Dr. Michelle Minihan:

As our report highlights, there were trends available at the plant which showed that the turbidity levels had risen over that period. They had risen again on another date, a few days later on 24 August. Those were not being assessed at the plant. There were no alarms in place to indicate to the operators that a critical alarm on turbidity had been breached. There was no incident response procedure in place at the plant to advise those at the plant what the operational performance should be or what they should do in the event that an issue occurred. There was a discussion on the Monday, when it was escalated within the plant management structure. Irish Water was not informed of that at the time. It was only when Irish Water queried it about ten days later, which was about 12 days after the event, that the information and trends became available to demonstrate what had actually happened. Then there was an investigation into the ultimate root cause, in which the failure of the alum dosing pump came to light.