incident Shortly after 16:00 on a weekday in late spring 2013 the municipal water company in Born heim started receiving complaints from customers about the water. It had an odd consistency although there was no unusual smell. The complaints all came from the lower lying area of the town. One of the first complaints was from a man who reported that his skin and scalp had turned red, and he felt pain and a burning sensation wherever he had been in contact with the water (Figs. 1–3).The water company called in its standby duty team and increased the flow of water through the pipes. At first the water
company suspected allergic reactions as a result of the cleaning ofthe municipal water pipes earlier in the day. Then the standby duty team realised the water had a soapy consistency and they detected a pH value of 11.96. They identified the source as a sodium hydroxide (NaOH) solution. They cut off the supply of this solution and further increased the flow of water through the pipes. In the meantime the company had arranged for the inhabitants of the streets where the complaints had come from to be warned. The police and fire service went door to door advising the residents not to use the water until the all clear. At 22:00 the flushing of the pipes was complete and the pH value was back to normal levels. The all clear was given.The authors were commissioned by town B to investigate the health aspects and the management of this incident