LOS ANGELES (CBSLA) — The Los Angeles County Department of Public Health was largely to blame for failing to more quickly notify the public of a 17-million-gallon sewage spill that forced the closure of beaches from El Segundo to Playa del Rey, according to a report discussed Tuesday by county officials.

U.S. Army National Guard members look at the water at Dockweiler State Beach in Playa del Rey, in Los Angeles County, California, on July 13, 2021, next to a sign indicating that the beach is closed to swimming after a sewage spill. (Photo by Frederic J. Brown/AFP via Getty Images)

The report found that workers at the Hyperion Water Reclamation Plant, operated by the city of Los Angeles’ sanitation department, followed protocol in the “once-in-a-career” July 11 event. The report went on to say that their extraordinary efforts saved the plant in what was called a “near miss.”

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According to the analysis by public consulting firm Citygate Associates LLC, plant personnel reached out to the duty officer at the California Office of Emergency Services as required, however the state agency failed to make the severity of the problem clear to the other federal, state and local agencies they were charged with alerting.

But the deputy director of Public Health’s Environmental Health Program took full responsibility for the events that followed the emergency sewage release, according to the July 19 report, and Director Dr. Barbara Ferrer apologized to the board Tuesday.

She said her department would be issuing a report of its own that outlines changed being made to avoid it from happening again.

“There’s no excuse for this,” she said of the department’s slow reaction. “It’s just multiple failure on top of multiple failure.”

According to the report, the OES reached out to Public Health at 8:11 p.m. the day of the spill with an email that said “most material was contained on site and ‘some’ had been discharged” into the outfall pipe, which Citygate said downplayed the seriousness of the incident. That same email was sent to numerous federal, state and county agencies.

However, the report found siloed operation, stale procedures, the lack of a central point of command and coordination within the Environmental Health Program were at the root of the failure to quickly notify residents of the spill.

The consulting firm recommended a number of changes to improve the emergency response, including a requirement for plant officials to notify county agencies of incidents alongside state agencies and a redoubling of public education efforts to keep debris out of the sewage system — the latter of which is called as essential as drinking water and electric power systems.

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According to officials, plant workers initially believed they could control the unexpected amount of large debris reported at about 2 p.m. without relying on a secondary containment system. But, as the debris flow quickly accumulated, workers were driven out of the building by “increasingly life-threatening circumstances” before they were able to open a bypass plate that led to the containment system.

The workers then installed filers on storm drains within the plant in an effort to catch as many solids as possible, however the flows became so high in the early evening that “approximately 50% of the plant had flooded and the secondary pump system was unable to keep up,” according to the report.

The report was not clear on whether the workers could have prevented the emergency release had they responded differently to the initial debris flow.

The report said the decision to initiate the emergency discharge into a one-mile offshore pipe was made at about 8:10 p.m. It was not until 9:30 p.m., when Environmental Health Program investigators arrived at the plant, that they realized a major incident was unfolding, the report said.

The first beach closure notices were not posted until midday July 12 when Public Health leadership was made aware of the extent of the problem — a delay the report said was due to an employee who was out sick — and took five hours to put into effect. Public notifications were not made until mid- to late-afternoon.

The beaches were reopened five days following the spill after ocean water samples collected over a two-day period met state standards for acceptable water quality, and financial assistance was being offered to impacted residents.

Citygate is expected to provide an after action report within 30 days that is expected to include more detailed recommendations on new procedures and protocols.

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(© Copyright 2021 CBS Broadcasting Inc. All Rights Reserved. City News Service contributed to this report.)