regulatory efficacy and the legiti-macy of the regulatory system

This logic seems initially to be reinforced by the literature on policychange Students of policy change know that dramatic changes in policy arefew and far between Normally the routines of politics predominate andpolicy change is incremental Depending on which perspective we take pol-icy is controlled by relatively closed communities advocacy coalitions orconstrained by path dependencies However crisis and disastrous episodeshave the capacity to punctuate the normal rhythms of policy-making andproduce rapid change (Boin and lsquot Hart 2003) Crises can act as trigger events(Cobb and Elder 1983) external perturbations (Sabatier and Jenkins-Smith2003) stressors (Wilson 2000) focusing events (Birkland 1997 2006) and pro-duce lsquolsquowindows of opportunityrsquorsquo (Kingdon 2003) for policy change to occur

If we dig deeper however the ideas on policy change and crisis manage-ment put forth in the literature are much more complex They do not indicatethat policy change is an inevitable product of crisis episodes Crises believedto result from unintended and unguided actions for example are not likelyto reveal a need for policy change in systems at most they result in the pun-ishment of those individuals deemed responsible (Stone 2002 Birkland andNath 2000) Furthermore agenda-setting theory suggests that while (sys-tem) crises will almost necessarily focus public attention on an issue unlessthere are coherent advocacy coalitions (Sabatier 1993 Wilson 2000) per-ceived viable solutions or favourable political climates they are unlikely tolead to policy change (Birkland 1997 2006 Kingdon 2003) Indeed politicalrealities and the actions of entrenched interests often thwart crisis-inducedpolicy reform

Recent thinking on the politics of crisis management (Boin and lsquot Hart2003 Boin et al 2005 Drennan and McConnell 2007) reinforces the complex-ity of the relationship between crisis and policy change Crisis management

92 ROBERT SCHWARTZ ALLAN MCCONNELL

is deemed to be a lsquolsquomission impossiblersquorsquo with leaders facing in two directionsin the wake of crisis They need to offer some lsquolsquolearningrsquorsquo commitment to en-sure that never again will society be exposed to the same risks but they alsoneed to offer reassurance that existing frameworks are essentially robustThis tension between reformism and conservatism in the aftermath of crisisis both an enabler and a constraint on policy change after crisis

In this article we add to existing literature by focusing specifically on theextent to which failures in regulatory systems lead to regulatory policychange in the wake of the crisis and disaster they helped precipitate Previ-ous studies have examined the effects of focusing events on policy changeand on administrative values (Vaughan 1996 Busenberg 1999 Romzek andIngraham 2000 Schwartz and Sulitzeanu-Kenan 2004) However they do notrelate specifically to learning and change from regulatory failures

Accordingly this article deals with two cases where regulatory failureswere implicated as causal factors in tragedies but subsequent processes ofinquiry and broader lesson-drawing culminated in very different policy out-comes The Walkerton water tragedy involved contamination of drinkingwater with the E-coli bacterium (Ontario Walkerton Commission of Inquiry(2002) It produced seven deaths caused some 2300 to fall ill and led sub-sequently to substantial reform of the environmental regulatory regime Bycontrast Jerusalemrsquos Versailles Banquet Hall collapse in 2001 caused twenty-three deaths and over four hundred injuries but did not lead to refinementsin building codes (Israel Commission of Inquiry into Safety of Buildings andPublic Places 2004) In reality changes were little more than symbolic ges-tures

The article draws on a variety of primary and secondary sources includ-ing investigative reports and interviews with stakeholder representativesOur goal is case-oriented viewing the Canadian and Israeli experiencesthrough the lenses of literature on policy change and risk regulation Ourcase comparison is essentially a lsquolsquomost similarrsquorsquo one (George and Bennett2004) which seeks to explain why two regulatory-induced crises in systemswith broadly similar policy and political characteristics produced markedlydifferent outcomes in terms of policy change We recognize that a two-casediscursive approach cannot provide a controlled comparison and rigoroustesting of a single independent variable but we do have the advantage ofrich description and country specificity

Our two cases share much common ground Both were tragedies broughtabout (in part) by failures in systems on which citizens relied for basic needsndash water and shelter Both failures generated substantial national and inter-national media scrutiny and coverage The institutional configurations anddemocratic contexts of the post-disaster inquiries were also broadly similarBoth were (and are) liberal democracies with parliamentary systems andprocesses for independent post-disaster investigations Furthermore the

DO CRISES HELP REMEDY REGULATORY FAILURE 93

chairs of each investigation ndash both highly respected ndash laid the blame princi-pally on the failures of the respective regulatory systems

The article is divided into three broad sections The first provides an over-view of each case focusing on the role of regulatory failure in the advent ofthe crisis The second section compares the subsequent policy reactions andpolicy change patterns It uses the lsquolsquopolicy streamsrsquorsquo model (Kingdon 2003) asa means of organizing and informing the analysis The discussion focuses onexplanatory variables from the politics stream (political context process ofinvestigation stakeholder interests) that affect post-crisis policy change Aswe will see the respective interactions of the problems solutions and politicsstreams help explain the different policy trajectories in the wake of disasterThe final section concludes by drawing out broader implications in terms ofthe relationship between societal risks and the regulatory regimes whichare in theory meant to mitigate these risks

Case presentations the role ofregulatory failure in the advent of crises

WalkertonThe rural town of Walkerton in southern Ontario is home to some 4800 res-idents In May 2000 heavy rain washed manure from a farm into the sourceof the townrsquos drinking water leading to contamination with the E-coli bac-terium (Eshericha coli 0157H71) Failures in the operation and oversight ofchlorination procedures resulted in the deaths of seven people who had in-gested the deadly bacteria and in excess of 2300 illnesses ndash the adverseeffects being long lasting for many individuals Public panic and fear aboutdrinking-water quality spread throughout the province and the governmentappointed the Walkerton Commission of Inquiry headed by Associate ChiefJustice Dennis OrsquoConnor

The inquiryrsquos report found that two operators of the water treatment plant(the Koebel brothers) had acted improperly in not complying with and in-deed flouting water treatment and reporting rules but that the responsibilityto ensure compliance with regulations should rest with the Ministry of En-vironment which had failed in this regards as well as with the municipalgovernment and the provincial government more generally The Ministry ofEnvironment had known for several years that there were substantive prob-lems with Walkertonrsquos water treatment facilities particularly in terms ofmicrobiological sampling and chlorination However lsquolsquo[t]he MOE took noaction to legally enforce the treatment and monitoring requirements thatwere being ignored I am satisfied that if the MOE had adequately ful-filled its regulatory and over-sight role the tragedy in Walkerton wouldhave been prevented (by the installation of continuous monitors) or at least


significantly reduced in scope (Ontario Walkerton Commission of Inquiry2002a 27ndash30)

The banquet hall collapse demonstrated that the regula-tory regime governing planning and construction waslargely ineffective

The inquiry report also highlighted the detrimental impact of budget cut-backs on the capacity of the Ministry of Environment to ensure safe drinkingwater for the residents of Ontario Budget cuts introduced in the mid-1990sby the neo-liberal Harris administration led to a significant reduction in in-spections and monitoring (by 1998ndash90 the ministryrsquos budget had beenreduced by more than $200 million and staff numbers had been cut by overthirty per cent (Ontario Walkerton Commission of Inquiry 2002a 34) Theregulatory regime was not only weak for drinking water but voluntary fornon-point source water pollution such as from agricultural waste pesticiderun-off and sewage overflow (Johns 2001) As the inquiry subsequently re-vealed the pressures were sufficient for ministers and the cabinet to bewarned in writing by senior officials of possible public-health risks althoughthe lsquolsquoimpartialrsquorsquo status of public servants and their inability to make publiccomment coupled with a lack of whistle-blowing procedures preventedthese warnings finding their way into the public domain The WalkertonCommission of Inquiry also found that the Ministry of the Environment didnot follow through on the findings of a 1998 inspection which sought tocorrect deficiencies in monitoring and chlorination procedures As the in-quiry report suggests lsquolsquoWith the proper follow-up these protectivemeasures would likely have resulted in the [Public Utilities Commssion]PUCrsquos adoption of chlorination and monitoring practices that would in turnvery likely have substantially reduced the scope of the outbreak in May2000rsquorsquo (Ontario Walkerton Commission of Inquiry 2002a 405ndash406)

JerusalemThe collapse of Jerusalemrsquos Versailles Banquet Hall in June 2001 grabbedthe attention of the international media particularly because it had access tospectacular video footage of the dance floor collapsing1 Twenty-three peo-ple died and over 400 were injured ndash many seriously Initial investigations byengineers found a number of deficiencies The building was designed for in-dustrial use rather than for dynamic lsquolsquoloadsrsquorsquo brought about by recreationaluse a supporting column had been partially removed during renovations ofthe ground floor and a new floor had been added Crucially the prohibitedPal-Kal method had been used to construct this new floor Pal-Kal involvesthe use of cheap steel plates or boxes for structural support rather than themore expensive and traditional system of concrete supporting columns


The banquet hall collapse demonstrated that the regulatory regime gov-erning planning and construction was largely ineffective Jerusalemrsquos cityengineer testifying before the Knesset Interior Committee made public thefact that the banquet hall had never received an lsquolsquoapproval for occupationrsquorsquoor a business licence (Israel Knesset 2001a) Attempts made through legalchannels to close the hall were unsuccessful All along the municipality hadnot scrutinized building plans closely enough to be aware that the prohib-ited Pal-Kal method had been used

Explanations offered by city engineers for abdicating their legal duty tocheck building plans focused particularly on the meagre budgetary alloca-tions afforded to engineering units by local authorities resulting in a lack ofsufficient numbers of qualified engineers to conduct detailed checks onbuilding plans (Israel Commission on New Building Methods 2001 39 Is-rael Knesset 2001b 23) At the time of the tragedy only eighteen out ofthirty-three inspectorate positions were filled Meanwhile the municipal taxrevenues that buildings generated for local authorities created strong incen-tives to get buildings operational The scale of the problem becameparticularly evident when at a meeting of the Knesset Interior Committeeit was revealed that there were almost 50000 buildings constructed in breachof legal requirements in Jerusalem each of which paid municipal taxes (Is-rael Knesset 2001a 18)

Early warnings of Pal-Kal deficiencies date back to 1987 when the head ofthe Station for Construction Research of Israelrsquos prominent engineering uni-versity the Technion sent a letter to the Ministry of Construction stating thatthe method was inappropriate and unsafe Yet no action was taken by gov-ernment oversight agencies until the mid-1990s when the chief inspector inthe Ministry of Labour with responsibility for investigating accidents atwork linked the Pal-Kal method lsquolsquowith a very high probabilityrsquorsquo of havingcontributed to three roof collapse incidents two deaths and numerous inju-ries over the period 1994mdash95 Nevertheless problems continued In 1996 adisaster was narrowly avoided when a crack was found in the ceiling of ashopping mall in the city of Rehovot The ceiling had been constructed usingthe Pal-Kal method

These dangerous incidents and near misses prompted some action In1996 the Ministry of Interior issued a circular to local authorities that statedthat the Pal-Kal construction method was dangerous and in breach of basicengineering principles The circular stated that local authorities should notgrant building permits or approve for use any buildings constructed usingPal-Kal Also in 1996 following tests conducted by the Israel Standards In-stitute an amendment was issued to the standard governing roofconstruction that made it clear that Pal-Kal roofs did not meet the requisitesafety standards Two years later in 1998 a second circular was issued by theMinistry of Interior that instructed local authorities to carry out visual in-


spections of all buildings constructed using the Pal-Kal method Later thatsame year pressure intensified when the Association of Contractors in Israelrecommended that the Pal-Kal method not be used by members

These new requirements and strong recommendations seemed sufficientto mark the end of Pal-Kal and the public health dangers that accompaniedit However as all policy scholars know policy implementation does notalways accord with decision goals The banquet hall collapse was preciselyevidence of this Local authorities did not put requirements into practiceLocal authorities in Israel suffered from chronic budget crises broughtabout by a combination of security-dominated national budgets as wellas central-local tensions and blame-shifting for service failures (Brender2003) Neither the Ministry of Interior nor municipal authorities werewilling and able to commit a level of resources that would enable compre-hensive and professional scrutiny of both building plans and existingstructures

Reaction and regulatory policy change

WalkertonThe Ministry of Environment with backing from the Government of On-tario took swift action to reassure residents throughout the province thattheir water was safe to drink All municipal water systems were subject toimmediate external review with results reported back to the ministry TheWalkerton Commission of Inquiry was appointed and the Ministry of theEnvironment began revamping its regulation of drinking water in accor-dance with preliminary findings The reforms were backed by governmentresources Roughly $18 million was provided initially for Operation CleanWater followed by an investment of almost half-billion dollars over the pe-riod 2002mdash03 in order to implement Justice OrsquoConnorrsquos recommendations(Ontario Ministry of Finance 2002) Changes occurred in the three maincomponents of regulatory regimes standard-setting information-gatheringand behaviour modification (Hood Rothstein and Baldwin 2001) Let usdeal briefly with each

What were previously objectives and guidelines became standardsOntariorsquos new water regulation regime became enshrined in three pieces oflegislation the Safe Drinking Water Act 2002 (SO 2002 c 32) the Sustain-able Water and Sewage Systems Act 2002 (SO 2002 c 29) the NutrientManagement Act 2002 (SO 2002 c 4) and the Drinking Water SystemsRegulation (O Reg 17003) as well as (in the longer-term) the Clean WaterAct 2006 (SO 2006 c 22) New requirements in 2002 and 2003 covered arange of issues from water sampling to chlorination For example a newdirective was put in place requiring owners of water treatment or distribu-tion systems to


mdash notify the medical officer of health and the ministry of sample resultsoutside established parameters or of any other indicators of adverse wa-ter quality (s 8)

mdash post warnings when sampling and analysis requirements have not beenmet (s 10)

mdash make available to the public free of charge copies of reports and recordsin relation to water samples (s 11)

mdash prepare written reports on a quarterly basis submitted to the directorand covering comprehensive water data analysis of results and mea-sures taken to ensure compliance with regulations and legislation (s 12)and

mdash submit triennial reports to the ministry conducted by an independentengineer with experience in sanitary engineering and water supplies (s13)

In terms of information-gathering systems were reformed and the newregime included mandatory and yearly inspections of all systems for thedistribution and supply of drinking water The duration of each inspectionoften lasted several days depending on the scale and complexity of each fa-cility New requirements with regard to sampling analysis and reportingalso allowed additional information to be gathered

Finally a behavioural change was evident on the part of inspectors Priorto the disaster inspectors and operators interacted on the basis of collegialityand advice rather than on the basis of lsquolsquoinspector as enforcerrsquorsquo Informal re-lationships and practices are typically the least effective in ensuringcompliance with regulations (May 2005) However in the aftermath of theWalkerton tragedy the Ministry of the Environment introduced a lsquolsquozero tol-erance policyrsquorsquo Breaches of standards were to be rigorously pursued andenforced according to stipulated time-frames lsquolsquoZero tolerancersquorsquo also in-cluded administrative infractions ndash such as financial penalties for improperposting of certificates Therefore within a short time-period the pendulumhad swung to the opposite side of the regulatory continuum ndash to a manda-tory approach (May 2005)

JerusalemIn the wake of the Versailles Banquet Hall tragedy the Knesset appointed theCommission of Inquiry into Safety of Buildings and Public Places (chairedby Justice Vardi Zeiler) to study the state of the regulatory regime for build-ing safety (Israel Commission of Inquiry into Safety of Buildings and PublicPlaces 2003) Reporting some two and a half years after the disaster in De-cember 2003 the inquiry found serious deficiencies in regulatory systems forthe construction and safety of buildings When the report was published theJerusalem Post (26 December 2003) described its findings as lsquolsquonothing less


than a searing indictment of the whole building industry the entire sys-tem of construction in Israel is flawed to its corersquorsquo Such pessimism seemswarranted in the light of Zeiler himself stating that lsquolsquoit will be a miracle ifthere isnrsquot a second Pal-Kal affairrsquorsquo

Accordingly the inquiry proposed a major overhaul of building-safetystandards and the establishment of a new national body for the regulation ofthe construction industry To date however no action has been taken on theinquiryrsquos major restructuring recommendations There have been minor re-finements to business licensing ministry instructions to enforce the businesslicensing law educative seminars and some meetings bringing various au-thorities together with a view to producing a more coordinated approach tobusiness licensing Yet such changes are clearly small and incrementalThere is no new legislation new building standards or new agency to pro-duce a coordinated approach to regulation and its enforcement

A framework for explaining differentpolicy trajectories in the wake ofregulatory failure

A study by M Lodge and Christopher Hood (2002) identifies a number ofpossible policy learning reactions to crises Knee-jerk responses (swift reac-tions to tragedy) tend to produce excessively rigid control regimes and leavelsquolsquoregulatory tombstonesrsquorsquo for years to come (Breyer 1993) lsquolsquoCrisis reformrsquorsquoresponses involve entrepreneurial exploitation of lsquolsquowindows of opportunityrsquorsquoto launch incubated proposals ndash which characterizes turning points that leadto institutional renewal (Boin and lsquot Hart 2000) lsquolsquoDynamic conservatismrsquorsquo orlsquolsquosystem-maintenancersquorsquo approaches protect borders and established modesof operation and preserve as much as possible pre-existing ways of life(Lodge and Hood 2002) Finally organizations that manage to avoid themost difficult changes and that focus on more readily practical programma-ble or the internally valued aspects of changes can be said to have effected anlsquolsquoinstitutional biases-coloured responsersquorsquo

Applying this classification scheme the two cases are clearly at oppositeends of the continuum Policy change after the Walkerton tragedy fits well inthe lsquolsquoknee-jerkrsquorsquo response category although the term can carry negativeconnotation in actual fact swift responses can also be measured and popu-lar By contrast changes stemming from the Jerusalem tragedy can becategorized by lsquolsquodynamic conservatismrsquorsquo and an lsquolsquoinstitutional biases-colouredresponsersquorsquo In the Walkerton case new standards required that even verysmall drinking-water facilities conduct frequent tests that frequent routineinspections be conducted of all facilities and that a zero-tolerance strategybe applied to even minor infractions It seems therefore that there has beena change in the allocation of attention and resources within the Ministry of


Environment from areas of higher science-based risk to addressing thelower risk of contaminated drinking water In contrast Israeli policy-makersmade only very minor adjustments to the regulatory regime governingbuilding safety

Existing literature on regulatory regimes is only of partial assistance inhelping us explain these two different policy pathways after crisis A majorstudy of risk regulation regimes by Hood Rothstein and Baldwin (2001) fo-cused more on comprehending the characteristics of each regime itself thanon explanations for change It identified three main factors that help explainrisk regime content (market failure popular opinion and interest pressures)but also factors in organizational micro-politics as well as increased pres-sures for openness and transparency There is a recognition that tragedy maybring about reform although its principle focus is on how effective such (ar-guably) hastily introduced changes can be

Hood and his colleagues concluded their study by recognizing the needfor alternative ways of understanding divergences between risk regulationregimes In this spirit we use the lsquolsquopolicy streams framersquorsquo (Kingdon 2003) toshed light on the conditions under which tragedy associated with regulatoryfailure leads to different types of policy response Following this approachwe offer three propositions They are parsimonious in nature but we wouldargue have sufficient explanatory power to be usefully applied to the Walk-erton and Jerusalem cases

1 The Problem Stream The greater the perception that a flawed regulatoryregime presents tangible and widespread risk to public health and safetythe greater the likelihood of significant regulatory policy reform includ-ing knee-jerk policy responses

2 The Solutions Stream The more that proposed regulatory regime changesare perceived as technically and economically viable the greater thechances they will be adopted

3 The Politics Stream a) The more a government is under political pressurefor reform (eg in the media or in public opinion) is vulnerable in itscapacity to govern (eg in relation to looming elections or slides in opin-ion polls) and reform does not challenge dominant governing values themore likely it is that policy reform will occur in the wake of crisis and b)the more powerful the stakeholders lobbying for change the more likelyit is that policy change will occur

In applying each proposition to the Walkerton and Jerusalem casesour analysis will attest to the importance of political dynamics inexplaining risk regulation despite the perceived ability of risk regulation toconduct precise calculations of relative risks Our analysis is summarized inTable 1


The problem streamThe risk issue at the core of the Walkerton tragedy was the risk that drinkingwater may be unfit for human consumption resulting in illness and possibledeath Water is a basic human need and safe drinking water has become oneof the signs of a modern society (Shiva 2002) ndash especially in comparison tomany developing nations where drought and water contamination is a wayof life (and death) In the developed world when public authorities fail toguarantee the safety of drinking water and its supply this focusing event(Birkland 2006) is likely to produce an lsquolsquoagenda-setting crisisrsquorsquo (Boin et al2005) connecting with deeper societal concerns about the fragile nature ofour environment Walkerton was about water ndash a basic human need ndash raisingthe stakes and creating considerable impetus for something to be done torestore public trust

The collapse of the Versailles Banquet Hall in Jerusalemcreated a watershed change in public perception of therisks of building collapse

Such arguments were reflected in much of the social anxiety and officialinvestigation In essence there was widespread recognition that the Walker-ton failure was fundamentally a systemic failure Justice OrsquoConnorrsquos inquirymade clear that issues surrounding Walkerton had ramifications beyond thissmall town There were serious concerns about drinking-water safety for theentire province of Ontario and its twelve million residents A citizensrsquo actiongroup set up in the immediate aftermath of the contamination episodestated before the inquiry that lsquolsquo[b]efore May of 2000 most Canadians turnedthe tap on for a drink of water with the full confidence that the water wasclean and safe for consumption Now however that sense of confidenceand trust in the safety and security of drinking water supplies hasdisappearedrsquorsquo (Canadian Environmental Law Association 2001 5) Theagenda-setting nature of these concerns (coupled with a separate contami-nation incident in North Battleford Saskatchewan in March and April 2001)spread to almost every other province and territory in Canada leading to an

Table 1 Strength of Factors Conducive to Regulatory Change in Walkerton and Jerusalem

Walkerton Jerusalem

Problem stream perception of the risk and its challenge to publichealth and safety

MediumHigh

Medium

Solutions stream technical and economic viability of proposedregulatory regime change

Medium Medium

Politics stream conducive political context High Low


upgrading of regulatory regimes new legislation new enforcement proce-dures and staff education and training Such developments are consistentwith the more general point made by BTimothy Heinmiller (2003) that Can-ada exhibits a high degree of inter-provincial policy emulation in waterexport regulations

The collapse of the Versailles Banquet Hall in Jerusalem created a water-shed change in public perception of the risks of building collapse Whileprevious Pal-Kal-related incidents were reported in the press and whilethere was general knowledge of regulatory weakness the shock of this trag-edy ndash including the visual images broadcast repeatedly on public television ndashcaused considerable concern about the safety of public buildings throughoutthe country The perception of there being a real problem was fanned by me-dia reports of hundreds of buildings with Pal-Kal construction includingschools hospitals and shopping malls While building safety is certainly vi-tal to anyone entering a building the enforcement of building codes incomparison to ensuring safe drinking water does not quite bring such strongsymbolic connections to modernism and civic values However the widerimplications of the discredited Pal-Kal method were that other buildingsmay be vulnerable to collapse For both Jerusalem and Walkerton thereforemedia attention parliamentary debate and the appointment of commissionsof inquiry clearly indicate broad perceptions with the public and in the me-dia of problems in need of solutions Although the tendency was to see thebanquet hall case as a tragic incident caused by failures to identify and applyappropriate building codes there was no general sense that it was a systemicfailure stretching to and including the government of the day

The solutions streamAll things being equal the more the proposed regulatory regime changes areperceived as technically and economically viable the more likely it is thatthey will be adopted In both cases respected commissions of inquiry pro-duced recommendations that detailed specific solutions to the problems athand The proposed solutions were quite similar in nature and involvedregulatory regime changes primarily in standard-setting and information-gathering with some attention to behaviour change Technically none ofthese recommendations was particularly challenging because there werewell established standards and procedures for measuring and securing boththe quality of drinking water and the safety of buildings However adher-ence to the recommendations would require in both the Walkerton andJerusalem cases organizational changes and considerable resource invest-ments to allow for sufficient quantity and quality of information-gatheringand behaviour modification efforts While correction of faulty water treat-ment facilities and unsafe buildings (ie those constructed with Pal-Kal)


incurs considerable expense these would be borne primarily by private andlocal enterprises not by the public purse

The broader political context of Walkerton was conduciveto change

One of the differentiating factors between the two sets of lsquolsquosolutionsrsquorsquo wasin terms of the locus of administrative authority Reform potential was high-est in the Walkerton case because changes would fall within the jurisdictionof one government department the Ministry of the Environment with apolicy competence in that field (a point that OrsquoConnor was clearly aware of)Justice Zeilerrsquos recommendations were not so straightforward because theyinvolved the setting up of a new national authority Therefore despite thefact that both the Walkerton and Jerusalem recommendations received broadpublic support the changes in Walkerton were probably more feasible be-cause they constituted a form of administrative incrementalism while thechanges in Jerusalem were probably less feasible because they required amore radical administrative creation

The politics streamThe broader political context of Walkerton was conducive to change Thetragedy was the subject of substantial public and media interest over thesubsequent five years ndash partly because of the lengthy inquiry (almost twoyears) and partly because the trials of two Walkerton public utility workers(brothers Stan and Frank Koebel) was concluded only with their sentencingin December 2004 Also the Concerned Citizens of Walkerton representedby the Canadian Environmental Law Association (CELA) made good use ofthe media to ensure that water reform issues stayed on the political agendaThe media itself also used Walkerton as the touchstone for subsequent policyfailures such as the infected meat scandal in Alymer Ontario and the failedattempt to privatize Ontariorsquos electricity transmission grid A further capa-city for change may also be evident in the point made by Eleanor Glor andIan Greene (2002) that Canadarsquos political culture places a particularly highvalue on integrity A post-crisis policy change pattern similar to that inWalkerton was evident in the Human Resources Development Canada crisis(Good 2003 Sutherland 2003 Phillips and Levasseur 2004)2 suggesting thatCanada may exhibit strong reaction to episodes where public officials fail intheir duty to ensure public safety and financial probity

The politics surrounding the Ontario government and its neo-liberal re-form agenda were also important Premier Mike Harris had proved a highlydivisive figure delivering tax reductions but pushing through budget cut-backs and unpopular education and urban reforms A backlash had already


gained momentum prior to Walkerton the governmentrsquos standing in thepolls was poor and it was vulnerable generally especially in relation to itsneo-liberal attitude to regulation With the advent of the failures in Walker-ton political divisions widened The crisis acted as a catalyst for an array ofcounter-Harris interests among environmental groups educationallegalelites trade unions and citizens (Snider 2004) The Walkerton tragedy wasalso one of the reasons behind Harrisrsquos resignation in April 2002 and thefailure of his successor Ernie Eves to get re-elected in October the followingyear

The points made here need to be tempered We need to avoid the impres-sion of a vulnerable Conservative government simply bowing down becauseof intense political pressures Certainly both the Harris and Eves govern-ments needed to be seen as acting in the public interest on critical issues ofpublic safety However it can also be argued that that post-Walkerton policychanges were pragmatic and piecemeal rather than involving a paradigmshift away from neo-liberalism Judith McKenzie (2004) argues persuasivelythat Walkerton did not bring about the end of lsquolsquonew public managementrsquorsquoprinciples and policies in Ontario She argues that Harrisrsquos blame-gameaimed at the Walkerton Public Utilities Commission and others enabled thegovernment to portray the tragedy as evidence of the weaknesses of the tra-ditional public administration model Doing so paved the way for a newproposal for the privatization of Ontariorsquos electrical generation and distri-bution networks

The official investigation under the chair of highly respected Justice Den-nis OrsquoConnor associate chief justice of Ontario was also a force for changeOperating within a tight budget he put together a panel of seven leadingacademics and practitioners and took a liberal interpretation of the inquiryrsquosterms of reference Our extensive research has not produced any evidence ofcriticism of OrsquoConnor and his handling of the inquiry He seems to have beenthoroughly professional astute fair good humoured and well organized instreamlining investigations by grouping witnesses into coalitions (Burke2001 197ndash200) Colin Perkelrsquos book Well of Lies on the Walkerton tragedyargues that lsquolsquo[i]n criticizing public inquiries as a cumbersome ineffectiveand seemingly never-ending process Premier Mike Harris might have mis-judged the man chosen to lead it Dennis OrsquoConnorrsquorsquo (Perkel 2002 201) Therisks to public water supplies in conjunction with OrsquoConnorrsquos leadershipmeant that the inquiry was able to investigate and construct narrativesaround the pillars of modernism (science and the law) avoiding accusationsof politicization yet nevertheless being critical of the Harris government itsbudget cutbacks at the Ministry of the Environment and the privatization ofwater laboratories (Snider 2004) Therefore the OrsquoConnor-led investigationwas clearly a catalyst for change although ndash as indicated ndash we must exercisesome caution in seeing the investigation as a revolutionary indictment of the


Harris years As Laureen Snider argues lsquolsquoThe Report is a liberal docu-ment not a radical scriptrsquorsquo (2004 282)

The dominance of lsquolsquohigh politicsrsquorsquo and the threat of ter-rorist attacks clearly contributed to the withering away ofpolitical and public salience of the banquet hall collapse

Stakeholder interests were also important A loose alliance of interests ndashled by the Concerned Walkerton Citizens CELA various environmentalgroups and the Canadian Union of Public Employees and the Ontario Pub-lic Service Employees Union ndash were the main proponents of regulatoryreform In opposition were agricultural groups which had been partly culpa-ble (because manure was the primary cause of contamination) but which wereresistant to the idea of stricter regulation However the agricultural lobbystruggled to produce a counter-frame that the inquiry was prepared to legit-imize As Snider argues lsquolsquoScience gave the Inquiry the stamp of lsquoobjectiveapolitical truthrsquo (Phillips 1996 145mdash46) legitimating claims that public interestgroups unions and environmentalists ndash demonized as lsquospecial interestsrsquo bythe Conservative Government ndash had been making for yearsrsquorsquo (2004 282)

Turning our attention to the banquet hall case the wider context of Israelipolitics was crucial Some momentum for change was evident The fact thatthe video footage was shown on international news networks ensured strongcitizen and media interest initially but this heightened state of awarenesssoon evaporated The timing was such that Ariel Sharon elected only threemonths previously had won a landslide victory over Ehud Barak ndash in a pol-ity where a highly proportional electoral system and strong multi-partypolitics are symptomatic of a highly fragmented society where vulnerablecoalition governments are the norm (Diskin and Hazan 2002) Sharon wasable to form a grand coalition strongly focused on security issues in the wakeof the second Palestinian uprising which had begun in September the pre-vious year

The dominance of lsquolsquohigh politicsrsquorsquo and the threat of terrorist attacks clearlycontributed to the withering away of political and public salience of the ban-quet hall collapse Table 2 provides an indicator of the scale and types ofevents that took place during the same month as the banquet hall collapse ndash aperiod in which Israel was on a state of high alert The events of that monthincluded a suicide bomb killing eighteen people in Tel Aviv a baby beingstoned mortar shells fired from Gaza and several soldiers and settlers beingkilled in a series of separate incidents Indeed the sirens that blared out afterthe banquet hall collapse were assumed by Jerusalemites to be related to an-other terrorist attack In his study of the political and operational aspects ofdisaster management in Israel Alan Kirschenbaum notes the extent to which


people must live in close proximity to tragedy At one time or anotherroughly one third of the urban population had been involved in emergencysituations that had resulted in death or injury (2004 113)

Our observation therefore is that the public policy agenda in Israel isoverloaded with crises Most pertain to issues of security or defence involv-ing complex issues such as the nature of Israel as a Jewish state greater(Eretz) Israel democracy and peace (which for some involves minimizingconflict) (Arian 1995) Yehezkel Dror (1988) suggests that the crowdedagenda means that accountability is effectively a non-issue in Israel Evenlsquolsquoroutinersquorsquo disasters and crises receive scant attention from senior policy-makers In this context it is perhaps unsurprising that the building-safetycrisis was of low political saliency It did not naturally fit into any particularpolitical agenda and so the cause was not taken up by any particular politicalparty or politician Therefore despite the capacity of many crises and disas-ters to punctuate policy agendas the banquet hall tragedy struggled tocompete against issues of security and the escalating high politics of the

Table 2 Terrorism-Related Events in Israel during June 2001

Date Event

106 Fourth terror killing this week

306 Eighteen dead more than ninety wounded by suicide bomber(dolphinarium)

506 Separation A loaded political decision

706 Terror alert continues

706 Masses rally against (IDF) restraint

806 Shiloh baby fights to survive after stoning

806 Three Israeli wounded in shooting near Ramallah

806 Six mortar shells fired in Gaza Strip

1106 Deliberations to postpone Maccabiah games due to terrorist surge

1106 Fatah terror cell responsible for bombings arrested

1106 Three Bedouin women killed by tank fire

1506 Underground Jewish group claims responsibility for Arabrsquos murder

1706 IDF pull back from West Bank and Gaza marred by PA violations

2106 Settler from Homesh murdered

2206 Long-range mortar from Gaza

2406 Two soldiers killed in Gaza

2506 Hizbollah fires on IAF planes

2506 Fatah leader blown up in Nablus

2806 Multiple shootings in West Bank

2906 Young mother killed by terrorist


Israel-Palestinian conflict Added to this the central role in Israeli society ofmemory and politics notably the special place of bereavement (Weiss 2002Lebel 2006) helps produce a very strong tradition of lsquolsquodebtrsquorsquo to victims ofconflict In sum therefore it can be argued that Israel has gone down astrong historical pathway where the maintenance of social order is predi-cated largely on insulating the country from lsquolsquoexternalrsquorsquo threats (as well asremembering previous tragedies) rather than protecting it and remember-ing lsquolsquointernalrsquorsquo threats

An initial examination of Justice Zeilerrsquos Commission of Inquiry intoSafety of Buildings and Public Places seems to reveal some potential as acounter to the above it seemed to be a driver for change ndash capable of break-ing through historical pathways Zeiler was a judge held in high esteem andhis four-strong committee examined the history of building codes over thepervious half century engaging with over 200 witnesses and delved intobuilding code practices throughout the world The inquiryrsquos research un-covered clear evidence from an early stage that Pal-Kal posed a threat topublic safety Therefore an interim report was produced with the intent ofpreventing further building collapses The second and final report ran totwenty-nine chapters and was thorough and meticulous in its approachGiven however that the investigation did not have the remit to look at thebanquet hall collapse as such (which victimsrsquo families had wanted) but in-stead looked into the broader issue of building codes the investigation hadonly low-level capacity to bring about lsquolsquotombstonersquorsquo reforms that symbolizelsquolsquohealingrsquorsquo and the debt owed to those who had suffered (Hood Rothsteinand Baldwin 2001) Indeed at a press conference to launch the inquiry Jus-tice Zeiler stated that the inquiry was largely about raising awareness andthat he did not expect the government to fully implement its eventual rec-ommendations (Lefkovits 2001) Even if such a statement reflects politicalpragmatism it is also self-limiting because it frames the inquiryrsquos work insuch a way that it anticipates its lack of influence

Added to the foregoing policy stasis was more likely because there wereno significant stakeholders lobbying for changes in building codes andtighter enforcement of these codes Regardless of the constraints of Israelihigh politics many interests had a stake in maintaining the status quo Mu-nicipal authorities were struggling to operate within chronic budgetaryconstraints ndash a squeeze initiated by the Ministry of Interior in its quest forbudget stringency For both sets of interests additional resources being de-voted to building-planning and upgrading existing structures was not afinancially viable option

Stream interactionsFor purposes of conceptualization John Kingdonrsquos multiple streams ap-proach focuses on each stream independently However one of the


particularly interesting features of Kindgonrsquos models is the way in whichstreams can interact to a point of confluence which produces lsquolsquoan idea whosetime has comersquorsquo (Kingdon 2003 1) Given the differences between our twocases it is useful to consider the interactions among the streams in each

Interactions of the problem and politicsstreams

The Walkerton case can be described as a positive feedback loop The imageof contaminated drinking water flowing out of kitchen taps coincided withan already unstable political situation where a vulnerable government hadlittle choice but to be receptive to policy change This political receptivityfurther encouraged sustained action by policy change advocates (a loose co-alition of anti-Harris pro-public sector groups) to continue and strengthenactions in favour of stronger regulation of the quality of drinking water Bycontrast in Jerusalem the image of unsafe buildings collapsing on innocentpeople could barely touch a political stream where a grand coalition hadbeen formed to concentrate on pressing issues of high politics (ie securityand the conflict with Palestine)

Interactions of the solution and politicsstreams

Proposed solutions to the problems of drinking water and building safetywere similar in the two cases in the sense that they were not tremendouslycostly and of reasonable administrative and political feasibility However inOntariorsquos political context of the day a policy solution of re-regulation wasadoptable with relative ease because it gave the Harris and Eves govern-ments the chance to restore their political legitimacy By contrast in Israelbuilding-safety lsquolsquosolutionsrsquorsquo barely encroached on the political stream exceptfor a very short lsquolsquoissue-attentionrsquorsquo-type arrival and dissipation The effortsrequired to implement this policy solution was not huge but would not beworthwhile in terms of enhancing political capital

Rather than lsquolsquoan idea whose time had comersquorsquo the prospectof regulatory reform in Israel was more akin to an ideathat got lost in the ether of national politics

How all three streams interact takes these issues a bit further Kingdontakes his cue from evolutionary biology and utilizes the metaphor of a policylsquolsquoprimeval souprsquorsquo where ideas bubble away and the strongest come to thesurface ndash not by chance but through factors such as changes in public opin-ion and vigorous lobbying Punctuated equilibrium theory (see for exampleBaumgartner and Jones 1993 True Jones and Baumgartner 2007) picks up


and develops Kingdonrsquos model in this regard Punctuated equilibrium the-ory seeks to explain when and why large-scale changes (punctuations) occurin the course of policy histories generally characterized by stasis and incre-mental change Policy images play a critical role in expanding the control ofissues beyond policy monopolies A central premise is that policy changecan occur when groupscoalitions and public opinion mobilize to overcomethe power of existing policy monopolies In Walkerton one could argue thatthere was confluence of streams conducive to change ndash a problem (a signif-icant public health hazard) a viable solution (regulatory reform) and apolitical situation that put a vulnerable government on the back foot to thepoint that embracing both the problem and the solution was the key to re-storing political legitimacy In effect regulatory reform was lsquolsquoan idea whosetime had comersquorsquo allowing a punctuation in the trajectory of a light-toughregulatory regime and the neo-liberal policy monopoly that supported it Bycontrast in Jerusalem the three streams remained largely independentDespite a well recognized problem (building-safety construction andregulation) and substantial overlap with a solution (new national authorityon building standards) the security-focused policy monopoly in Israelmeant that the politics stream continued to forge its own route Rather thanlsquolsquoan idea whose time had comersquorsquo the prospect of regulatory reform in Israelwas more akin to an idea that got lost in the ether of national politics

ConclusionOrthodox thinking would imply that when regulatory failure leads to disas-ter processes of inquiry culminate in corresponding and proportionatepolicy reforms in order to plug the regulatory gap Our two cases challengesuch an assumption Both crises were broadly similar (public health trage-dies regulatory failures due-process investigations) but they culminated inremarkably different policy outcomes Walkerton produced a swift anddecisive response swinging the regulatory pendulum from deregulation tore-regulation The Jerusalem case by contrast produced the most minor offine-tuning to an already weak regulatory regime

Far from being an exact science the regulation of risks isan inherently political activity requiring that we locate itwithin appropriate historical geographical and policy-sector contexts

The policy streams prism proves valuable in understanding the differentoutcomes and in illuminating the magnitude of political context Given theclear responsibility of regulatory failure in the advent of both tragedies in-tuitively one would expect substantial regulatory policy change in both


cases After all we are dealing with tangible risks to innocent civilian livesYet our analysis highlights the supremacy of politics over both intuition andstraightforward reasoning In Israel a political context dominated by secu-rity issues was not conducive to policy reform in the regime of building-safety regulations despite the near certain risk to human life Conversely thevolatile political context of Walkerton displayed strong propensity forchange triggered by a water crisis and leading to regulatory reforms thatwere part of a broader turn against a radical neo-liberal government

Our two cases indicate the importance of political context when we at-tempt to comprehend the aftermath of disasters in which regulatory failuresare heavily implicated Far from being an exact science the regulation of risksis an inherently political activity requiring that we locate it within appropri-ate historical geographical and policy-sector contexts Ultimately thereforethe fact that broadly similar tragedies produced markedly different outcomesin terms of regulatory reform should not come as too much of a surprise

Notes1 The video can be viewed on YouTube at httpwwwyoutubecomwatchv=vt_AaFtmIk2 In January 2000 the media public figures and opposition MPs demanded the head of a gov-

ernment minister the disbanding of an entire department and the termination of theTransitionalCanada Jobs Fund ndash a $125-million program to encourage the creation of sus-tainable jobs in areas of high unemployment They charged the prime minister with abusingthe program to promote job projects in his riding They also accused the ruling political partyof using the TJFCJF as a lsquolsquopolitical slush-fund with no accountability at allrsquorsquo Media sensa-tionalism and political opportunism combined to make this what some termed Canadarsquoslsquolsquobiggest scandal everrsquorsquo In this case the crisis (or manufactured crisis) is nothing but the failureof Human Resources Development Canada to properly oversee grants and contributions TheHRDC had consciously loosened control over the administration of these funds in the frame-work of lsquolsquonew public managementrsquorsquo reforms dramatic cutbacks and internal reorganization Itreacted to the media-generated crisis by immediately swinging the regulatory pendulum wayback to the control side of the continuum Within a short time HRDC established a lsquolsquocompre-hensive and elaborate set of administrative checklists and formsrsquorsquo (Good 2003 115)

ReferencesArian A 1995 Security Threatened Surveying Israeli Public Opinion on Peace and War New York

Cambridge University PressBaumgartner FR and BD Jones 1993 Agendas and Instability in American Politics Chicago

University of Chicago PressBirkland T 1997 After Disaster Agenda Setting Public Policy and Focusing Events Washington

DC Georgetown University Pressmdashmdashmdash 2006 Lessons of Disaster Policy Change after Catastrophic Events Washington DC George-

town University PressBirkland TA and R Nath 2000 lsquolsquoBusiness and political dimensions in disaster managementrsquorsquo

Journal of Public Policy 20 (3) SeptemberndashDecember 275ndash303Boin Arjen and Paul lsquot Hart 2000 lsquolsquoInstitutional crises and reforms in institutional crises

and reforms in policy sectorsrsquorsquo In Government Institutions Effects Changes and NormativeFoundations edited by H Wagenaar Kluwer Academic Publishers pp 9ndash31


mdashmdashmdash 2003 lsquolsquoPublic leadership in times of crisis Mission impossiblersquorsquo Public AdministrationReview 63 (5) SeptemberOctober 544ndash53

Boin Arjen P lsquot Hart E Stern and B Sundelius 2005 The Politics of Crisis Management PublicLeadership under Pressure Cambridge Cambridge University Press

Brender A 2003 lsquolsquoThe effect of fiscal performance on local government election results in Israel1989ndash1998rsquorsquo Journal of Public Economics 87 (910) 2187ndash205

Breyer S 1993 Breaking the Vicious Circle Cambridge Harvard University PressBurke BL 2001 Donrsquot Drink the Water The Walkerton Tragedy Victoria Trafford PublishingBusenberg G 1999 lsquolsquoThe evolution of vigilance Disasters sentinels and policy changersquorsquo Envi-

ronmental Politics 8 (4) Winter 90ndash109Canadian Environmental Law Association 2001 Walkerton Inquiry Part 1A and 1B Final Argu-

ment on Behalf of the Concerned Walkerton Citizens Toronto Association Toronto CELAAvailable at httpwwwcelacapublicationscardfileshtmlx=1067

Cobb RW and C Elder 1983 Participation in American Politics The Dynamics of Agenda BuildingBaltimore Johns Hopkins University Press

Diskin A and RY Hazan 2002 lsquolsquoThe 2001 prime ministerial election in Israelrsquorsquo Electoral Studies21 (4) 659ndash64

Drennan LT and A McConnell 2007 Risk and Crisis Management in the Public Sector AbingdonUK Routledge

Dror Y 1988 lsquolsquoPublic administration in Israelrsquorsquo In Public Administration in Developed DemocraciesA Comparative Study edited by DC Rowat New York Marcel Dekker

George AL and A Bennett 2004 Case Studies and Theory Development in the Social SciencesCambridge Mass MIT Press

Glor Eleanor and Ian Greene 2002 lsquolsquoThe Government of Canadarsquos approach to ethics Theevolution of ethical governmentrsquorsquo Public Integrity 5 (1) 39ndash66

Good DA 2003 The Politics of Public Management Toronto Institute of Public Administration ofCanada

Heinmiller B Timothy 2003 lsquolsquoHarmonization through emulation Canadian federalism andwater export policyrsquorsquo Canadian Public Administration 46 (4) Winter 495ndash513

Hood Christopher Henry Rothstein and Robert Baldwin 2001 The Government of Risk Under-standing Risk Regulation Regimes Oxford Oxford University Press

Israel Commission of Inquiry into Safety of Buildings and Public Places 2004 Report JerusalemState of Israel Chaired by Justice V Zeiler

mdashmdashmdash Commission on New Building Methods 2001 Recommendations for InstitutionalizingProcedures for Checking and Approving New Building Methods Jerusalem Ministry ofInterior

mdashmdashmdash Knesset 2001a Protocol of the Meeting of the Committee for the Interior and Environment 5June Jerusalem State of Israel

mdashmdashmdash mdashmdashmdash 2001b Protocol of the Meeting of the Committee for the Interior and Environment 7 JulyJerusalem State of Israel

Johns Carolyn M 2001 Effective Policy Regimes for the Management of Non-point SourceWater Pollution Ontario and the US in Comparative Perspective Available at httpsozonescholarsportalinfobitstream18738143110294253pdf

Kingdon John 2003 Agendas Alternatives and Public Policies 2nd ed New York LongmanKirschenbaum Alan 2004 Chaos Organization and Disaster Management New York Marcel

DekkerLasswell H 1936 Politics Who Gets What When How New York McGraw-HillLebel U 2006 lsquolsquoThe creation of the Israeli lsquopolitical bereavement modelrsquo ndash Security crises and

their influence on the political behaviour A psycho-political approach to the study of poli-ticsrsquorsquo Israeli Affairs 12 (2) 439ndash61

Lefkovits Etgar 2001 lsquolsquoState building probe to begin soonrsquorsquo Jerusalem Post 3 September 4


Lodge M and C Hood 2002 lsquolsquoPavlovian policy responses to media feeding frenzies Danger-ous dogs regulationrsquorsquo Comparative Perspectives 10 (1) 1ndash13

May P 2005 lsquolsquoRegulation and compliance motivations Examining different approachesrsquorsquo PublicAdministration Review 65 (1) JanuaryFebruary 31ndash43

McKenzie Judith I 2004 lsquolsquoWalkerton Requiem for the new public management in OntariorsquorsquoInternational Journal of Environment and Pollution 21 (4) 309ndash24

Ontario Ministry of Finance 2002 Ontario Budget ndash Growth and Prosperity Keeping the PromiseToronto Queenrsquos Printer Available at httpwwwfingovoncaenglishbudgetontariobudgets2002statementpdf

mdashmdashmdash Walkerton Commission of Inquiry 2002 Report Part One The Events of May 2000 and Re-lated Issues Toronto Queenrsquos Printer Chaired by Associate Chief Justice Dennis R OrsquoConnorAvailable at httpwwwattorneygeneraljusgov oncaenglishaboutpubswalkertonpart1

mdashmdashmdash mdashmdashmdash 2002 Report Part Two A Strategy for Safe Drinking Water Toronto Queenrsquos PrinterChaired by Associate Chief Justice Dennis R OrsquoConnor Available at httpwwwattorneygeneraljusgovon caenglishaboutpubswalkertonpart2

Perkel CN 2002 Well of Lies The Walkerton Water Tragedy Toronto McLelland amp StewartPhillips L 1996 lsquolsquoDiscursive deficits a feminist perspective on the power of technical knowl-

edge in fiscal law and policyrsquorsquo Canadian Journal of Law and Society 11 (1) 141ndash76Phillips Susan and Karine Levasseur 2004 lsquolsquoSnakes and ladders of accountability Contradic-

tions between contracting and collaborating for Canadarsquos voluntary sectorrsquorsquo Canadian PublicAdministration 47 (4) Winter 451ndash74

Romzek B and P Ingraham 2000 lsquolsquoCross pressures of accountability Initiative command andfailure in the Ron Brown plane crashrsquorsquo Public Administration Review 60 (3) MayJune 240ndash53

Sabatier Paul A and Hank C Jenkins-Smith 1993 Policy Change and Learning An Advocacy Co-alition Approach Boulder Colo Westview Press

Schwartz R and R Sulitzeanu-Kenan 2004 lsquolsquoManagerial values and accountability pressuresChallenges of crisis and disasterrsquorsquo Journal of Public Administration Research and Theory 14 (1)January 79ndash102

Shiva V 2002 Water Wars Privatization Pollution and Profit Cambridge Mass South End PressSnider L 2004 lsquolsquoResisting neo-liberalism The poisoned water disaster in Walkerton Ontariorsquorsquo

Social amp Legal Studies 13 (2) June 265ndash89Stone D 2002 Policy Paradox The Art of Political Decision Making 2nd ed New York WW Nor-

tonSutherland S 2003 lsquolsquoBiggest scandal in Canadian history HRDC audit starts probity warrsquorsquo

Critical Perspectives on Accounting 13 (1) 187ndash224True JL BD Jones and FR Baumgartner 2007 lsquolsquoPunctuated-equilibrium theory Explaining

stability and change in public policymakingrsquorsquo In Theories of the Policy Process edited by PaulA Sabatier Boulder Colo Westview Press 155ndash88

Vaughan D 1996 The Challenger Launch Decision Risky Technology Culture and Deviance atNASA Chicago University of Chicago Press

Weiss M 2002 lsquolsquoBereavement commemoration and collective identity in contemporary Israelisocietyrsquorsquo Anthropological Quarterly 70 (2) April 91ndash101

Wilson CE 2000 lsquolsquoPolicy regimes and policy changersquorsquo Journal of Public Policy 20 (3) SeptemberndashDecember 247ndash74


When regulatory failures are significant and precipitate crisis and disasterone might expect subsequent reform of these regulatory systems to reducethe risk of further fatal episodes The democratic logic of this assumption isquite straightforward As Christopher Hood Henry Rothstein and RobertBaldwin suggest risk regulation is lsquolsquogovernmental interference with marketor social processes to control potential adverse consequences to healthrsquorsquo(2001 3) Therefore the greatest damage to a regulatory regime is likely to bewhen its weaknesses lead to death and disaster We might reasonably expectthat the ensuing loss of political and public confidence coupled with inquiryfindings that demonstrate that operational systems are not capable of per-forming the public safety functions for which they were designed will leadto lessons and regulatory reform In fact given the prominence and scrutinygiven to public health issues by the media citizensrsquo groups opposition par-ties and others it may be difficult to conceive of a situation where there areno post-crisisdisaster moves to restore regulatory efficacy and the legiti-macy of the regulatory system

This logic seems initially to be reinforced by the literature on policychange Students of policy change know that dramatic changes in policy arefew and far between Normally the routines of politics predominate andpolicy change is incremental Depending on which perspective we take pol-icy is controlled by relatively closed communities advocacy coalitions orconstrained by path dependencies However crisis and disastrous episodeshave the capacity to punctuate the normal rhythms of policy-making andproduce rapid change (Boin and lsquot Hart 2003) Crises can act as trigger events(Cobb and Elder 1983) external perturbations (Sabatier and Jenkins-Smith2003) stressors (Wilson 2000) focusing events (Birkland 1997 2006) and pro-duce lsquolsquowindows of opportunityrsquorsquo (Kingdon 2003) for policy change to occur

If we dig deeper however the ideas on policy change and crisis manage-ment put forth in the literature are much more complex They do not indicatethat policy change is an inevitable product of crisis episodes Crises believedto result from unintended and unguided actions for example are not likelyto reveal a need for policy change in systems at most they result in the pun-ishment of those individuals deemed responsible (Stone 2002 Birkland andNath 2000) Furthermore agenda-setting theory suggests that while (sys-tem) crises will almost necessarily focus public attention on an issue unlessthere are coherent advocacy coalitions (Sabatier 1993 Wilson 2000) per-ceived viable solutions or favourable political climates they are unlikely tolead to policy change (Birkland 1997 2006 Kingdon 2003) Indeed politicalrealities and the actions of entrenched interests often thwart crisis-inducedpolicy reform

Recent thinking on the politics of crisis management (Boin and lsquot Hart2003 Boin et al 2005 Drennan and McConnell 2007) reinforces the complex-ity of the relationship between crisis and policy change Crisis management

























































Walkerton Jerusalem


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Documents

Robert Schwartz and Do crises help remedy regulatory Allan