Open Recommendations

(U) Rec. 1.a: The DoD OIG recommended that the Secretary of the Navy designate an entity to be responsible for ensuring that all laws, policies, and agreements made in response to the 2021 drinking water contamination incident at the Joint Base Pearl Harbor-Hickam Community Water System are implemented, and that appropriate action is taken with regard to recommendations made in prior oversight reports and command investigation reports. Specifically, implement the requirements of the 2015 Administrative Order on Consent and the 2023 Administrative Consent Order related to the Joint Base Pearl Harbor-Hickam Community Water System.

(U) Rec. 1.b: The DoD OIG recommended that the Secretary of the Navy designate an entity to be responsible for ensuring that all laws, policies, and agreements made in response to the 2021 drinking water contamination incident at the Joint Base Pearl Harbor-Hickam Community Water System are implemented, and that appropriate action is taken with regard to recommendations made in prior oversight reports and command investigation reports. Specifically, implement the requirements put forth in the FY 2024 National Defense Authorization Act.

(U) Rec. 1.c: The DoD OIG recommended that the Secretary of the Navy designate an entity to be responsible for ensuring that all laws, policies, and agreements made in response to the 2021 drinking water contamination incident at the Joint Base Pearl Harbor-Hickam Community Water System are implemented, and that appropriate action is taken with regard to recommendations made in prior oversight reports and command investigation reports. Specifically, implement the recommendations of the U.S. Environmental Protection Agency Safe Drinking Water Act Investigation.

(U) Rec. 1.d: The DoD OIG recommended that the Secretary of the Navy designate an entity to be responsible for ensuring that all laws, policies, and agreements made in response to the 2021 drinking water contamination incident at the Joint Base Pearl Harbor-Hickam Community Water System are implemented, and that appropriate action is taken with regard to recommendations made in prior oversight reports and command investigation reports. Specifically, implement the recommendations of the Agency for Toxic Substances and Disease Registry.

(U) Rec. 1.e: The DoD OIG recommended that the Secretary of the Navy designate an entity to be responsible for ensuring that all laws, policies, and agreements made an response to the 2021 drinking water contamination incident at the Joint Base Pearl Harbor-Hickam Community Water System are implemented, and that appropriate action is taken with regard to recommendations made in prior oversight reports and command investigation reports. Specifically, implement the recommendations of the Vice Chief of Naval Operations command investigation related to the Joint Base Pearl Harbor-Hickam Community Water System.

(U) Rec. 1.f: The DoD OIG recommended that the Secretary of the Navy designate an entity to be responsible for ensuring that all laws, policies, and agreements made in response to the 2021 drinking water contamination incident at the Joint Base Pearl Harbor-Hickam Community Water System are implemented, and that appropriate action is taken with regard to recommendations made in prior oversight reports and command investigation reports. Specifically, implement the recommendations of the Naval Facilities Engineering Systems Command command investigation.

(U) Rec. 1.g: The DoD OIG recommended that the Secretary of the Navy designate an entity to be responsible for ensuring that all laws, policies, and agreements made in response to the 2021 drinking water contamination incident at the Joint Base Pearl Harbor-Hickam Community Water System are implemented, and that appropriate action is taken with regard to recommendations made in prior oversight reports and command investigation reports. Specifically, implement the requirements of Commander, Navy Installation Command Instruction 5090.7.

(U) Rec. 2.a: The DoD OIG recommended that the Secretary of the Navy revise Operations Navy Manual 5090.1. Specifically, include the roles, responsibilities, and training requirements for the Operator in Responsible Charge for Treatment and Distribution.

(U) Rec. 2.b: The DoD OIG recommended that the Secretary of the Navy revise Operations Navy Manual 5090.1. Specifically, align requirements of Operations Navy Manual 5090.1 with Commander, Navy Installation Command Instruction 5090.7. Specifically, clarify conflicting requirements for roles and responsibilities, including for the preparation and publication of public notices and contingency plans for alternate drinking water supplies during a drinking water emergency.

(U) Rec. 3.a: The DoD OIG recommended that the Secretary of the Navy direct the Commander, Navy Installations Command to revise Commander, Navy Installation Command Instruction 5090.7. Specifically, define the roles and responsibilities of the Installation Community Officer.

(U) Rec. 3.b: The DoD OIG recommended that the Secretary of the Navy direct the Commander, Navy Installations Command to revise Commander, Navy Installation Command Instruction 5090.7. Specifically, include the roles, responsibilities, and training requirements for the Operator in Responsible Charge for Treatment and Distribution.

(U) Rec. 3.c: The DoD OIG recommended that the Secretary of the Navy direct the Commander, Navy Installations Command to revise Commander, Navy Installation Command Instruction 5090.7. Specifically, require the standing membership of the Installation Drinking Water Committee to include owners and operators of consecutive water systems.

(U) Rec. 3.d: The DoD OIG recommended that the Secretary of the Navy direct the Commander, Navy Installations Command to revise Commander, Navy Installation Command Instruction 5090.7. Specifically, periodically require the Installation Drinking Water Committee to assess committee membership, no less than annually, to determine whether additional stakeholders with the potential to affect drinking water quality should participate on the committee, such as users of aqueous film?forming foam, owners and operators of oil or hazardous substance facilities, or managers of solid waste facilities.

(U) Rec. 3.e: The DoD OIG recommended that the Secretary of the Navy direct the Commander, Navy Installations Command to revise Commander, Navy Installation Command Instruction 5090.7. Specifically, require that the annual table?top exercise of the installation's drinking water Emergency Response Plan include triggers and timelines for updating and editing the Emergency Response Plan when the table?top exercise identifies a need.

(U) Rec. 3.f: The DoD OIG recommended that the Secretary of the Navy direct the Commander, Navy Installations Command to revise Commander, Navy Installation Command Instruction 5090.7. Specifically, include roles and responsibilities for the risk communication requirements of DoD Instruction 6055.20, including recurring training.

(U) Rec. 4: The DoD OIG recommended that the Secretary of the Navy direct the appropriate Joint Base Pearl Harbor-Hickam official to issue a retroactive Tier 1 public notice including the 10 required elements of information for the October 2022 water main break.

(U) Rec. 5: The DoD OIG recommended that the Secretary of the Navy direct a study to assess the location of Navy?owned drinking water systems, identify all co?located infrastructure that poses a threat to the safety of the drinking water, and make plans to mitigate the threats to the drinking water systems.

(U) Rec. 1.a: The DoD OIG recommended that the Secretary of the Navy direct the Commander, Navy Region Hawaii, in coordination with the Under Secretary of Defense for Acquisition and Sustainment, to conduct a comprehensive review of the Navy's response to incidents involving aqueous film-forming foam at Defense Fuel Support Point Joint Base Pearl Harbor-Hickam, including the incidents discussed in this management advisory. This review should include a determination of whether the response, reporting, and cleanup for the incidents identified complied with Federal and State of Hawaii laws, and with Department of Defense and Navy policy; and whether the locations…

(U) Rec. 1.b: The DoD OIG recommended that the Secretary of the Navy direct the Commander, Navy Region Hawaii, in coordination with the Under Secretary of Defense for Acquisition and Sustainment, to implement corrective actions found during the review to address incident response and reporting at Defense Fuel Support Point Joint Base Pearl Harbor-Hickam in the future.

(U) Rec. 2.a: The DoD OIG recommended that the Secretary of the Navy direct the Assistant Secretary of the Navy (Energy, Installations, and Environment), in coordination with the Under Secretary of Defense for Acquisition and Sustainment and the Commander, Navy Installations Command, to determine whether a broader review of the handling of aqueous film-forming foam incidents at all Navy facilities is warranted based on this management advisory and the review completed for Recommendation 1.

(U) Rec. 2.b: The DoD OIG recommended that the Secretary of the Navy direct the Assistant Secretary of the Navy (Energy, Installations, and Environment), in coordination with the Under Secretary of Defense for Acquisition and Sustainment and the Commander, Navy Installations Command, to conduct the review, if warranted.

(U) Rec. 2.c: The DoD OIG recommended that the Secretary of the Navy direct the Assistant Secretary of the Navy (Energy, Installations, and Environment), in coordination with the Under Secretary of Defense for Acquisition and Sustainment and the Commander, Navy Installations Command, to implement corrective actions found during the review to address aqueous film-forming foam incident response and reporting across the Navy.

We recommend that the Maine Department of Health and Human Services, Office of Child and Family Services provide additional training to caseworkers and supervisors as appropriate, to achieve compliance with requirements for the immediate screening, risk and safety assessment, and investigation of reports of child abuse and neglect.

We recommend that the Maine Department of Health and Human Services, Office of Child and Family Services develop written policies and procedures that require its supervisors to review and approve documentation of caseworker interviews with children and adults.

We recommend that the Maine Department of Health and Human Services, Office of Child and Family Services develop written policies and procedures that require its supervisors to monitor aging reports on a weekly basis to promptly identify delays in the investigation process.