- Before
- Owns 312 hazardous events and 1,148 barriers across two treatment works, a desalination plant and 46 service reservoirs and towers. “The plan says the hatch is checked monthly. Nothing told me when it wasn't.”
- Now
- Opens the hazard that changed overnight, sees the record that changed it and the response already drafted, and confirms or keeps the rating with a reason.
One missed hatch inspection, from the 06:00 check to a signed plan
Kestrel Ridge service reservoir SR-07 holds 18 ML in two cells, was built in 1964 and supplies 41,200 people in Brackenfield and Oakmere. Its monthly hatch inspection was due on 12 October. On Monday 13 October 2026, here is what happens, screen by screen, in the working solution.
- 0105:58
The plan opens on a bowtie, not a spreadsheet
Amara Osei · Water safety plan leadAmara owns the plan's 312 hazardous events. HZ-ST-017, microbial ingress into treated water at Kestrel Ridge, is drawn as a bowtie: four causes and nine preventive barriers on the left, three consequences and six recovery barriers on the right. The live risk is 5 · Medium, the same as plan v4.3. Barrier B1, hatch seals and locks, reads “Due 12 Oct · grace to 06:00”.
WO-77310: “Monthly hatch inspection cancelled: crew diverted to a 12-inch burst on Fenwick Road”
- 0206:00
The morning check reads every record and every clock
Record matcher and Barrier watcherThe record matcher reads 2,914 new records: 41 inspections, 2,806 telemetry readings, 58 laboratory results, 6 alarms and 3 complaints. The barrier watcher checks 1,148 barrier clocks and 412 limits. B1 has no inspection record by its due date, so it turns red. Hatch H2 opened on 9 Oct from 14:12 to 14:19 with no work permit or keyholder visit matched, so the hatch alarm turns amber; outlet chlorine has fallen from 0.62 to 0.41 mg/L in three days, so the outlet analyser turns amber too.
“B1 hatch seals and locks, SR-07: failing” — “Due 12 Oct, no record.”
- 0306:04
The live risk rises from 5 to 15 — and waits for Amara
Risk re-raterOne critical preventive barrier is failing and one is weakened, so the risk re-rater steps the likelihood from 1 to 3 and the dial swings to 15 · High. The plan still says 5 · Medium: only Amara can change it. The re-rater drafts the response: an urgent hatch inspection today at P1, daily outlet sampling at SR-07 until B1 is restored, and a message to Declan Muir and Samuel Adeyemi.
Left unticked: “Take cell 2 out of supply as a precaution — not advised: outlet samples clear, chlorine above alarm”
- 0407:12
Rating confirmed, response raised in one step
Amara Osei · Water safety plan leadAmara confirms the interim rating of 15 · High. Urgent hatch inspection WO-77418 is raised at P1. At 07:40 Declan Muir assigns Tobias Lund; at 09:55 Hana Kovač's first daily sample, S-26-48113, is taken at the outlet. Each new record joins the feed beside the bowtie.
“Interim rating 15 · High confirmed · WO-77418 raised · daily sampling at SR-07”
- 0511:40
On the roof: an 8 mm gap in the H2 seal
Tobias Lund · Service reservoir inspectorInspection INS-SR07-1013 arrives from the roof of SR-07: the H2 seal has perished on the hinge side, with an 8 mm gap and bird droppings on the outer rim, none inside cell 2. The seal is replaced with part HS-600, the hatch relocked and four photos attached. The record matcher ties it to B1 at 99 %, and it also explains the 9 Oct alarm.
“Also explains: the H2 contact event on 9 Oct — a perished seal lets the hatch lift in wind”
- 0611:42
Barrier restored, risk back to Medium, plan updated
Amara Osei and the Plan writerAmara accepts the inspection as evidence for B1. The barrier turns green, the likelihood returns to 1 and the live risk to 5 · Medium, with the H2 finding kept on the hazard. A minute later the plan writer adds the change to plan v4.4 and proposes improvement action IP-2026-031: seal condition checks and spare seals at the 9 reservoirs whose hatches are over 30 years old.
No barrier turns green without a record that proves it.
- 07The lesson
A cancelled inspection becomes a rule for every site
Incident analystThe incident analyst opens INC-2026-041, “Critical inspection cancelled and not re-raised, Kestrel Ridge SR-07”, and proposes two changes for Amara to accept or reject: a new rule for all 86 critical barriers, and a change to the hatch check on 46 reservoirs, so that an H2 seal marked “fair” at an inspection triggers a seal replacement within 30 days. It proposes only; Amara decides what reaches the hazard register.
New rule: “A cancelled inspection on a critical barrier is re-raised within 24 hours, on any site”
- 08Plan v4.4
The plan document writes its own change log
Plan writerDraft v4.4 follows the plan's 11 modules, from the team to revision after incidents, and supersedes v4.3, approved on 14 Mar 2026. It lists 14 changes since v4.3, each with who, when, why and the evidence. HZ-ST-017 reads: 5 · Medium, interim 15 · High from 06:00 to 11:42 on 13 Oct, B1 restored by INS-SR07-1013.
Sign-off: “Drafted by Plan writer · Reviewed by Amara Osei · Approved by Samuel Adeyemi — waiting”
- 09Signed
Samuel approves v4.4, with the meaning of his signature
Samuel Adeyemi · Head of Drinking Water QualitySamuel signs as Head of Drinking Water Quality and chooses the meaning: “I approve this plan as the current water safety plan”. v4.3 stays readable. The audit pack follows from the same records: the plan document, an evidence index for the 86 critical barriers, the change log, the improvement plan and incident learning.
“Plan v4.4 approved by Samuel Adeyemi · v4.3 kept read-only”
- 10The last 12 months
Plan health, month by month
Samuel Adeyemi · Head of Drinking Water QualityToday 99.5 % of barriers carry current evidence — 1,142 of 1,148. Since the daily check went live in May, failing critical barriers are found by the check, and in October they were restored in a median of 1.2 days, against 142 days for the 23 found at the March review. Hazards rated Very high fell from 4 to 2 between Q4 2025 and Q3 2026.
“60 failing barriers found in 12 months; 21 on storage, 14 of them hatch, vent or roof checks”