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WSTD Incident Report <br />Report ID <br /> <br />Water Supply and Treatment (WSTD) Incident Report Page 6 of 6 <br />Revision Date: 10/18/18 <br />C. Incident Review <br />16. Reviewer’s name <br />Click or tap here to enter text. <br />17. Incident Type <br />☐ Unplanned partial/total facility outage <br /> <br />☐ Water quality violations <br /> ☐ Unplanned discharges <br /> <br />☐ Reporting to a regulatory agency <br /> D. Possible Root Cause <br />18. Check all that apply <br />☐ Inadequate preventative maintenance ☐ Poor procedures <br />☐ Inadequate design ☐ Poor communication <br />☐ Poor specifications ☐ Operator Error <br />☐ Inadequate training ☒ Unknown <br />19. Additional Root Cause Information <br /> <br />E. Corrective Action Plan <br />20. Check all that apply <br />☐ Evaluate equipment / facility condition ☐ Review formal work procedures <br />☐ Provide personal protective equipment ☐ Assess newly identified hazards <br />☐ Provide initial/refresher training ☐ Review inspection or maintenance program <br />☐ Provide appropriate tool / equipment ☐ Review as job performance issue <br />☐ Post signage in area ☐ Unknown <br />21. Describe the corrective action plan <br /> <br />Assigned To Click or tap here to enter text. <br />Corrective Action Completed On Click or tap to enter a date. <br />Maximo Event ID Click or tap here to enter text. <br />Maximo Work Order Click or tap here to enter text. <br />F. Required Approval Signature <br />22. Superintendent Signature and Date <br /> <br />