South East Water did not have the right processes in place to identify and mitigate risks at Pembury Works, despite previous warnings from the DWI. That the company had “normalised” critical risks and was “flying blind” in the lead up to the crisis is a fundamental failure for a water company responsible for a critical natural resource. In a perverse sense, Mr Hinton was right in saying that the events were “unforeseeable”; but only because the company had actively chosen to not put in the essential monitoring processes that would have enabled action before the outages began. As a result, the company failed to properly monitor threats such as ineffective coagulant dosing systems. A failure to have the right jar test processes meant that manageable problems escalated unnecessarily, undermining routine coagulant treatments, eventually and unnecessarily turning off the taps for businesses, essential services and tens of thousands of customers. (Conclusion, Paragraph 16) 39