Management Weaknesses 

Delayed Response to Flint 

Water Crisis 

Report No. 18-P-0221 July 19, 2018

U.S. ENVIRONMENTAL PROTECTION AGENCY

OFFICE OF INSPECTOR GENERAL

Ensuring clean and safe water

Compliance with the law
Report Contributors: Stacey Banks

 Charles Brunton 

 Kathlene Butler

 Allison Dutton 

 Tiffine Johnson-Davis

 Fred Light

Jayne Lilienfeld-Jones 

Tim Roach

 Luke Stolz 

 Danielle Tesch

 Khadija Walker 

Abbreviations 

CCT Corrosion Control Treatment

CFR Code of Federal Regulations

EPA U.S. Environmental Protection Agency 

FY Fiscal Year

GAO U.S. Government Accountability Office 

LCR Lead and Copper Rule 

MDEQ Michigan Department of Environmental Quality 

OECA Office of Enforcement and Compliance Assurance 

OIG Office of Inspector General

OW Office of Water

ppb parts per billion

PQL Practical Quantitation Limit

PWSS Public Water System Supervision 

SDWA Safe Drinking Water Act

Cover Photo: EPA Region 5 emergency response vehicle in Flint, Michigan. (EPA photo)

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 18-P-0221

July 19, 2018

Why We Did This Project

The U.S. Environmental 

Protection Agency’s (EPA’s) 

Office of Inspector General 

(OIG) conducted this audit to 

examine the circumstances of, 

and the EPA’s response to, 

contamination in the city of 

Flint, Michigan’s community 

water system, including the 

EPA’s exercise of its oversight 

authority. After Flint switched 

its drinking water supply in

April 2014, inadequate water 

treatment exposed many Flint 

residents to lead. 

In October 2016, the OIG 

issued a Management Alert 

to the EPA about specific 

factors that delayed its 

emergency response. Our 

current report evaluates 

additional matters concerning 

the agency’s management 

controls when responding to the 

Flint contamination incident.

According to the MDEQ, more 

than $400 million in public funds 

has been spent by the EPA and 

Michigan to address the Flint 

crisis. Eight other federal 

agencies also provided support. 

This report addresses the 

following:

• Ensuring clean and safe

water. 

• Compliance with the law.

Send all inquiries to our public

affairs office at (202) 566-2391

or visit www.epa.gov/oig.

Listing of OIG reports.

 

 Management Weaknesses Delayed 

Response to Flint Water Crisis 

 What We Found

 The circumstances and response to Flint’s

drinking water contamination involved

implementation and oversight lapses at 

the EPA, the state of Michigan, the Michigan 

Department of Environmental Quality (MDEQ), 

and the city of Flint. Since January 21, 2016, 

the EPA has overseen the implementation of

its emergency administrative order and 

amendment issued in response to the drinking water contamination. 

 EPA Region 5 and EPA headquarters officials have worked with the MDEQ and 

Flint personnel to help improve the city’s water system. As of May 2018, the state 

of Michigan and city of Flint have completed some actions and are working on 

remaining actions.

Michigan: Under the MDEQ’s supervision, the Flint water system did not adhere 

to two Lead and Copper Rule requirements: (1) develop and maintain an 

inventory of lead service lines needed for sampling, and (2) maintain corrosion 

control treatment after the water source switch in April 2014. The rule requires 

utilities to minimize consumers’ exposure to lead in drinking water. As the primacy 

agency, the MDEQ is responsible for enforcing this rule for Michigan water 

systems. The MDEQ did not issue a notice of violation or take other formal 

enforcement action regarding either requirement until August 2015. Instead, the 

MDEQ advised Flint public water system staff to conduct additional tests and to 

delay corrosion control treatment installation. The decision to delay corrosion 

control treatment prolonged residents’ exposure to lead. 

The EPA: The agency retains oversight and enforcement authorities to provide 

assurance that states with primacy comply with Safe Drinking Water Act

requirements, such as those in the Lead and Copper Rule. However, Region 5 

did not implement management controls that could have facilitated more informed 

and proactive decision-making when Flint and the MDEQ did not properly 

implement the Lead and Copper Rule. While Flint residents were being exposed 

to lead in drinking water, the federal response was delayed, in part, because the

EPA did not establish clear roles and responsibilities, risk assessment

procedures, effective communication and proactive oversight tools.

 Recommendations and Planned Agency Corrective Actions

We recommend that EPA headquarters and EPA Region 5 use lessons learned 

from Flint to improve its oversight of Safe Drinking Water Act compliance. We also 

recommend that EPA headquarters revise the Lead and Copper Rule to improve 

the effectiveness of monitoring requirements. The EPA agreed with eight of the 

nine recommendations and provided adequate planned corrective actions and 

completion dates. Eight recommendations are resolved pending completion of 

corrective actions. Recommendation 1 is unresolved.

U.S. Environmental Protection Agency

Office of Inspector General

At a Glance

The EPA should strengthen 

its oversight of state drinking 

water programs to improve 

the efficiency and 

effectiveness of the agency’s 

response to drinking water 

contamination emergencies. 
July 19, 2018

MEMORANDUM

SUBJECT: Management Weaknesses Delayed Response to Flint Water Crisis 

Report No. 18-P-0221 

FROM: Arthur A. Elkins Jr. 

TO: Susan Bodine, Assistant Administrator

 Office of Enforcement and Compliance Assurance 

David P. Ross, Assistant Administrator

 Office of Water

Cathy Stepp, Regional Administrator

Region 5 

This is our report on the subject audit conducted by the Office of Inspector General (OIG) of the U.S. 

Environmental Protection Agency (EPA). The project number for this audit was OPE-FY16-0031. This 

report contains findings that describe the problems the OIG has identified and corrective actions the OIG 

recommends. This report represents the opinion of the OIG and does not necessarily represent the final 

EPA position. Final determinations on matters in this report will be made by EPA managers in 

accordance with established audit resolution procedures. 

The EPA offices responsible for responding to issues in this report are the Office of Enforcement and 

Compliance Assurance; the Office of Water; and the Office of the Regional Administrator, Region 5. 

Action Required

This report contains one unresolved recommendation. In accordance with EPA Manual 2750, the 

resolution process begins immediately with the issuance of this report. We are requesting a meeting 

within 30 days between the Assistant Administrator for Water and the OIG’s Assistant Inspector 

General for Audit and Evaluation. If resolution is still not reached, the Office of Water is required to 

complete and submit a dispute resolution request to the Chief Financial Officer to continue resolution. 

We will post this report to our website at www.epa.gov/oig. 

UNITED STATES ENVIRONMENTAL PROTECTION AGENCY

WASHINGTON, D.C. 20460

THE INSPECTOR GENERAL
Management Weaknesses Delayed 18-P-0221

Response to Flint Water Crisis

Table of Contents

Chapters

1 Introduction ...................................................................................................... 1

Purpose ..................................................................................................... 1

Background................................................................................................ 1

Responsible Offices ................................................................................... 11

Prior Reports.............................................................................................. 11

Scope and Methodology ............................................................................ 11

2 Circumstances Leading to Flint Drinking Water

Contamination and EPA Emergency Administrative Order........................... 13

Inventory of Required Tier 1 Locations Was Not Maintained...................... 13

Corrosion Control Treatment Was Not Maintained..................................... 13

Conclusion................................................................................................. 15

Recommendations..................................................................................... 15

Agency Response and OIG Evaluation...................... ............................ 15

3 EPA Region 5’s Management Weaknesses

Delayed Federal Intervention........................................................................... 17

 Region 5 and MDEQ Did Not Establish Clear Oversight 

Roles and Responsibilities..................................................................... 17

EPA and MDEQ Did Not Communicate Effectively .................................... 19

Region 5 Did Not Have an Effective System 

 for Risk Assessment ............................................................................. 21

Region 5 Did Not Use Oversight and Monitoring 

 Authorities and Tools to Influence MDEQ............................................... 24

Conclusion................................................................................................. 27

Recommendations..................................................................................... 27

Agency Response and OIG Evaluation ...................................................... 28

Status of Recommendations and Potential Monetary Benefits ............................. 30

Appendices

A Timeline of Key Events .................................................................................... 32

B Status of Emergency Administrative Order and Amendment ....................... 38

C Agency Comments and OIG Evaluation.......................................................... 50

D Distribution.............................................................................................. 69
18-P-0221 1

Chapter 1

Introduction

Purpose

The U.S. Environmental Protection Agency’s (EPA’s) Office of Inspector 

General (OIG) conducted this review to examine the circumstances of, and the 

EPA’s response to, the contamination in the city of Flint, Michigan’s community 

water system,

1 including the EPA’s exercise of its oversight authority.

EPA OIG Report No. 17-P-0004, Management Alert: Drinking Water 

Contamination in Flint, Michigan, Demonstrates a Need to Clarify EPA Authority 

to Issue Emergency Orders to Protect the Public, issued October 20, 2016, alerted

the EPA about specific factors that delayed its response. Our current report 

evaluates management controls at EPA Region 5 (responsible for Michigan), and 

EPA headquarters’ response to the Flint contamination incident.

Background

Drinking Water Contamination in Flint, Michigan

In April 2014, Flint’s water system, serving 

drinking water to a population of nearly 

100,000 residents, switched from purchasing 

treated water from the Detroit Water and 

Sewerage Department (now called Great Lakes 

Water Authority) to sourcing and treating its 

own water supply from the Flint River. 

Governor-appointed emergency managers 

charged with improving Flint’s finances

initially opposed this change, but ultimately 

implemented it as a cost-saving measure. 

Since 1967, the Flint drinking water plant had only distributed drinking water 

purchased from Detroit. Flint emergency managers considered the use of the Flint

River to be temporary. They planned to purchase water from a new utility, the

Karegnondi Water Authority, starting in 2016.

Detroit’s water system included an additive that coated pipes to prevent corrosion. 

The city of Flint’s process for treating water from the new source did not include 

 1 The Safe Drinking Water Act and its regulations classifies Flint’s public water system as a large community 

drinking water system, hereafter referred to as the Flint “water system.”

Flint Water Treatment Plant sign. (EPA OIG photo)
18-P-0221 2

treatment for reducing corrosion. Without this treatment, lead from components 

within the distribution system can leach into drinking water. 

After the April 2014 source switch, consumers began complaining about water 

quality issues. In August 2014, EPA Safe Drinking Water Act (SDWA) data 

showed the city of Flint violated regulations for total coliform (bacteria), and in 

December 2014, total trihalomethanes (a byproduct of the disinfection process).

In February 2015, citizens started reporting concerns about lead contamination to 

EPA Region 5.

Appendix A contains a detailed timeline of events associated with the Flint 

drinking water incident.

SDWA and State Primacy

The SDWA, 42 U.S.C. § 300f et seq., is the federal law that protects public 

drinking water supplies throughout the nation. The law assigns the EPA 

Administrator the ultimate authority to protect public health by setting and 

enforcing drinking water quality standards. However, the SDWA allows the EPA 

to grant states the authority to implement and enforce SDWA regulations in an 

arrangement referred to as “primacy.”

To receive EPA approval for primacy, states must demonstrate that they have

adopted regulations that are at least as stringent as national requirements, are 

implementing adequate procedures for the enforcement of these regulations, and 

will keep records and make reports as the EPA may require. The EPA has granted 

nearly all states—including Michigan—primacy to implement the SDWA.2 When 

states are granted primacy, the EPA retains the responsibility for overseeing state 

implementation and federal enforcement authority. In 1978, the EPA determined 

that Michigan met all SDWA requirements to be granted primacy, including 

adopting and implementing enforcement procedures. 

Guidance from the EPA’s Office of Enforcement and 

Compliance Assurance (OECA) instructs EPA regional 

offices to “ensure that primacy agencies fulfill the 

enforcement conditions of their primacy agreements.”3

The EPA uses a variety of tools to oversee state drinking 

water implementation, such as providing technical 

assistance and regularly conferring with state agencies. 

Specifically, the SDWA authorizes the EPA to request 

information, take independent enforcement actions, and 

revoke state primacy when states do not implement the 

SDWA with the stringency required by federal law. 

 2 The state of Wyoming, Washington, D.C., and most tribes are not authorized to implement the SDWA. 3 OECA National Program Manager Guidance for fiscal years (FYs) 2016–2017.

Sign directing residents to water distribution 

center during response efforts. (EPA photo)
18-P-0221 3 

Lead Contamination and SDWA

Drinking water distribution systems include water main pipes and service line 

pipes (Figure 1). These systems may contain lead or copper components. 

Drinking water leaving a treatment plant may be generally free of lead, but the 

water can corrode pipes in the distribution system and plumbing materials in 

homes, and release lead into drinking water. For additional information, see the 

EPA’s “Sources of Lead in Drinking Water” factsheet.

In children, exposure to lead 

can cause serious health 

problems, including the 

potential for developmental 

disorders, lower IQs and 

delinquent behavior. In adults, 

lead exposure may result in 

poor pregnancy outcomes, 

dementia and cardiovascular 

disease. 

In 1991, the EPA issued the 

Lead and Copper Rule (LCR), 

40 CFR § 141.80 et seq., to

minimize lead and copper in

Figure 1: Diagram of a distribution system showing a service line and water main

Source: An EPA OIG image. 

Reduce Your Exposure to Lead 

in Drinking Water at Home

• Use only cold water for drinking, cooking and 

making baby formula. Boiling water does not 

remove lead from water.

• Regularly clean your faucet’s screen (also known 

as an aerator).

• Consider using a water filter certified to remove 

lead and know when it is time to replace the filter.

• Before drinking, flush your pipes by running your 

tap, taking a shower, doing laundry or a load of 

dishes.

Source: The EPA’s Basic Information About Lead in 

Drinking Water webpage.
18-P-0221 4

drinking water.

4 Lead and copper are only two of over 90 contaminants regulated 

under the SDWA. The National Primary Drinking Water Regulations establish 

either a maximum contaminant level (a health-based standard), or a treatment 

technique requirement.

There is no safe level of lead in drinking water. However, the LCR established the 

treatment technique requirements to minimize exposure. These requirements 

compel drinking water systems to conduct tap sampling for lead and copper to 

determine the treatment techniques and other steps systems must take to reduce 

exposure. To adhere to the LCR, utilities must conduct monitoring for lead and 

copper in water systems, and demonstrate that they comply with monitoring and 

treatment technique requirements.

5 Figure 2 illustrates key components of the 

LCR relevant to the city of Flint. 

 4 Some LCR requirements vary based on the water system size and type. Since Flint is a large community system, 

this report discusses the requirements for large community systems—those serving more than 50,000. 5 In 1986, Congress amended the SDWA to prohibit the use of pipes, solder or flux that are not “lead free” in public 

water systems, or in plumbing where facilities provide water for human consumption. In 1996, Congress further 

amended the SDWA by prohibiting the sale of any pipe or plumbing fixture that was not lead free, except for a pipe 

used in manufacturing or industrial processing. In 2000, the EPA published revisions to the LCR to address 

implementation issues arising from legal challenges to the 1991 rule. The revisions also streamlined and reduced the 

monitoring and reporting burden. In 2007, the EPA revised the LCR to enhance implementation in the areas of 

monitoring, treatment, customer awareness and lead service line replacement.

Lead tap 

monitoring 

No exceedance

Lead exceedance

Action level = 15 parts per billion (ppb)

Remedial treatment 

requirements

Corrosion 

control 

testing and 

adjustment 

Public 

education

Lead 

service line 

replacement

Periodic 

monitoring

Figure 2: Key components of the LCR relevant to Flint

Source: An EPA diagram modified by the OIG. The red outline boxes are discussed in sections below.
18-P-0221 5

Treatment Technique Requirements: Corrosion Control 

(40 CFR § 141.81 and § 141.82)

The LCR requires community water systems to optimize corrosion control. 

Utilities have optimized corrosion control when the treatment method that 

they use has minimized the potential for corrosion in the distribution system, 

thus minimizing lead contamination. The rule does not prescribe specific 

corrosion control treatments. Instead, there is a range of methods that water 

systems can use. 

When the LCR was 

implemented in 1991, it 

established timelines for 

the installation of corrosion 

control treatment and for 

subsequent monitoring. 

The LCR required large 

water systems to install 

optimal corrosion control 

treatment by January 1, 

1997, unless they qualified

for certain exemptions.

6

One exemption was to 

demonstrate low lead levels 

at consumers’ taps, where 

water systems monitor drinking water over two consecutive 6-month periods. 

Water systems were required to show whether lead concentrations fell at or 

below 5 ppb (the PQL) between the entrance to the distribution system and 

consumers’ taps. If results exceeded 5 ppb, water systems were required to 

establish and optimize corrosion control treatment.

According to the LCR, if a water system has optimized 

its corrosion control treatment and plans to change 

water sources or drinking water treatment methods, the 

state must review and approve plans before the change 

can be implemented.

The LCR requires states to review and approve the 

optimized corrosion control treatment for all systems. 

The LCR also requires states to designate optimal 

water quality parameters intended to represent the 

conditions under which systems must operate their 

corrosion control treatment. The rule requires that

 6 The exemption criteria are specified in 40 CFR § 141.81(b)(2)-(b)(3).

LCR Terms 

Action level of 15 ppb: Utilities are required 

to monitor so that lead concentrations in the 

90th percentile do not exceed the federal 

action level of 15 ppb.

Water quality parameters: State-approved 

measures that are used to determine whether 

corrosion control is working within the 

distribution system.

Practical Quantitation Limit (PQL) of 

5 ppb: Level of lead concentration in a large 

system where the LCR required optimal 

corrosion control treatment.

Drinking water samples taken from Flint 

residences during the emergency response.

(EPA OIG photo, taken April 2016)
18-P-0221 6

water systems measure against those parameters, which are typically set as 

ranges or minimums. Without set water quality parameters, a state does not 

have a reliable method for gauging the adequacy of corrosion control

treatment or determining compliance.

The LCR allows the EPA to intervene if a state fails to approve appropriate 

treatment plans. The rule authorizes EPA regional administrators to review 

state treatment determinations and issue alternate federal determinations, if the 

EPA finds the following:

• A state has failed to issue a treatment determination 

by the applicable deadlines,

• A state has abused its discretion in a substantial 

number of cases or in cases affecting a substantial 

population, or

• The technical aspects of a state’s determination would 

be indefensible in an expected federal enforcement 

action taken against a system.7

Tap Water Monitoring for Lead (40 CFR § 141.86)

After a system has optimized corrosion control, the LCR requires water 

systems to monitor for changes in lead concentration on a regular basis. These 

tests verify that when drinking water reaches the 

consumer, lead concentrations do not exceed the 

federal action level of 15 ppb in more than 10 

percent of homes.

8

To conduct the monitoring, the LCR requires 

utilities to identify the highest-priority sampling 

sites, such as single-family homes served by lead 

service lines. The highest-priority sampling sites 

are identified as “tier 1” locations and, for Flint,

constitute the entire sampling pool for regular 

testing.

The LCR instructs water systems to regularly report tap water sample results 

from tier 1 sites. Water systems monitor tap water on a semiannual, annual or 

triennial basis to verify lead contamination does not exceed the federal action 

level. When a large water system exceeds that level in more than 10 percent of 

home tap water samples, the water system must provide public education on 

 7 40 CFR § 142.19 provides the procedures for the EPA Administrator’s review of state determinations and issuance 

of a federal order.

8 40 CFR § 141.80(c)(1) describes this as the “90th percentile” lead level exceeding 0.015 milligrams per liter.

Lead service lines showing inner surface without 

any coating from corrosion control treatment (left),

with coating (right), and fully corroded (middle). 

(EPA photo)
18-P-0221 7

lead, remove a percentage of lead service lines, and conduct source water 

monitoring.

Public Education (40 CFR § 141.85)

The LCR requires systemwide public education when tap-monitoring results 

show that a system exceeds the federal action level for lead. There are also 

supplemental lead-monitoring requirements for all water systems to provide 

consumer notices to those whose taps were tested. The purpose of public 

education is to inform consumers about lead results, the health effects of lead,

and steps the public can take to reduce exposure.

Water systems must submit all written public education materials to the state 

prior to releasing the information to the public. 

Lead Service Line Replacement (40 CFR § 141.84)

In the event of a lead action level exceedance, the LCR requires water systems 

to identify the number of lead service lines present in the distribution system,

and requires water systems to meet the minimum 7 percent replacement rate 

through either physically replacing lead service lines or individually testing 

them to demonstrate their lead concentrations are below 15 ppb. However, if 

the system returns to a lead level below the action level after two monitoring 

periods, the utility is not required to continue removing lead service lines. In 

addition, if a system is in violation of 40 CFR § 141.81 for failure to install 

corrosion control treatment, the state can require the system to commence lead 

service line replacement until the system is below the lead action level for two 

consecutive monitoring periods. 

Emergency Administrative Order and Amendment 

On January 21, 2016, OECA issued an Emergency 

Administrative Order requiring the state of 

Michigan, the Michigan Department of 

Environmental Quality (MDEQ), and the city of 

Flint to take steps to reduce lead contamination. 

EPA managers monitoring compliance with the 

order determined that while the state of Michigan,

the MDEQ, and the city of Flint made a good-faith 

effort to comply, the EPA did not see progress in 

completing some of the required actions. In 

November 2016, EPA Region 5 issued its First

Amendment to Emergency Administrative Order. 

The amendment set new goals and allowed the city 

to develop milestones it could achieve.

A bottled water distribution site in Flint. 

(EPA OIG photo, taken April 2016)
18-P-0221 8

Subsequently, OECA and EPA Region 5 have overseen the respondents’

compliance with both the order and the amendment to the order (Appendix B).

According to Region 5, the EPA worked with the city and the MDEQ to do the 

following: 

• Oversee treatment plant operations. 

• Provide outreach to impacted residents. 

• Mobilize the largest sampling effort in EPA history.

• Address technical problems through a cross-agency expert task force. 

• Hold open-house information sessions for residents.

• Hold science summits with federal, state and local scientists and 

experts.

The EPA maintains a list of activities 

and progress updates for the order and its

amendment on the agency’s Flint Drinking 

Water Documents webpage. The MDEQ 

reported that by December 2017, lead 

levels in Flint’s drinking water had fallen 

below the federal action level of 15 ppb. 

However, the EPA and local authorities 

continued to recommend that residents 

filter their water for drinking and cooking. 

As of May 2018, the state of Michigan 

and the city of Flint have not completed 

all actions in the order and amendment.

Please see Appendix B for status of order and amendment actions. 

Currently, the city and state are working to replace lead service lines. 

Through its Public Water System Supervision (PWSS) program, the EPA 

awarded Michigan an average of $4.2 million annually to fund over 11,000 water 

systems in the state.

9 According to the EPA, as of June 2016, the agency spent 

more than half of that amount (over $3 million) on the Flint drinking water 

contamination incident in the first 6 months after the order was issued (Figure 3).

The state of Michigan provided approximately $250 million to address problems 

in Flint’s water system, and to increase the city’s technical and managerial 

capacity. 

 9 Average of funding awards in FYs 2011–2016.

A billboard in the city of Flint. (EPA OIG photo, 

taken April 2016)
18-P-0221 9

In March 2017, the EPA awarded an additional $100 million10 to the MDEQ for 

Flint water infrastructure upgrades, which required a state match of 20 percent or 

$20 million. In September 2017, the MDEQ reported that combined federal and 

state spending to address the contamination totaled more than $400 million.11

Challenges with the LCR

Assuring public health under the LCR presents 

challenges. A key challenge is that the LCR is 

based on treatment, not health-based 

requirements. The EPA has recognized the need 

to clarify and strengthen the rule, and the agency 

is in the process of revising it.

In October 2016, the EPA’s Office of Water 

released the Lead and Copper Rule Revisions 

White Paper for the purpose of keeping the 

public informed about options being considered 

by the agency. The report suggests that proposed revisions to the rule should 

include technology-driven and health-based elements to avoid high lead levels 

and health risks. Some of the elements under consideration include the following:

• Incorporating health-based goals for lead to guide actions and 

communicate risk at the household level.

 10 EPA press release: EPA Awards $100 Million to Michigan for Flint Water Infrastructure Upgrades

(March 17, 2017). 11 In addition to the EPA, other federal agencies also provided support and funding.

An EPA employee collects a water sample 

to send to a laboratory for analysis during 

response efforts. (EPA photo)

Figure 3: Comparison of Michigan’s statewide water system funding and Flint 

contamination spending

Source: An EPA OIG image.
18-P-0221 10

• Implementing and enforcing the mechanism for lead service line removal 

programs.

• Requiring all systems to implement corrosion control treatment, regardless 

of system size, tap sampling results, or presence of lead service lines.

• Using “point of use” filters when addressing risks from lead and copper at 

the household level.

• Clarifying and strengthening sampling requirements, reducing uncertainty, 

and ensuring broader and more consistent proactive application of 

corrosion control treatment.

• Increasing the transparency associated with implementing the LCR by 

publicly posting the locations of lead service lines and sampling results.

• Strengthening public education requirements in the LCR.

Management Controls for Government Programs

All federal agencies must establish certain standards, policies and practices to 

create a sound internal control structure for their programs. Internal controls help 

to prevent and detect errors, fraud and noncompliance with provisions of laws and 

regulations. Agencies and individual federal managers are required to develop 

internal controls for programs to achieve results and comply with applicable laws 

and regulations. 

The U.S. Government Accountability Office (GAO) developed internal control 

standards in 1999 (revised in 2014) to assist agencies in achieving their objectives.

The standards focus on effective internal control through communication, risk 

assessment and oversight. The EPA instructed managers to use these standards in 

the agency’s EPA Order, Management’s Responsibility for Internal Control (2008).

Likewise, the EPA’s FY 2017 Guidance for Enterprise Risk-Based Decision 

Making at EPA: Integrating Strategic Reviews and Management Integrity Internal 

Controls incorporates GAO guidelines and tools to integrate risk assessment into 

the strategic planning process.
18-P-0221 11

Responsible Offices

EPA Region 5 drinking water program staff and managers primarily oversee

SDWA implementation in regional primacy states, including Michigan. Two 

headquarters offices help EPA regions implement the SDWA:

• The Office of Water (OW) provides programmatic and implementation

guidance.

• The Office of Enforcement and Compliance Assurance (OECA) advises 

EPA regions about enforcing SDWA provisions. 

Prior Reports 

EPA OIG Report No. 17-P-0004, titled Management Alert: Drinking Water 

Contamination in Flint, Michigan, Demonstrates a Need to Clarify EPA Authority 

to Issue Emergency Orders to Protect the Public, was issued October 20, 2016. The 

report noted that the EPA needs to clarify for its employees how its emergency 

authority can and should be used to intervene in a public health threat. The OIG

recommended that OECA update the EPA’s 1991 guidance on SDWA § 1431 

emergency authority. We also recommended that OECA require all relevant EPA 

drinking water, and water enforcement program management and staff, attend 

training on SDWA § 1431 authority. The agency agreed with the recommendations 

and corrective actions are in progress.

GAO Report No. GAO-17-424, titled Drinking Water: Additional Data and 

Statistical Analysis May Enhance EPA's Oversight of the Lead and Copper Rule,

is a congressionally requested report dated September 2017. The report found that 

available EPA data reported by states show that of the approximately 68,000 water 

systems subject to the LCR, at least 10 percent had at least one open violation of 

the rule. However, these and other data are not complete. GAO made three

recommendations, including one recommendation that the EPA require states to 

report data on lead pipes, and develop a statistical analysis on the likelihood of 

LCR violations to supplement the EPA’s current oversight. The EPA agreed with 

the GAO’s recommendations.

Scope and Methodology

We conducted this performance audit from February 2016 through April 2018,

in accordance with generally accepted government auditing standards. Those 

standards require that we plan and perform the audit to obtain sufficient, 

appropriate evidence to provide a reasonable basis for our findings and 

conclusions based on our audit objectives. We believe that the evidence 

obtained provides a reasonable basis for our findings and conclusions based 

on our audit objectives. 
18-P-0221 12

We reviewed the laws, regulations, policies, procedures and guidance related to 

the SDWA program. At EPA headquarters, we interviewed the former EPA 

Administrator; the former EPA Deputy Administrator; and staff and officials from

the EPA’s Office of General Counsel, the Office of Water, and the Office of

Enforcement and Compliance Assurance. We also interviewed EPA Region 5 

staff and officials, including the former Regional Administrator (who served until 

January 2016), and the former acting Regional Administrator (who served from 

January 2016 through January 2018). Further, we interviewed MDEQ Office of 

Drinking Water and Municipal Assistance personnel, former and current 

employees of the city of Flint, residents of Flint, and external experts. We also

reviewed documents from the EPA and the MDEQ. 
18-P-0221 13

Chapter 2

Circumstances Leading to Flint Drinking 

Water Contamination and EPA Emergency 

Administrative Order

Under the MDEQ’s oversight, the Flint water treatment plant did not adhere to 

two LCR requirements: (1) identify and maintain a pool of tier 1 sampling sites,

and (2) install and maintain corrosion control treatment throughout the system.

State and local decisions to not adhere to these LCR requirements led to the 

corrosion of the Flint distribution system, which exposed residents to lead in their 

drinking water.

Inventory of Required Tier 1 Locations Was Not Maintained

The city of Flint did not develop or maintain accurate records of lead service line 

locations to identify tier 1 sampling sites. Primacy states like Michigan must 

require water systems to collect and maintain lead service line information, in 

accordance with the LCR.12 Without this information, Flint could not prioritize its 

sampling efforts to collect water samples where higher levels of lead 

contamination were most likely to occur, as required by the LCR.

The January 2016 EPA Emergency Administrative Order required Flint to provide 

the agency with the city’s existing inventory of homes with lead service lines.

When the city submitted the inventory, the EPA found that it was not complete or 

accurate. However, Flint did not update its inventory of lead service lines until 

August 2016. EPA Region 5 staff stated that other cities face similar challenges 

with inventories for lead service lines in their water systems. The EPA identified 

this as a nationwide weakness in its October 2016 Lead and Copper Rule

Revisions White Paper. 

Corrosion Control Treatment Was Not Maintained

The MDEQ did not require Flint’s water system to maintain corrosion control 

treatment when Flint changed water sources in April 2014. According to EPA 

Region 5, the MDEQ concluded that Flint’s change in source water would require 

Flint to revert to the LCR provision that required the water system to conduct tests 

to determine whether corrosion control treatment was necessary.

13 To do this, 

MDEQ personnel instructed Flint system staff to conduct monitoring during two 

consecutive 6-month periods to determine whether corrosion control treatment 

was necessary. 

 12 40 CFR § 141.86(1); 40 CFR § 141.91. 13 40 CFR § 141.81(b)(3). EPA Region 5 learned about the MDEQ’s conclusion in April 2015.
18-P-0221 14

EPA Region 5 disagreed with the MDEQ’s interpretation. The LCR treats systems 

(such as Flint’s) that change their source water or treatment as an existing system.

As a result, Region 5 concluded that Flint’s system was an existing system with a 

new source. Therefore, under the LCR, the city needed to maintain continuous 

corrosion control treatment.

In January 2015, results from Flint’s 

first round of testing found a 90th

percentile lead concentration of 6 ppb. 

However, the MDEQ did not instruct 

Flint to install corrosion control 

treatment (per the LCR) but instead 

required an additional 6-month round 

of sampling. In July 2015, results from 

the second round of 6-month tests 

showed 90th percentile lead 

concentrations had increased 

to 11 ppb. 

At that time, EPA Region 5 and the MDEQ reached an agreement to require the 

Flint water system to begin corrosion control treatment as soon as possible. In 

August 2015, the MDEQ required Flint to select a corrosion control treatment (no 

later than January 2016).

In August and September 2015, a private researcher conducted testing and

identified the following:

• 110 homes sampled with lead levels over 5 ppb.

• 43 homes sampled with lead levels over 15 ppb. 

• 7 homes sampled with lead levels over 100 ppb.

• 1 home sampled with a lead level over 1,000 ppb.

In September 2015, a local doctor issued a study showing an increase in the blood 

lead levels of children living in Flint. 

In October 2015, instead of installing corrosion control treatment, Flint’s water 

system returned to purchasing drinking water from the Great Lakes Water 

Authority (formerly called the Detroit Water and Sewerage Department), which 

already included corrosion control treatment. At the time of this change, almost a 

year-and-a-half of exposure to improperly treated water had damaged the city’s 

drinking water infrastructure, and lead concentrations continued to rise. In 

December 2015, the MDEQ reported that Flint began supplementing Detroit

water with additional corrosion control treatment. However, due to the damage

done to the Flint distribution system, the lead levels in drinking water did not fall

below the federal action level until late 2016.

Excavated lead service lines used to test water 

chemistry at the Flint water treatment plant. 

(EPA OIG photo)
18-P-0221 15

Conclusion

The MDEQ did not enforce LCR provisions that require Flint’s water system to 

keep an accurate and complete inventory of tier 1 sample site locations, or 

maintain corrosion control treatment. As a primacy agency, the MDEQ bore 

responsibility for advising Flint’s water system staff about the drinking water 

source change and meeting SDWA standards. However, MDEQ personnel 

misinterpreted the law, which led them to provide incorrect advice to Flint on 

corrosion control treatment requirements. This resulted in infrastructure damage 

and the prolonged exposure of Flint residents to lead in their drinking water.

Recommendations

We recommend that the Assistant Administrator for Enforcement and Compliance 

Assurance, and the Assistant Administrator for Water:

1. Establish controls to annually verify that states are monitoring compliance 

with all Lead and Copper Rule requirements, including accurately 

identifying tier 1 sampling sites and maintaining continuous corrosion 

control treatment. 

We recommend that the Assistant Administrator for Water:

2. Revise the Lead and Copper Rule to improve the effectiveness of 

monitoring and corrosion control treatment protocols.

Agency Response and OIG Evaluation

The agency provided a coordinated response from EPA Region 5, the OW and 

OECA. The offices provided planned corrective actions in their response, and 

additional clarifications during a June 5, 2018, meeting with the OIG. 

OECA and the OW agreed with Recommendation 1; however, the offices did not 

provide acceptable corrective actions to address the recommendation. In their 

original response, the offices stated that they would develop metrics related to 

LCR implementation and incorporate the metrics into the regional protocol for 

conducting annual PWSS program reviews by September 30, 2019. The two offices

also would implement a national oversight approach for drinking water programs 

by June 30, 2019.

The EPA provided supplemental information in the June 5, 2018, meeting with the 

OIG. In that meeting, and in subsequent correspondence on June 13, 2018, OECA 

and the OW revised their response to state that they agree on the value of national 

oversight for compliance monitoring and enforcement of the EPA’s Drinking 

Water Program, but they said it is vital that they evaluate and develop it in a 

collaborative manner with their state partners. The offices planned to work with 
18-P-0221 16

states to develop an approach or a pilot for implementing a national compliance 

monitoring and enforcement oversight program for drinking water, as appropriate, 

by June 2019. 

The OIG does not agree that developing a pilot or approach constitutes establishing 

annual controls, per the recommendation language. The OIG did not accept this 

response as meeting the intent of Recommendation 1, and this recommendation 

remains unresolved. 

The OW agreed with Recommendation 2. To address this recommendation, the 

OW will continue to evaluate input received from state, local and tribal partners,

and evaluate the best available peer-reviewed science to ensure that the revised rule 

reflects the best ways to improve public health protection. The OW plans to 

complete this action by February 28, 2019. Based on the response and 

clarifications, the EPA provided acceptable planned corrective actions and 

completion dates for Recommendation 2.

Region 5, OECA and the OW provided supplemental technical comments that 

the OIG incorporated as appropriate. The EPA’s coordinated response is found in 

Appendix C.
18-P-0221 17

Chapter 3

EPA Region 5’s Management Weaknesses 

Delayed Federal Intervention

The EPA retains oversight and enforcement authorities to provide assurance that 

primacy states comply with the SDWA. However, timely oversight interventions 

rely on effective management systems that govern how and when the agency 

should intervene. EPA Region 5 did not manage its drinking water oversight 

program in a way that facilitated effective oversight and timely intervention in 

Flint. EPA Region 5 did not:

• Establish clear roles and responsibilities with the MDEQ.

• Communicate clearly and effectively.

• Use effective risk assessment protocols.

• Proactively use available SDWA authorities and oversight tools to 

intervene in Michigan’s drinking water program. 

These weaknesses limited Region 5’s ability to monitor, adapt and respond to 

changing situations in Michigan and the city of Flint. 

Region 5 and MDEQ Did Not Establish Clear Oversight Roles and 

Responsibilities

The EPA retains the authority and responsibility to oversee states with primacy 

over their drinking water programs. The EPA is empowered and required to 

intervene when states do not fulfill their responsibilities. However, EPA Region 5 

staff and managers did not establish clear roles and responsibilities needed to 

foster a constructive federal-state relationship with the MDEQ’s drinking water 

program staff. As previously mentioned, state primacy agreements obligate states 

to implement the SDWA in a manner that is at least as stringent as federal 

requirements. Further, the EPA’s National Program Manager Guidance directs 

EPA regions to “ensure that primacy agencies fulfill the enforcement conditions 

of their primacy agreements” under the SDWA.

EPA Region 5 aimed to foster a collaborative relationship with the MDEQ. 

The region’s focus on maintaining a partnership influenced how Region 5 staff 

conducted oversight and enforcement in the state. In the case of the MDEQ, this 

partnership limited effective EPA oversight. While Region 5 needs to work with 

states to accomplish the mission of the agency, the region also needs to establish 

clear roles and responsibilities so that both the MDEQ and the region know how 

and when the EPA may intervene to implement and enforce the SDWA. 
18-P-0221 18

As a result of this relationship, Region 5 managers did not use their knowledge 

about the MDEQ’s incomplete implementation of the SDWA when assessing the 

risks in Flint. For example, in 2010, an EPA contractor reviewed the MDEQ’s 

drinking water program and identified MDEQ implementation deficiencies.14 The 

review noted that the MDEQ disinvested from 10 SDWA requirements, which

Michigan designated as temporary and non-health related.15 However, the review 

concluded that the MDEQ should reconsider these disinvestments because at least 

one of them could impact public health. The contractor recommended that the 

MDEQ implement all of the SDWA requirements, as noted in the following 

quote: 

MDEQ should reconsider the disinvestment activities. MDEQ’s 

actions and policies should be as stringent as federally mandated 

rules and policies. All instances where the federal rules were not 

correctly implemented were treated as discrepancies.

In the 2010 report, Region 5 responded that the disinvestments were intended to 

be temporary and only include nonpublic-health-related primacy activities. 

Region 5 said these disinvestments were allowed because the region viewed these

disinvestments as an “innovative way for states to continue to ensure safe 

drinking water is provided to the public, even as states are struggling with 

diminishing resources.”

Despite the recommendation from the contractor, these disinvestments continued 

and increased to 11 by 2015. Region 5 managers told us that being informed 

about implementation deficiencies in advance was a “proactive” approach to 

oversight. They maintained that disinvestments were more administrative and 

generally did not have a direct public health impact. 

The MDEQ continued these disinvestments through 2015, and the OIG 

concluded that the disinvestments did have potential public health effects. 

However, Region 5 did not intervene to ensure that the MDEQ’s drinking water 

program met minimum federal standards. It was not until 2016, while under the 

emergency order, that the MDEQ discontinued the majority of the 

disinvestments.

16

In 2017, Region 5 began requiring states to submit implementation plans to 

describe how and when they would begin implementation of any primacy 

activities the states could not fully implement at that time. Table 1 contains

examples of MDEQ disinvestments and OIG analysis of potential effects.

 14 U. S. Environmental Protection Agency Public Water System Supervision Program, Final Report: Program 

Review for the Michigan Department of Environmental Quality Water Bureau, August 30, 2010. 15 A disinvestment is a means to temporarily forfeit oversight functions required to implement the SDWA. 

Due to limited resources, the MDEQ proposed, and EPA Region 5 approved, disinvestments on an annual basis. 16 In 2016, an EPA manager told us that the MDEQ continued to be disinvested in three areas noted in the 2010 

review. 
18-P-0221 19

Table 1: Examples of MDEQ disinvestments and potential effects

SDWA requirement Disinvestment Potential effect

All water systems must 

report to the state the 

results of all tap samples 

on a defined schedule.

MDEQ would no longer issue 

violations for late reporting of 

monitoring results.

By not issuing these 

violations, identification of 

contamination could be 

delayed, further prolonging 

consumer exposure to 

contamination.

All systems must submit 

reporting forms to the state, 

including the location of 

each site and the criteria 

under which the site was 

selected for the system's 

sampling pool. Include an 

explanation of why 

sampling sites have 

changed.

MDEQ would no longer issue 

violations for failure to submit 

the LCR reporting form.

Without the LCR reporting 

forms, the state could not 

review information showing 

whether lead sampling met 

LCR requirements.

The state must require 

utilities to publish annual 

Consumer Confidence 

Reports with specific 

content requirements on a 

defined schedule (reports 

are public).

MDEQ would no longer issue 

violations for late reporting or 

insufficient content in

Consumer Confidence 

Reports.

By not enforcing rules for 

Consumer Confidence 

Reports, the state loses a 

method for providing water 

system users complete and 

timely reports about their 

water quality.

Source: OIG analysis. 

EPA and MDEQ Did Not Communicate Effectively

Communication weaknesses contributed to a delayed federal response in Flint.

For effective oversight, management needs accurate and complete information,

and clear communication. However, the communication between the EPA and the 

MDEQ did not convey key information about human health risks from lead 

contamination in Flint. Communication within the EPA was also problematic. 

These issues limited the EPA’s knowledge about risks and contributed to the 

delayed federal response. For example:

• MDEQ personnel did not provide Region 5 with accurate information 

regarding corrosion control treatment. In February 2015, when EPA 

Region 5 staff asked about corrosion control, MDEQ personnel told them

that Flint had an optimized corrosion control program in place, that the 

city conducted quarterly water quality parameter monitoring and did not 

have any unusual results, and that Flint continued to meet all applicable 
18-P-0221 20

plant tap standards and treatment technique requirements. However, in 

April 2015, the state admitted that Flint was not using corrosion control 

treatment and argued that it was not required. Before that admission, 

Region 5 personnel did not have key information needed to intervene. 

• Region 5 told us that communication with the MDEQ was frequent, 

consistent and clear, but the MDEQ failed to take appropriate actions 

when Region 5 consistently identified problems. According to EPA 

Region 5 managers, in April 2015, the EPA voiced concerns about the 

lack of corrosion control treatment to the MDEQ’s Water Director. 

Region 5 managers said that in June 2015 they advised the MDEQ that 

the LCR required Flint to maintain consistent corrosion control treatment. 

However, an MDEQ manager stated that Region 5 did not advise them 

to initiate corrosion control at that point. 

• Region 5 stated that the length of time that it took to obtain a legal 

interpretation delayed formal intervention. In a July 2015 meeting, the 

EPA and the MDEQ disagreed over interpretations of LCR corrosion 

control treatment requirements in Flint. The MDEQ requested, and 

Region 5 program staff agreed to obtain, a legal opinion from EPA 

headquarters. In August 2015, Region 5 and EPA headquarters began 

discussing Flint compliance with the requirements and the MDEQ’s 

interpretation of those requirements. 

However, headquarters personnel stated that Region 5’s characterization 

of the situation lacked a sense of urgency. Region 5 did not make an 

official request for a headquarters’ opinion until September 30, 2015. 

Region 5 did not receive a legal opinion, but the region’s request 

ultimately resulted in a November 2015 Office of Water memo clarifying 

the LCR corrosion control treatment requirements for all large water 

systems. 

Although the memo mentioned Flint, 

it did not specifically address the 

Flint situation (see green box). For 

this reason, it was of limited use in

dealing with the incident in Flint.

A Region 5 official expressed 

concern that states would not follow

guidance from the memo because it 

lacks the authority of law. In an effort

to further clarify requirements, an

EPA official stated that headquarters 

has provided training to EPA staff 

with regard to the memo.

Summary of the “Lead and Copper 

Rule Requirements for Optimal 

Corrosion Control Treatment for 

Large Drinking Water Systems” 

In this November 2015 memo, the 

EPA’s Office of Water acknowledged 

differing interpretations of the LCR. 

The EPA’s intent was to clarify that 

the rule requires any large system to 

continuously maintain corrosion 

control treatment. 
18-P-0221 21

Region 5 Did Not Have an Effective System for Risk Assessment

EPA Region 5 did not have effective risk assessment processes that would have 

alerted the region to growing issues in Flint. An effective risk assessment system 

provides the basis for responding to threats that impact human health. While 

bacterial violations alone would not have signaled to the EPA that lead 

contamination was occurring, the combined information available to Region 5 

painted a picture of a system at risk from multiple angles. 

By compiling and examining 

these factors, Region 5’s staff and 

managers could have intervened 

sooner after the source switch, as 

evidence of risk grew. Instead, the 

federal response was delayed while 

residents continued to be exposed to

lead in their drinking water.

Risks at the State Level

In addition to the disinvestments 

previously mentioned, in 2016, 

EPA managers discovered that 

MDEQ personnel did not establish 

water quality parameters required by

the LCR.

17 As stated in Chapter 1, the parameters define a range of water 

chemistry constraints to protect infrastructure from corrosion. The LCR requires 

water systems to use lead tap and water quality parameter sampling results to 

verify corrosion control treatment programs are effective. When water samples 

demonstrate that a system does not meet the parameters, violations can result.

Risks at the Local Level

Despite known economic challenges in the city, EPA Region 5 staff did not 

identify Flint’s source water switch as an event that could impact the city’s ability 

to comply with the SDWA. Beginning in May 2014, a number of problems 

emerged that should have warned the agency about the risk. 

 17 The LCR requires that water quality parameters include measures for lead, copper, pH, alkalinity, calcium, 

conductivity, orthophosphate or silica, and temperature. The EPA discovered the lack of water quality parameters in 

Michigan during the agency-led program review of the state’s drinking water program: U.S. Environmental 

Protection Agency Public Water System Supervision Draft Program Review of the Michigan Department of 

Environmental Quality Drinking Water Program 2016.

EPA staff reviewing lead sampling data in Flint 

during emergency response efforts. (EPA photo)
18-P-0221 22

For example, in June 2015, an EPA Region 5 

scientist drafted an interim report that outlined

concerns about lead in Flint’s drinking water 

and the lack of corrosion control treatment. 

This report indicated the potenial for serious 

human health risks and recommended

potential EPA actions. 

Even with this memo and other information, 

a senior regional official told the Regional 

Administrator for Region 5 that the region 

and state were in the process of reaching an 

agreement that would require Flint to 

implement corrosion control treatment. 

According to the Regional Administrator, the problem was not presented in a way 

that conveyed the gravity of the situation. The Regional Administrator said that 

no wide-spread public health issues were apparent at the time. This delayed the 

EPA’s formal intervention. Table 2 shows the growing evidence of risk in Flint. 

Table 2: Evidence of growing risk in Flint

May 2014

• EPA Region 5 learned of Flint drinking water source switch.

• EPA Region 5 received first citizen complaints about drinking water 

quality.

August 

2014 • First total coliform violation occurred.

December 

2014 • First total trihalomethanes violation occurred.

February 

2015

• EPA Region 5 learned of elevated lead level in Flint resident’s drinking 

water.

• EPA Region 5 manager voiced concerns to colleagues that sampling 

protocol is biasing lead results.

March 

2015

• Engineering firm contracted to work on the Flint water system issued 

report that recommends the addition of corrosion control treatment.

• EPA Region 5 learned that Genesee County was investigating an 

increase in Legionella cases.

April 2015 • MDEQ staff member told an EPA Region 5 manager that the Flint 

system does not have any corrosion control treatment.

Flint Water Treatment Plant. 

(EPA OIG photo, taken April 2016) 
18-P-0221 23

June 2015

• EPA Region 5 learned that at least four homes had lead in drinking 

water above the action level.

• EPA Region 5 manager shared interim report on high lead levels in 

Flint’s drinking water with an affected resident. The report was 

subsequently released to the public.

Source: OIG analysis of EPA Region 5 records.

Between May 2014 and the issuance of the EPA Emergency Administrative Order 

in January 2016, EPA Region 5 staff received 87 citizen complaints about 

drinking water conditions in Flint. The complaints described distress about water 

quality (color and odor), more specific concerns about total trihalomethanes, total 

coliform and E. coli, Legionella and, ultimately, lead. 

Of the complaints received before the order, 30 (34.5 percent) included concerns

about lead. Even so, Region 5 staff did not identify the volume of complaints as

indications of unusual problems in Flint’s water system. Region 5 officials 

responded with form letters that recommended citizens resolve their concerns 

by contacting the MDEQ or Flint’s water system staff. In six cases, Region 5’s

response came more than a year after the citizen made the complaint. In 11 cases, 

we found no documentation of any response. 

In April 2016, we interviewed a sample of the 

complainants. Some expressed frustration at the lack 

of resolution of their complaints by Region 5. Staff 

and managers in Region 5 did not have a system for 

cataloguing and responding to citizen complaints, 

nor did they use citizen complaints or the volume of 

calls as indicators of problems with Flint’s water 

system. As a result, Region 5 could not assess the 

severity of the situation, and staff were not able to 

alert management to an emerging incident. 

Region 5 staff and managers told us that these risk 

factors individually or taken together would not have 

indicated elevated lead levels. They stated, “Generally, there is little or no 

correlation between citizen complaints about water and lead content.” Region 5 

staff said residents often complain about aesthetic concerns that are unrelated to 

lead levels. Further, staff told us that aesthetic complaints are common, especially 

in under-resourced water systems like Flint’s.

Region 5’s comments regarding citizen complaints contradict the EPA’s Drinking 

Water Action Plan, which was issued in November 2016 and stresses the 

importance of assessing risks at the local level. Issued after the Flint crisis, the 

plan states that EPA staff should do the following: 

Multilingual sign directing residents to a water 

distribution site in Flint. (EPA photo)
18-P-0221 24

Develop priority indicators to identify troubled water systems. In a 

world of limited oversight resources, it is critical the EPA and 

primacy agencies become more effective at proactively directing

oversight and technical assistance resources to systems that are 

most likely to face problems or risks that may adversely affect 

public health. Indicators may also be used to identify systems that 

are likely to be in violation, and follow-up with the appropriate 

compliance assistance and enforcement response.

18

Although EPA Region 5 receives drinking water complaints regularly, we believe 

that complaints can serve as a critical indicator of potential problems. Instead of 

referring complainants back to state and local officials to resolve, the region could 

have taken a more proactive stance. Further, the volume of complaints should 

have alerted Region 5 to a developing drinking water risk in Flint. A more 

proactive approach could have enabled the region to respond more swiftly to the 

contamination incident.

Region 5 Did Not Use Oversight and Monitoring Authorities 

and Tools to Influence MDEQ

Region 5 used several tools to oversee the MDEQ’s handling of contamination in 

Flint. However, when those approaches did not result in swift action to protect 

public health, Region 5 did not employ other SDWA authorities at its disposal to 

require compliance in Flint. Most authorities were not used because regional

managers did not recognize them or deem them appropriate. Table 3 provides 

examples of drinking water oversight authorities available to Region 5, and our 

analysis of the region’s use of those authorities. Table 4 provides examples of 

oversight tools available to Region 5, and our analysis of the region’s use of those 

tools.

Table 3: Region 5’s available oversight authorities in Flint

Authorities Region 5’s use of authorities

Authority to negotiate resolution of grant issues or 

impose additional conditions (such as withholding 

funds) if a grantee is in noncompliance or issues 

cannot be resolved. 

(Authority: SDWA § 1443; 

Regulation: 40 CFR § 35.115 and 2 CFR § 200.338)

Region 5 did not place additional 

conditions on the Michigan public water 

systems supervision grant, even when 

issues were identified. 

Authority to issue an administrative order or 

commence a civil action when the state does 

not act. 

(Authority: SDWA § 1414)

Region 5 did not use this authority. 

 18 EPA Drinking Water Action Plan, November 2016, page 8.
18-P-0221 25

Authority to issue a federal corrosion control 

treatment requirement when the state does not 

adequately do so. 

(Regulation: 40 CFR § 141.82)

Region 5 did not use this authority.

Emergency authority to act when a contaminant 

may present an "imminent and substantial 

endangerment" to human health, and the 

appropriate state and local authorities have not 

acted to protect public health. 

(Authority: SDWA § 1431)

Region 5 did not use this authority;

however, EPA headquarters issued an 

Emergency Administrative Order on 

January 20, 2016.

Authority to require information to determine 

whether a system is acting in compliance with 

drinking water regulations. 

(Authority: SDWA § 1445)

Region 5 requested and received

information from Michigan about 

corrosion control treatment and other 

issues.

Authority to revoke primacy if a state does not meet 

primary enforcement requirements. 

(Authority: SDWA § 1413)

Region 5 did not use this authority. 

Source: OIG analysis.

Table 4: Region 5’s available oversight tools in Flint

Drinking water oversight tools Region 5’s use of oversight tools

Coordinate enforcement efforts. 

(Guidance: EPA Office of Water National Program 

Manager Guidance)

Region 5 conducted regular meetings.

It was during these meetings that the 

state expressed a different 

interpretation from Region 5 

regarding the LCR.

Provide technical and scientific support. 

(Guidance: EPA Office of Water National Program 

Manager Guidance)

Region 5 provided technical assistance

that the state initially was reluctant to 

accept. According to Region 5, the 

MDEQ failed to take appropriate actions 

when the region consistently identified 

problems with Flint's water switch.

Receive drinking water compliance data. 

(Guidance: EPA Office of Water National Program 

Manager Guidance)

Region 5 received correspondence and 

reports from the MDEQ, which 

uncovered compliance issues.

Use Drinking Water State Revolving Fund program 

monies in support of the PWSS program to help 

achieve the public health objectives of the SDWA.

(Authority: SDWA § 1452; Regulation: 40 CFR Part 

35, Subpart L; Guidance: Drinking Water State 

Revolving Fund Program Guidance)

Region 5 awarded Flint a grant for 

infrastructure improvements after the 

2016 crisis.

Conduct compliance reviews of state programs. 

(Guidance: EPA Office of Water National Program 

Manager Guidance)

Region 5 conducted 2010 and 2016 

reviews of the MDEQ’s SDWA program. 

Source: OIG analysis.
18-P-0221 26

Region 5 senior officials told us that 

the LCR limited their ability to 

intervene. For example, they stated 

that the rule “does not require the 

primacy agency to notify and/or seek 

approval from EPA for significant 

changes to public water systems.”

Although the LCR does not require 

the EPA to be notified of the 

changes, regional staff knew

of the source switch soon after it 

happened. When the region was 

informed—a year after the switch—

that Flint did not have corrosion 

control treatment, the region could have intervened earlier to verify the changes 

occurred in accordance with SDWA regulations.

Sampling results from two 6-month tests indicated the 90th percentile of the 

results exceeded the 5 ppb limit at which optimized corrosion control treatment is 

required, and lead concentrations increased over the course of testing. According 

to Region 5 officials, these results did not alert the region to widespread problems 

in Flint’s water system. However, if the results of these tests were combined with

other issues identified in Flint, this could have signaled problems in Flint’s water 

system and the region could have intervened more forcefully. For example, 

Region 5 could have done the following:

• Taken enforcement action under SDWA § 1414, which would have 

required Flint to install corrosion control treatment after notifying the

state.

• Issued an order under SDWA § 1431 when the region had evidence there 

was “imminent and substantial endangerment” to human health, and when 

the region knew the state did not act.

• Alerted Flint residents about the potential harm to public health (although 

not required under the SDWA).

The Flint water crisis demonstrates that public health is not protected when EPA 

regional staff—with multiple warning signs—do not use the agency’s SDWA 

authorities in conjunction with EPA oversight tools.

EPA staff and management at the Flint Response 

Center at Kettering University in Flint. (EPA OIG 

photo, taken April 2016)
18-P-0221 27

Conclusion

Effective program management tools provide 

a foundation for federal programs to achieve 

important goals like those in the SDWA. 

Oversight tools found in the SDWA are designed

to protect public health from drinking water 

contamination, but they are only effective when 

used.

During the Flint water crisis, Region 5 leadership 

did not employ many of its SDWA authorities, as 

the state continued to debate LCR requirements

and residents continued to drink potentially 

contaminated water. Flint drinking water 

contamination continued, in part, because 

the public health protection authorities of the 

SDWA were not used effectively. The EPA and 

its regional offices must understand their oversight 

tools and authorities, and not be reluctant to use 

them to protect public health.

To understand roles and responsibilities, Region 5 should clarify its region-state 

relationship with the state of Michigan. Region 5 also should establish a schedule 

for periodically training drinking water program staff and managers to confirm 

understanding of their roles and responsibilities, and the EPA’s authorities for 

intervention. To improve drinking water oversight, Region 5 should establish a 

risk assessment protocol to heighten awareness, and establish control activities to 

properly monitor state programs. Cognizance of roles and responsibilities, as well 

as EPA authorities, is important not only for Region 5, but also for the EPA at the 

national level.

Recommendations

We recommend that the Regional Administrator, Region 5:

3. Publicly document clear expectations, roles and responsibilities between

the EPA and the state of Michigan in an official document, such as a

memorandum of understanding or a supplemental primacy document.

4. Implement a system for regional drinking water staff, managers and senior 

leaders, which incentivizes staff elevating and managers addressing 

important and emerging issues in accordance with the EPA’s “Policy on 

Elevation of Critical Environmental and Public Health Issues.”

Bottled water distribution in Flint 

was established during response 

efforts. (EPA photo)
18-P-0221 28

5. Provide the public with all results from EPA reviews of Michigan’s Safe 

Drinking Water Act program, and track the progress of identified 

corrective actions. 

We recommend that the Assistant Administrator for Enforcement and Compliance 

Assurance, and the Assistant Administrator for Water:

6. Provide regular training for EPA drinking water staff, managers and senior

leaders on Safe Drinking Water Act tools and authorities; state and agency 

roles and responsibilities; and any Safe Drinking Water Act amendments or 

Lead and Copper Rule revisions.

7. Implement a system to identify management risks in state drinking water 

programs, including elements such as atypical events, emerging public 

health concerns, environmental justice concerns and public health analyses. 

8. Create a system that tracks citizen complaints and gathers information on 

emerging issues. The system should assess the risk associated with the 

complaints, including efficient and effective resolution. 

9. Improve oversight by establishing a clear and credible escalation policy for 

EPA intervention in states. The policy should provide steps the EPA will 

take when states do not act.

Agency Response and OIG Evaluation

The EPA provided a coordinated response from Region 5, the OW and OECA. 

They provided planned corrective actions in their response, and provided additional 

clarifications in a June 5, 2018, meeting with the OIG. Based on the coordinated 

response and additional clarifications, the EPA provided acceptable planned 

corrective actions and completion dates for Recommendations 3 through 9.

Region 5 agreed with Recommendations 3, 4 and 5. For Recommendation 3, 

Region 5 will add clear roles and expectations, and post the annual Michigan 

PWSS program work plan and end-of-year evaluation on the EPA’s website so 

that the information is available to the public. The projected completion date is 

October 1, 2018.

To address Recommendation 4, by October 31, 2018, Region 5 plans to incentivize 

and provide midyear and end-of-year feedback to staff, managers and senior leaders 

on elevating and addressing issues of concern. To address Recommendation 5, 

Region 5 noted that the 2010 and 2016 Michigan Drinking Water Program Review

reports and the FY 2010 through FY 2016 End-of-Year Evaluation reports are 

currently available to the public online. They also plan to finalize a corrective 

action plan that stems from the 2016 Program Review Report and post this plan 
18-P-0221 29

online by September 30, 2018, and provide updates on progress by April 30 and 

September 30 each year thereafter.

OECA and the OW agreed with Recommendations 6 through 9. To address 

Recommendation 6, the EPA has been providing training on the LCR’s optimal 

corrosion control treatment and optimal water quality parameter requirements. 

The workshops provide a review of LCR requirements and emphasize the tools 

and authorities drinking water programs can leverage to implement the 

requirements more effectively. The training has been delivered through in-person 

workshops at all EPA regions, as well as through special conference sessions. 

Since the inaugural workshop in FY 2016, the training has reached approximately 

1,300 drinking water professionals (staff and managers) from federal and state 

drinking water programs, technical assistance providers and water utilities. 

Training was completed on May 31, 2018, and training needs will be reassessed 

by September 30, 2019. OECA and the OW also stated the training will be 

provided to senior leaders. 

To address Recommendation 7, OECA and the OW initiated a work group with 

participants from both offices and EPA regions. This work group will identify 

ways to use drinking water data and other information to identify water systems 

that present, or are likely to present, a significant risk to public health. The work

group will develop procedures and strategies by December 31, 2018.

To address Recommendation 8, OECA and the OW committed to either enhancing 

an existing system, or developing a new system to track and resolve citizen 

complaints by September 30, 2019. 

For Recommendation 9, a work group including OECA, the OW and EPA regions 

will develop procedures and strategies to provide timely and effective EPA 

intervention where a state’s response to risks is insufficient to protect human 

health. The EPA plans to make a policy decision by July 31, 2019.

Region 5, OECA and the OW provided supplemental technical comments that the 

OIG incorporated as appropriate. The EPA’s coordinated response is found in 

Appendix C.
18-P-0221 30

Status of Recommendations and 

Potential Monetary Benefits

RECOMMENDATIONS

Rec. 

No.

Page 

No. Subject Status1 Action Official

Planned 

Completion 

Date

Potential 

Monetary 

Benefits 

(in $000s)

1 15 Establish controls to annually verify that states are monitoring 

compliance with all Lead and Copper Rule requirements, 

including accurately identifying tier 1 sampling sites and 

maintaining continuous corrosion control treatment.

U Assistant Administrator for 

Enforcement and 

Compliance Assurance,

and the 

Assistant Administrator 

for Water

2 15 Revise the Lead and Copper Rule to improve the effectiveness 

of monitoring and corrosion control treatment protocols.

R Assistant Administrator 

for Water

2/28/19

3 27 Publicly document clear expectations, roles and responsibilities

between the EPA and the state of Michigan in an official 

document, such as a memorandum of understanding or a 

supplemental primacy document.

R Regional Administrator, 

Region 5

10/1/18

4 27 Implement a system for regional drinking water staff, managers 

and senior leaders, which incentivizes staff elevating and 

managers addressing important and emerging issues in 

accordance with the EPA’s “Policy on Elevation of Critical 

Environmental and Public Health Issues.”

R Regional Administrator, 

Region 5

10/31/18

5 28 Provide the public with all results from EPA reviews of 

Michigan’s Safe Drinking Water Act program, and track the 

progress of identified corrective actions.

R Regional Administrator, 

Region 5

9/30/18

6 28 Provide regular training for EPA drinking water staff, managers

and senior leaders on Safe Drinking Water Act tools and 

authorities; state and agency roles and responsibilities; and any 

Safe Drinking Water Act amendments or Lead and Copper Rule 

revisions.

R Assistant Administrator for 

Enforcement and 

Compliance Assurance, 

and the 

Assistant Administrator 

for Water 

9/30/19 

7 28 Implement a system to identify management risks in state 

drinking water programs, including elements such as atypical 

events, emerging public health concerns, environmental justice 

concerns and public health analyses.

R Assistant Administrator for 

Enforcement and 

Compliance Assurance, 

and the 

Assistant Administrator 

for Water

12/31/18 

8 28 Create a system that tracks citizen complaints and gathers

information on emerging issues. The system should assess the 

risk associated with the complaints, including efficient and 

effective resolution. 

R Assistant Administrator for 

Enforcement and 

Compliance Assurance, 

and the 

Assistant Administrator 

for Water

9/30/19
18-P-0221 31

RECOMMENDATIONS

Rec. 

No.

Page 

No. Subject Status1 Action Official

Planned 

Completion 

Date

Potential 

Monetary 

Benefits 

(in $000s)

9 28 Improve oversight by establishing a clear and credible escalation 

policy for EPA intervention in states. The policy should provide 

steps the EPA will take when states do not act.

R Assistant Administrator for 

Enforcement and 

Compliance Assurance, 

and the 

Assistant Administrator 

for Water

7/31/19

C = Corrective action completed. 

R = Recommendation resolved with corrective action pending. 

U = Recommendation unresolved with resolution efforts in progress.
18-P-0221 32

Appendix A

Timeline of Key Events

Date Event

Pre-2014

1967 Flint switched from the Flint River as its primary water supply source to 

Lake Huron water supplied by Detroit.

2014

April 17 The Flint water system water quality manager tells the MDEQ that if 

drinking water from the Flint River is distributed within the next couple of 

weeks, it will be against his direction.

April 25 City of Flint switched from purchasing water from Detroit to using the Flint 

River as a water source and using the Flint plant for treatment.

April 30 The MDEQ requires Flint to conduct two 6-month rounds of monitoring for 

lead and copper (July–December 2014 and January–June 2015) to 

determine whether corrosion control treatment is necessary.

May Region 5 staff member first learns about Flint’s source water switch from an 

MDEQ employee. He provided analysis that lead levels were in compliance 

when leaving the plant.

May 15 First record of citizen complaint to Region 5 after the change in water 

source. The complaint was about the poor quality of Flint’s drinking water.

June 17 An MDEQ staff member emails a Flint water treatment plant operator to 

confirm that no orthophosphate (a corrosion inhibitor) is to be added so no 

monitoring is necessary.

July 1 Flint begins first 6-month monitoring period for lead and copper.

August City of Flint violates the National Primary Drinking Water Regulations 

(NPDWRs) for E. coli bacteria and total coliform. The city issues a boil 

advisory on August 15. 

Aug. 15 Flint increases flushing of water and boosts chlorine disinfectant use.

Oct. 17 Genesee County Health Department expresses concerns about a 

Legionellosis outbreak and possible connection to water supply. 

Dec.16 The MDEQ notifies Flint of initial quarterly violation of SDWA Disinfection 

Byproducts (total trihalomethanes) requirements. Subsequent notices of 

violations were issued in March and June 2015. 
18-P-0221 33

Date Event

Dec. 30 Flint completes its first 6-month round of lead monitoring with results above 

the PQL of 5ppb. 

2015

Jan. 1 Flint begins the second 6-month monitoring period for lead and copper.

Jan.12 Detroit offers to reconnect Flint’s water system to its water 

system and waive the $4 million connection fee. Flint declines the offer 

on January 29, 2015.

Feb. 10 Genesee County Health Department epidemiologist consults outside 

experts about 47 Legionellosis cases, and a possible connection with the 

Flint water system.

Feb. 16 Flint posts its Flint water frequently asked questions, and states that Flint 

water is safe to drink.

Feb. 18 Lead levels of 104 ppb found in tap water of a Flint resident’s home.

Feb. 25 The EPA assigns an EPA disinfection by-products expert to participate on 

Flint’s Technical Advisory Committee.

Feb. 26 Region 5 staff member receives a call from a Flint resident regarding high 

lead levels in the water in her home. The resident said the city of Flint and 

the MDEQ attributed it to premise plumbing, but the resident has plastic 

pipes in her home.

Region 5 notifies the MDEQ of high lead levels in tap water of Flint resident. 

Test results show lead levels at 104 ppb. The MDEQ advises Flint to collect 

a follow-up sample from the resident’s home.

The sentiment at MDEQ staff discussions: Flint is not above the 90th

percentile of 15 ppb for lead, so “not sure why Region 5 (EPA) sees this 

one sample as such a big deal.”

Feb. 26–27 Region 5 scientist emails various EPA staff members, an expert from the 

EPA’s Office of Research and Development, and the MDEQ to inquire 

about the type of corrosion control treatment (CCT) now used in Flint.

Feb. 27 MDEQ manager informs Region 5 that Flint has an optimized corrosion 

control program. He also shares the results of the first 6-month round of 

testing to determine whether the system needs CCT. The 90th percentile of 

the results were 6 ppb, which is over the PQL of 5 ppb. The result is an 

indication that CCT is necessary.

Region 5 scientist voices concerns to EPA colleagues that Flint’s leadsampling protocol (pre-flushing) is biasing lead results toward the low side.
18-P-0221 34

Date Event

Mar. 3 A follow-up sample of tap water collected by the city of Flint had a lead level 

of 397 ppb at the same Flint residence where the lead level had been 104 

ppb when a sample was first taken on February 18.

Mar. 10 Region 5 staff member emails the MDEQ saying that she has been 

inundated with citizen emails referred to her from the White House about 

Flint’s water quality problems.

Mar. 26 EPA learns that Genesee County is investigating an increase in Legionella

cases.

April 7 Region 5 scientist emails other Region 5 and EPA Office of Research and 

Development staff saying Flint needs help, and the system needs to be 

evaluated. The city's practice of pre-flushing ahead of collecting samples 

results in an inadequate capture of lead released in the service lines.

April 24 An MDEQ staff member tells Region 5 scientist that the Flint system does 

not have any CCT.

April 25 Region 5 scientist notifies MDEQ staff that CCT should have been 

maintained with the source switch. Region 5 scientist also tells the MDEQ 

that lead levels may be much higher than the compliance results indicate 

due to lack of CCT and pre-flushing.

April 27 Region 5 scientist meets with Flint resident to review internal plumbing, and 

provide sampling bottles to take water samples for lead in the resident’s

home.

May 1 The MDEQ informs Region 5 that it had not made a formal decision as to 

whether the city meets the exemption criteria for corrosion control 

treatment. The MDEQ also reasoned that since Flint would be switching 

source water in another year to the Karegnondi Water Authority (KWA), 

requiring the study at this time would be of little value.

May 6 EPA Region 5 visits a Flint resident’s home (see Feb. 18, March 3 and April 

27 entries) to collect pipe samples from the service line. Three sections of 

the service line were extracted and sent to Virginia Tech University for 

analysis. The EPA leaves sample bottles for the resident to collect 

sequential samples following the expected replacement of the service line. 

EPA Region 5 collects a set of sequential samples from two additional Flint 

residences, one had low lead levels, the other high lead levels. 

The city of Flint tests the water at two more homes. Both homes had high 

lead results.
18-P-0221 35

Date Event

May 11 Region 5 staff member asks an EPA Office of Research and Development 

expert about the value of starting CCT immediately. The expert notes that 

Flint has multiple problems, and CCT should be integrated into a long-term 

plan.

May 13 Region 5 scientist samples the Flint residence (see Feb. 26 and Mar. 8 

entries) after disconnection from an old service line. Results show that 

water is below the action level.

June 10 During a conference call, Region 5 tells the MDEQ that Flint is likely to need 

corrosion control treatment, and the expertise of the Office of Research and 

Development should be used to avoid problems moving forward. 

June 24 Region 5 had information that at least four homes in Flint had lead in 

drinking water in concentrations above the action level.

Region 5 scientist releases interim report on high lead levels in Flint 

drinking water.

July 10 Region 5 Regional Administrator writes to Flint’s Mayor and states the EPA 

will work with the MDEQ on issues related to lead in the water.

July 21 Region 5 informs the MDEQ about the region’s interpretation of the LCR, 

and that Flint should have been maintaining corrosion control treatment 

since the source switch. The MDEQ disagreed with the interpretation, 

stating that it was premature, and requests a legal opinion. However, the 

MDEQ did agree to start CCT as soon as possible.

The MDEQ will not change its sampling protocol regarding pre-flushing until 

new state regulations are issued.

July 24 The MDEQ emails the EPA the results from the second 6-month monitoring 

period. The 90th percentile result is 11 ppb, above the PQL of 5 ppb. 

Aug. 17 The MDEQ orders Flint to optimize CCT within 6 months.

Aug. 23 Independent researcher notifies city of Flint that his research team has 

started collecting samples for a water quality study in Flint.

Sept. 3 Flint Mayor announces that CCT will be implemented and invites EPA 

corrosion control experts to join Flint technical advisory committee.

Sep. 8 Independent research team issues a report indicating that 40 percent of 

Flint homes have elevated lead levels. “Flint has a very serious lead in 

water problem.”

Sep. 10 OECA Water Enforcement Division (EPA headquarters) attorney 

acknowledges learning about the Flint situation and articulates plans to 

follow up with Region 5 staff.
18-P-0221 36

Date Event

Sep. 11 Local doctor convenes study of children’s blood lead levels following 

findings about lead in drinking water from independent research team. 

Sep. 15 Region 5 Regional Administrator calls the MDEQ and Flint Mayor to urge 

action on drinking water.

Sep. 24 Study completed by local doctor is released showing the numbers of 

children with elevated blood lead levels increased 90 percent after the 

switch to Flint River.

Sep. 25 Flint issues formal health advisory regarding lead in the drinking water.

Sep. 27 Region 5 Regional Administrator calls the MDEQ to expedite corrosion 

control treatment and to provide bottled water to residents.

Sep. 28 Region 5 Regional Administrator emails a 10-Point Plan to the EPA 

Administrator and asks the Office of Research and Development Director to 

encourage the MDEQ to call in Michigan Department of Health and Human 

Services for assistance.

Oct. 1 Michigan’s Chief Medical Officer confirms the results from the local doctor’s 

blood lead level study.

Genesee County Health Department issues do not drink advisory.

Private and public sources donate $105,000 to fund 5,000 water filters for

Flint residents to be distributed to those with the highest risk first.

Oct. 5 EPA learned that the city of Flint claimed to use lime softening as CCT.

Oct. 6 The Technical Advisory Committee recommends a return to Detroit water. 

The MDEQ and the EPA agree to additional phosphate treatment for the 

already finished Detroit water.

Oct. 8 Michigan announces that Flint will go back to Detroit water system for 

drinking water.

Oct. 9 Michigan Congressman requests assistance from EPA Administrator.

Oct. 16 Flint returns to using treated water from Detroit.

The EPA established the Flint Safe Drinking Water Task Force to provide 

the agency’s technical expertise through regular dialogue with designated 

officials from the MDEQ and the city of Flint.

Oct. 18 The MDEQ’s Office of Drinking Water and Municipal Assistance Director 

issues statement regarding how his office was mistaken in how it 

interpreted federal rules governing CCT.
18-P-0221 37

Date Event

Oct. 23 The EPA’s Flint Safe Drinking Water Task Force provides the MDEQ with 

technical comments on Flint’s CCT plan.

Nov. 3 The EPA’s Office of Water issues a memo that clarifies the agency’s 

interpretation that the LCR requires large water systems such as Flint to 

have optimized technologies in place.

Nov. 25 The EPA’s Flint Safe Drinking Water Task Force releases its preliminary 

assessment, with recommendations on sampling protocol, operating 

procedures, corrosion control, and outreach during transition to the KWA.

Dec. 9 Flint begins supplemental corrosion control treatment.

Dec. 14 Mayor of Flint declares state of emergency.

2016

Jan. 5 Michigan Governor declares state of emergency for Genesee County due to 

health and safety issues caused by lead in Flint’s drinking water.

Jan. 12 Michigan Governor requests assistance from Federal Emergency 

Management Agency and activates the Michigan National Guard to help 

distribute bottled water.

Jan. 14 Michigan Governor requests major disaster and emergency declaration and 

federal aid.

Jan. 15 Michigan Attorney General initiates investigation to determine whether state 

laws were violated.

Jan. 16 President declares federal state of emergency for city of Flint with $5 million 

in aid.

Jan. 21 The EPA issues Emergency Administrative Order to the state of Michigan, 

the MDEQ and the city of Flint. 

Nov. 17 Region 5 acting Regional Administrator issues First Amendment to 

Emergency Administrative Order.

Source: OIG-created timeline of events. The timeline ends on the date the First Amendment to Emergency 

Administrative Order was issued. For all subsequent EPA activity, see the EPA’s Flint Drinking Water Documents 

webpage. 
18-P-0221 38

Appendix B

Status of Emergency Administrative 

Order and Amendment

Emergency Administrative Order, January 21, 2016

The SDWA provides the EPA with the authority to order actions when there is imminent and 

substantial endangerment to human health, and when actions taken by state or local authorities 

are inadequate to protect public health. The EPA determined that responses from the city of Flint 

and the MDEQ were inadequate, and the EPA issued the SDWA emergency administrative order 

to the state of Michigan, the MDEQ and to Flint. Paragraphs 1–49 contain the EPA’s findings 

and conclusions. Paragraphs 50–64 identify actions required by the order, with assigned

completion dates where applicable.

19 The EPA provided the status of actions on May 30, 2018.20

Paragraph

Number

Due 

Date*

Required Action Status 

50 1/22/16 Within one day of the effective date 

of this Order, Respondents21 shall 

notify EPA in writing of their 

intention to comply with the terms 

of this Order. For the purposes of 

this Order, ''day" shall mean 

calendar day.

Complete

Reporting Requirements 

51 1/26/16

and 

weekly 

thereafter

Within five days of the effective 

date of this Order, the State shall 

create, and thereafter maintain, a 

publicly available website. 

Respondents must post on this 

website all reports, sampling 

results, plans, weekly status reports 

on the progress of all requirements 

and all other documentation 

required under this Order. The

Respondents shall not publish to 

this website any personally 

identifiable information.

Complete 

Weekly status reports are

ongoing 

 19 Text is not verbatim. 20 Region 5’s Office of Compliance and Enforcement tracks progress on the emergency order and amendment. 21 Respondents are the state of Michigan, the Michigan Department of Environmental Quality, and the city of Flint.
18-P-0221 39

52 1/31/16 The Respondents shall within 10 

days of the effective date of this 

Order respond in writing, in 

accordance with Paragraph 51, to 

all of the EPA Flint Task Force's 

requests and recommendations 

made on November 25, 2015 and 

subsequent dates. The response 

shall include all actions 

Respondents have taken and intend 

to take in response to those requests 

and recommendations. The EPA 

Flint Task Force's requests and 

recommendations are publicly 

available at

http://www.epa.gov/mi/flint-drinkingwater-documents

Ongoing – Respondents 

continue to respond in 

writing to all of the Technical 

Support Team’s (TST) (f/k/a 

EPA Flint Task Force) 

recommendations, including 

the TST’s 1-22-2018 

recommendation relating to 

the implementation of the 

American Water Works 

Association 810-17 Standard 

for replacement and flushing 

of lead service lines. All of 

the TST’s recommendations 

and the corresponding 

City/State responses are on 

EPA’s website.

53 1/31/16 Within 10 days of the effective date 

of the Order the Respondents shall 

provide the following information 

in accordance with Paragraph 51:

a. Water quality parameter 

measurements (pH, total alkalinity, 

orthophosphate, chloride, turbidity, 

iron, calcium, temperature, 

conductivity) in the distribution 

system. The City is required by the 

MDEQ permit to monitor for these 

parameters at 25 sites quarterly and 

at 10 of these sites weekly;

Complete

1/31/16 b. All lead in water testing results 

for the City since January 2013, 

including those not used for LCR 

compliance; and 

Complete

1/31/16 c. Identification of areas (e.g., zip 

codes, neighborhoods) in the City 

with elevated blood lead levels.

Complete
18-P-0221 40

54 1/31/16 Within 10 days of the effective date 

of the Order, the Respondents shall 

provide, without publicly disclosing 

any personally identifiable 

information, the following directly 

to the EPA in accordance with 

Paragraph 66:

a. Existing inventory of homes with 

lead service lines in Excel or 

similar format

Ongoing – An initial existing 

inventory was submitted; 

however, the inventory was 

severely lacking in 

completeness and accuracy. 

Flint recently submitted an 

updated estimate of their 

inventory based on Flint 

Action and Sustainability 

Team (FAST Start) project 

findings

b. Addresses of homes that have 

had water service interruptions or 

street disturbances (e.g., water main 

breaks, road/sidewalk construction, 

etc.) within the last year; and

Complete

c. Addresses of currently 

unoccupied homes.

Complete

55 Ongoing Respondents shall cooperate with 

EPA as the Agency conducts LCR 

sampling and other diagnostic 

activities in the City.

Ongoing

Treatment and Source Water

56 ~ To Ensure that treated water meets 

finished water quality goals and is 

consistently maintained throughout 

the distribution system, that 

existing and potential plant 

operational and mechanical start-up 

issues are identified and addressed, 

and that water plant operations staff 

are proficient in treating the 

existing and new source water, 

Respondents shall comply with 

Paragraphs 57, 58 and 59. 

Ongoing- Flint distribution 

system water quality 

monitoring reports are posted 

on the State of Michigan’s 

Flint website. Current 

certified plant operator duties 

are being performed by a 

contractor. The operator 

certification level of this 

contractor meets the state 

requirements for operating 

the Flint water treatment 

plant. Two current employees 

of the Flint water plant took 

the D-1 Operator 

Certification Exam in early 

May 2018—still awaiting 

results.
18-P-0221 41

57 Ongoing Respondents shall maintain 

chlorine residual in the distribution 

system in accordance with SDWA 

and the National Primary Drinking 

Water Regulations ("NPDWRs")

Ongoing- The City's 

contractor worked with the 

City and MDEQ to increase 

residual monitoring to 25 

sites from 10 sites. City 

continues to sample at these 

locations to verify that an 

adequate chlorine residual is 

present throughout the 

distribution system.

MDEQ approved the City’s 

updated Revised Total 

Coliform Rule sampling plan 

on 5-14-2018 to include the 

required 25 sampling sites.

58 Ongoing The City shall continue to add 

corrosion inhibitors (e.g., 

orthophosphate booster) at levels 

sufficient to re-optimize corrosion 

control in the distribution system.

Ongoing- The City continues 

to add orthophosphate as a 

corrosion inhibitor with 3.1 

mg/L orthophosphate WQP 

requirement. There was an 

LCR violation and public 

notice triggered in January 

2017. Orthophosphate data 

kept current on the State’s 

website. Ongoing corrosion 

control studies will further 

inform the City on corrosion 

control treatment. 

59 2/4/16 To address optimization of 

corrosion control for the system as 

operated with its current water 

source, within 14 days of the 

effective date of this Order the 

Respondents shall submit to MDEQ 

and post in accordance with 

Paragraph 51:
18-P-0221 42

a. Submit a plan and schedule to the 

MDEQ to review and revise as 

needed designated optimal 

corrosion control and water quality 

parameters as well as monitoring 

plans for LCR compliance and all 

other monitoring plans developed to 

ensure that the treatment plant is 

consistently and reliably meeting 

plant performance criteria and all 

other NPDWRs;

Ongoing - WQPs were 

submitted, but EPA continues 

to work with the Respondents 

to ensure that all the 

requirements of paragraph 59 

are fully met. EPA is 

currently working with the 

Respondents to ensure that an 

LCR Compliance Plan is in 

place before the City takes 

over LCR compliance 

monitoring from MDEQ.

b. Submit a sampling plan for daily 

monitoring of water quality 

parameters in the distribution 

system with results compiled in a 

weekly report in an approved 

format; and

Ongoing – WQP monitoring 

is being conducted by the 

City, but EPA continues to 

work with the Respondents 

on the development of a 

formal monitoring plan. The 

City is in the process of 

developing this plan.

c. Submit an operations plan for the 

corrosion control equipment 

(storage day tanks, feed/injection 

systems), with results compiled in a 

weekly format, that includes 

monitoring, calibration, verification 

(pump catch, etc.) as well as daily 

monitoring of finished water 

corrosion control parameters. 

Results shall be submitted and 

posted weekly.

Ongoing – The corrosion 

control equipment plan 

initially submitted was 

inadequate. EPA, MDEQ, 

and the City continue to 

discuss how to finalize this 

plan. The City's contractor 

continues to work on related 

Standard Operating 

Procedures (SOP). 
18-P-0221 43

60 Ongoing Respondents shall not effectuate a 

transition to a new water source for 

the City's PWS (e.g., from KWA) 

until such time as they have 

submitted a written plan, developed 

through consultation with 

appropriate experts and after 

providing adequate advanced notice 

and an opportunity for public 

comment, to MDEQ and in 

accordance with Paragraph 51, 

demonstrating that the City has the 

technical, managerial and financial 

capacity to operate its PWS in 

compliance with SDWA and the 

NPDWRs and that necessary 

infrastructure upgrades, analysis, 

and testing have been completed to 

ensure a safe transition. Such plans 

shall include, but not be limited to, 

provisions addressing:

Revised in the First 

Amendment to the 

Emergency Order issued on 

November 17, 2016

The City has agreed to a 30-

year long-term water source, 

blend of Great Lakes Water 

Authority (GLWA)/ Genesee 

County Drainage 

Commissioner (GCDC)

water agreement.

See section 60 in the 

Amendment below for 

details. 

a. The impacts on corrosion control 

for any new source water and an 

operations plan for periodic use of 

existing sources of water;

b. Completion of corrosion control 

study for any new sources;

c. Implementation of a 

"performance period" that allows 

for the demonstration of the 

adequacy of treatment of the new 

water source to meet all NPDWRs 

before it can be distributed to 

residents; and

d. The City's technical, managerial 

and financial capacity to meet 

SDWA 's applicable requirements, 

including the NPDWRs, during and 

after the transition to any new water 

source.
18-P-0221 44

Treatment and Distribution System Management

61. 2/5/16 Within 15 days of the effective date 

of this Order, the City must 

demonstrate, and the MDEQ and 

State must ensure, the City has the 

necessary, capable and qualified 

personnel required to perform the 

duties and obligations required to 

ensure the PWS complies with the 

SDWA and the NPDWRs.

Ongoing –Hiring additional Public 

Water System staff remains a 

challenge for the City of Flint because 

of fiscal limitations. The City now 

meets operator-in-charge, laboratory 

supervisor, and technician needs 

through the use of a contractor. Two 

current staff from the water treatment 

plant are scheduled to take the 

Operator Certification exam in May 

2018. EPA continues to request hiring 

updates during its monthly meetings 

with the Respondents to ensure that 

the plant is properly staffed.

62. 2/21/16 To ensure the City's PWS is 

adequately operated to meet SDWA 

and all NPDWRs, within 30 days of 

the effective date of this Order, the 

Respondents shall submit the steps 

they will take to develop and 

implement a distribution system 

water quality optimization plan to 

MDEQ and in accordance with 

Paragraph 51, to evaluate and 

improve its programs that affect 

distribution system water quality, 

including: evaluating conditions 

within the distribution system; 

creating better documentation; and 

enhancing communication between 

the various utility functions that 

impact distribution system water 

quality. The MDEQ must ensure that 

this plan is adequate to ensure 

SDWA compliance and the State 

must ensure it is executed.

Ongoing— An inadequate plan was 

submitted in 2016. The City’s 

contractor recently updated the 

distribution system optimization plan, 

and this document is expected to be 

finalized soon. Ongoing work on SOP 

development continues. 
18-P-0221 45

Independent Advisory Panel (“IAP”)

63. 1/28/16 Within seven days of the effective 

date of this Order, the MDEQ and 

State, with the City's input and 

concurrence, shall engage a panel of 

independent, nationally recognized 

experts on drinking water treatment, 

sampling, distribution system 

operation, and members of the 

affected community to advise and 

make public recommendations to the 

City on steps needed to mitigate the 

imminent and substantial 

endangerment to the health of 

persons and general operation of the 

City's PWS to ensure compliance 

with SDWA and the NPDWRs.

Panel was engaged and is known as 

the Flint Water Interagency 

Coordination Committee (FWICC). 

However, no public recommendations 

have been made. NOTE: Frequency of 

meetings reduced from monthly to 

every other month. Only one meeting 

has occurred in 2018. 

64. Ongoing The charge to the IAP will include 

the following:

a. Make recommendations to the 

Respondents, and for consideration 

by the EPA, to ensure the safe 

operation of the City's PWS.

Ongoing

See Michigan governor's website. One 

resolution was passed, but was not a 

recommendation. It was to extend the 

declaration of the Flint Water 

Emergency. However, MDEQ 

frequently refers to "FWICC 

Recommendations" and then says they 

are not "official." No 

recommendations have been made for 

consideration by EPA.

b. Make other recommendations to 

the Respondents, and for 

consideration by the EPA, to better 

serve the community served by the 

City's PWS.

See above

* Stated as within number of days since the effective date of this order—January 21, 2016.

Note: For current status and details, see the MDEQ’s Taking Action on Flint webpage.
18-P-0221 46

First Amendment to Emergency Administrative Order, November 17, 2016

Issued by Region 5, the First Amendment to Emergency Order clarifies what is expected from 

the state of Michigan, the MDEQ and the city of Flint. The amendment is intended to provide 

flexibility for respondents to develop their own plan while creating accountability to provide safe 

and reliable drinking water. The amendment also was designed to restore public confidence.

Required Actions Due Date Status

Paragraph 60 in the January 21, 2016, Order Shall 

Now Read:

a. Confirmation of Water Sources

The City shall confirm in writing to EPA its intended 

new water source and emergency back-up water 

source within five days of the effective date of the 

First Amendment. Nothing in this First Amendment 

prevents the City from identifying a different new 

water source. The City must notify EPA in writing 

within five days if there are any changes in its initial, 

or any subsequent, new water source designation.

11/22/2016

Extension granted 

to 12/1/2016

Completed- On

11/30/2016.

Initial notification 

of recommended 

source change 

received from 

Mayor on 4/19/2017 

– staying on GLWA 

and using GCDCtreated KWA water 

as emergency backup. The City 

Council entered into 

a long-term water 

supply contract with 

GLWA on 

11/21/2017.

b. Development and Implementation for New Water 

Source Treatment

i. Pipeline Plan

It is necessary to complete the KWA pipeline 

connection to the Flint water treatment plant ("WTP"). 

Respondents shall submit to MDEQ for its review and 

approval, to EPA for its review, and post to the public 

website under Paragraph 51, a written plan for

completing the KWA pipeline connection to the Flint 

WTP ("Pipeline Plan"), within twenty-one days of the 

effective date of this First Amendment. The Pipeline 

Plan shall specify dates for major milestones, 

including at a minimum, the following:

A. Complete engineering drawings;

B. Submit permit applications and receive approvals;

C. Request contract bidding and award; and

D. Develop construction time table, including final 

completion date.

12/8/2016 This requirement 

is no longer 

applicable due to 

the City choosing 

to continue to rely 

on GLWA as its 

primary water 

source. However, 

the City still needs 

to complete the 

pipeline to 

connect to its 

backup source, 

GCDC. 
18-P-0221 47

Upon MDEQ's written approval of the Pipeline Plan, 

Respondents shall implement the Pipeline Plan, which 

must provide for pipeline completion and operation at 

least three months before the planned distribution date 

from any new water source.

ii. Water Treatment Plant Modification Plan 

("WTPMP")

Respondents shall submit to MDEQ for its review and 

approval, to EPA for its review, and post to the public 

website under Paragraph 51, by February 1, 2017, a 

written WTPMP that provides a preliminary 

evaluation for Flint's treatment of its identified new 

source water. The WTPMP shall include:

A. An assessment of the treatment processes for the 

new source water;

B. Identification of necessary Flint WTP infrastructure 

improvements, including the assessment of associated 

operation and maintenance needs; and

C. A schedule with completion dates for major 

milestones, including, at a minimum, the following:

(1) identifying, securing and utilizing funding 

source(s) and (2) implementing the necessary 

infrastructure upgrades and other identified 

improvements. Upon MDEQ's written approval of the 

WTPMP, Respondents shall implement the WTPMP.

2/1/2017 Submitted- On 

3/1/2018 the City 

of Flint submitted 

the Water 

Treatment Plant 

Modification Plan 

to EPA and 

MDEQ. The 

document is 

currently under 

review.

iii. New Source Treatment Plan ("NSTP")

Respondents shall submit to MDEQ for its review and 

approval, to EPA for its review, and post to the public 

website under Paragraph 51, as soon as available and 

no later than the dates set forth below, a written plan 

to treat the new source water. The NSTP shall address 

the City's technical, managerial, and financial capacity 

to operate its PWS in compliance with the SDWA and 

NPDWRs, including requirements for optimal 

corrosion control treatment and water quality 

parameter monitoring. The NSTP shall be developed 

in consultation with appropriate experts and the public 

through adequate advanced notice and

opportunity for comment. Prior to submittal of the 

NSTP, Respondents shall develop a corrosion control 

study for the new source water and submit the study to 

MDEQ for its review and approval, and to EPA for its 

review, by February I, 2017. The NSTP shall be 

submitted by March 1, 2017, and shall specify a 

schedule with completion dates for major milestones, 

including, at a minimum, the following:

A. Finalizing necessary standard operating procedures 

("SOPs") for each aspect of the water treatment 

process for the Flint WTP;

2/1/2017 In Progress- The 

City completed a 

"coupon study" 

(not requested or 

required by EPA) 

on 11-20-2017 to 

further inform the 

pipe loop 

corrosion control 

study (required by 

EPA). The City is 

currently 

conducting Phase 

1 of the pipe loop 

study for the 

current GLWA 

primary source, 

despite the TST 

urging the City to 

bypass Phase 1 

and go directly to 

Phase 2. The City 

will also conduct 
18-P-0221 48

B. Implementing infrastructure upgrades that were 

identified under the WTPMP;

C. Conducting a corrosion control study for the new 

source water, including the analysis and testing of the 

impacts on corrosion control treatment under various 

circumstances to ensure a safe transition;

and

D. Developing and implementing a "performance 

period," which shall begin after the completion of the 

KWA pipeline connection to the Flint WTP, addressed 

in Paragraph 60(b)(i), and after the completion and 

implementation of all applicable requirements in 

Paragraph 60(b)(ii) and (iii). The performance period 

shall last as long as necessary, but no less than three 

months, to allow for the demonstration of the 

adequacy of treatment of the new water source to meet 

all SDWA and NPDWRs before it can be distributed 

to consumers.

Upon MDEQ's written approval of the NSTP, 

Respondents shall implement the NSTP. After 

completion of the approved NSTP, and at least five 

days before the proposed distribution of the new 

source water, Respondents shall: (1) certify in 

accordance with Paragraph 60(c)(iv) that all elements 

of the NSTP have been implemented and (2) notify the 

public in accordance with Paragraph 51.

Phase 2 of the 

pipe loop study, 

but has suggested 

it focus only on 

the premise 

plumbing and not 

lead service lines, 

and will not 

consist of the final 

source water blend 

of GLWA and 

GCDC. EPA 

continues to 

discuss how to 

move forward and 

complete this 

study with 

Respondents. 

Unable to be 

completed until 

Flint has an 

approved New 

Source Treatment 

Plan that it is 

implementing and 

until Flint has 

been approved to 

start distribution 

of new source 

water. Flint is 

currently working 

on its New Source 

Treatment Plan 

and will not be 

ready to distribute 

new source water 

until late 2019 at 

the earliest.

iv. Use of the Current Water Source

Respondents must continue to use the current GLWA 

source to provide drinking water to the City until the 

City has demonstrated that all requirements of 

Paragraph 60 are met and EPA has concurred. 

Respondents shall provide documentation to EPA, and 

make publicly available under Paragraph 51, within 

thirty days of the effective date of the First 

12/17/2016 Completed- An 

extension of

several months

was requested by 

Mayor Weaver on 

12/16/2016. On 

11/30/2017, EPA 
18-P-0221 49

Amendment, that Respondents have made 

arrangements to have continued access to its current 

GLWA source water until its transition to a new 

source water is complete.

received the City’s 

signed Master 

Agreement for the 

30-year GLWA 

contract with the 

State, GLWA, 

KWA, and GCDC 

as other parties to 

the agreement.

c. Reporting and Notification Requirements

i.Respondents shall provide monthly updates 

regarding schedules and milestones, including amount 

of funds committed, by whom, and when funds will be 

available for disbursement under Paragraph 60, on the 

1st day of each month on the public website under 

Paragraph 51. Respondents shall continue to report 

monthly until all necessary requirements of Paragraph 

60 are met.

By the first of 

each month

Ongoing- All 

reports due thus 

far have been 

completed and 

respondents 

continue to 

compile and 

submit reports for 

future monthly 

updates.

ii. If any event occurs, or has occurred, that may delay 

Respondents' ability to meet any schedule or milestone 

in Paragraph 60, Respondents shall notify EPA of that 

event within five days. If Respondents anticipate any 

reason they may be delayed in meeting any schedule 

or milestone in Paragraph 60, Respondents shall notify 

EPA within five days of the date they become aware 

of that reason for delay. 

Within 10 days of providing such notice to EPA 

regarding a delay in meeting schedules or milestones, 

Respondents shall provide contingency plans to 

address each delay to MDEQ for its review and 

approval and to EPA for its review.

Within 5 days 

of Respondent 

becoming 

aware of delay

Within 10 days 

of notifying 

EPA of delay

Ongoing

iii. If at any point the City decides to change its water 

source specified under Paragraph 60(a), the City shall 

notify EPA in writing within five days of such 

decision. All provisions of Paragraph 60 will apply to 

any change in water source.

Within 5 days 

of a decision to 

change Flint’s 

water source

Ongoing -

Currently the City 

has agreed to a 30-

year, long-term 

GLWA/GCDC 

agreement. 

iv. Respondents shall provide to EPA a written 

certification, as specified under Paragraph 67 of the 

Order, each time a plan, schedule, or milestone 

required under Paragraph 60 is fully implemented, 

until EPA has concurred that all requirements under 

Paragraph 60 have been fully implemented.

Each time a 

plan, schedule, 

or milestone 

under this 

paragraph is 

implemented

Ongoing
18-P-0221 50

Appendix C

Agency Comments and OIG Evaluation

May 30, 2018

MEMORANDUM

SUBJECT: Response to the April 13, 2018, Office of Inspector General’s Draft Report,

“Management Weaknesses Delayed Response to Flint Water Crisis” 

FROM: Susan Parker Bodine, Assistant Administrator

Office of Enforcement and Compliance Assurance

David P. Ross, Assistant Administrator 

Office of Water

Cathy Stepp, Regional Administrator 

Region 5

TO: Kevin L. Christensen, Assistant Inspector General

Office of Audit and Evaluation

Thank you for the opportunity to respond to the issues and recommendations presented in the 

Office of Inspector General (OIG) Draft Report (Project No. OPE-FY16-0031) regarding the 

response to the Flint water crisis. We also appreciate the additional time you provided us, so the 

Office of Enforcement and Compliance Assurance (OECA), the Office of Water (OW) and 

Region 5 could review OIG’s April 13, 2018, Draft Report and provide this joint response. 

OECA, OW and Region 5 agree with all of OIG’s recommendations and have already begun 

undertaking steps consistent with these recommendations. Below we provide our planned 

corrective actions and projected completion dates. Further, we have included as an attachment an 

update regarding the status of the Safe Drinking Water Act (SDWA) emergency order EPA 

issued in the Flint, Michigan, case (Attachment 1).

A critical part of EPA’s core mission is to protect public health and ensure the safety of our 

nation’s drinking water. We appreciate OIG’s efforts to bring attention to these important issues. 

The Agency is working actively to improve SDWA compliance and help safeguard human 

health. 

AGENCY’S RESPONSE TO REPORT RECOMMENDATIONS

OECA, OW and Region 5 appreciated the opportunity to ask clarifying questions regarding the 

recommendations during our May 7, 2018 teleconference. The Report makes nine 

recommendations. As explained during the teleconference, OECA, OW and Region 5 concur 

with these recommendations and will work expeditiously to implement them. 
18-P-0221 51

Recommendation No. 1 

OIG recommends OECA and OW establish controls to annually verify that states are monitoring 

compliance with all LCR requirements, including accurately identifying tier 1 sampling sites and 

maintaining continuous corrosion control.

OECA and OW concur with this recommendation. OW has recently developed a standardized 

Annual Program Review template for the Public Water System Supervision (PWSS) program. 

This management review is conducted by the Regions for each State and covers required 

elements, including rule implementation. Within this section, specific LCR implementation 

metrics can be, and often are, discussed. This Annual Program Review template is being 

implemented in FY 2018, and OW will continue to adjust for future reviews to potentially 

include requiring an LCR implementation discussion in all future reports. In addition, EPA also 

conducts file reviews, which are data audits of the State’s program files, approximately every 

three to five years. During a file review, EPA evaluates state implementation of LCR 

requirements, including tier 1 sampling sites and corrosion control. For compliance monitoring 

and enforcement programs, OECA will continue to explore options for creating a national 

oversight approach for the drinking water programs and present recommendations to its senior 

managers by June 2019.

Supplemental EPA Response and OIG Disposition of Corrective Actions:

The EPA provided supplemental information in a June 5, 2018, meeting with the OIG. In that 

meeting, and in subsequent correspondence on June 13, 2018, OECA and the OW revised the 

response herein to state that they agree on the value of national oversight for compliance 

monitoring and enforcement of the Drinking Water Program, but added that it is vital that they 

evaluate and develop it in a collaborative manner with their state partners. The offices plan to 

work with the states to develop an approach or a pilot for implementing a national compliance 

monitoring and enforcement oversight program for the Drinking Water Program, as 

appropriate, by June 2019. The OIG did not accept this response as meeting the intent of the 

recommendation, which asked that OECA and the OW establish annual controls. We do not 

agree that developing a pilot or approach constitutes establishing annual controls, per the 

recommendation language. Recommendation 1 is unresolved.

Recommendation No. 2

OIG recommends OW include in the revised LCR the most protective protocol for monitoring 

and corrosion control.

OW concurs with this recommendation regarding the importance of proper implementation of 

the protocol for monitoring and corrosion control, and we continue to work on the long-term 

revisions to the existing LCR. Most recently, OW engaged stakeholders as part of a federalism 

consultation. The Agency is evaluating input we received from our state, local and tribal partners 
18-P-0221 52

as well as the best available peer-reviewed science to ensure the Rule reflects the best ways to 

improve public health protection.

Supplemental EPA Response and OIG Disposition of Corrective Actions:

During a June 5, 2018, meeting, the OIG agreed to revise this recommendation. The revised 

recommendation reads as follows: 

We recommend that the Assistant Administrator for Water:

2. Revise the Lead and Copper Rule to improve the effectiveness of monitoring and corrosion 

control treatment protocols.

This revision takes into account information the EPA must consider in developing the revised Lead 

and Copper Rule. Based on the revision, the OIG accepted this response from the EPA as meeting the 

intent of Recommendation 2. The recommendation is resolved pending completion of corrective 

actions. 

Recommendation No. 3 

OIG recommends Region 5 publicly document clear expectations, roles and responsibilities 

between the EPA and the state of Michigan in an official document, such as a memorandum of 

understanding or a supplemental primacy document. 

Region 5 concurs with this recommendation. To implement this recommendation, the Region 

will document clear expectations, roles and responsibilities between the EPA and Michigan in 

the annual workplan for the PWSS program grant. To implement this recommendation, Region 5 

will post the annual Michigan PWSS program workplan and end of year evaluation on EPA’s 

website so that the information is publicly available.

The PWSS grant workplan covers work conducted as part of SDWA primacy/regulatory 

requirements, voluntary program efforts and EPA/State work sharing. It also includes 

commitments as well as additional expectations in the form of specific targets and measures, 

including both national and Regional measures. These extensive performance measures provide 

additional expectations of the State and assist the Region in evaluating the State’s performance. 

The new PWSS program workplan for FY 2019 provides an overall summary that identifies 

state-specific priorities and core program descriptions that serves as a brief overview for senior 

management. The workplan also provides separate files with the program-specific summaries 

that have more detail for staff and mid-level management, such as rules/primacy, data 

management and reporting, enforcement and compliance assistance, laboratory certification and 

sanitary surveys. 
18-P-0221 53

Supplemental EPA Response and OIG Disposition of Corrective Actions:

The EPA provided supplemental information during a June 5, 2018, meeting with the OIG. In that 

meeting, EPA Region 5 said it will develop a clarified statement of roles and responsibilities. The 

region will document clear roles and responsibilities in the annual PWSS work plans. Based on the 

revisions, the OIG accepted this response as meeting the intent of Recommendation 3. The 

recommendation is resolved pending completion of corrective actions. 

Recommendation No. 4

OIG recommends Region 5 implement a system for regional drinking water staff, managers and 

senior leaders, which incentivizes staff elevating and management addressing important and 

emerging issues in accordance with EPA’s Policy on Elevation of Critical Environmental and 

Public Health Issues. 

Region 5 concurs with this recommendation and has worked to foster an environment where 

management encourages issue elevation and staff have opportunities to elevate issues of concern 

to management, especially when there appears to be a substantial threat to public health. On 

August 15, 2017, Administrator Pruitt reaffirmed to all staff the importance of elevating critical 

environmental and public health issues so that EPA can properly assess them and respond at 

appropriate policy and governmental levels in a timely and effective manner.

Within Region 5, staff are encouraged to participate and share concerns in a variety of meetings 

including team, section, branch, division, and regional meetings. These regular check-in 

meetings among managers and staff allow for information to flow from regional leaders down to 

staff and vice versa. Region 5 agrees to explore ways to incentivize staff to elevate issues of 

concern during these engagement opportunities including providing feedback during mid-year 

and end-of-year reviews with staff, specifically on the customer service critical element present 

in all staff PARS agreements.

In addition to discussion during performance reviews, supervisors have the following award 

mechanisms available to recognize staff efforts: Agency’s annual awards process recognizing 

key accomplishments, time-off awards, and monetary awards. Region 5 will further explore 

ways to incentivize staff and management to elevate and address important and emerging issues, 

such as a peer-to-peer recognition system.

Supplemental EPA Response and OIG Disposition of Corrective Actions:

The EPA provided supplemental information during a June 5, 2018, meeting with the OIG. In that 

meeting, Region 5 said it will incentivize staff, managers and senior leaders to elevate issues of 

concern. Region 5 also clarified that it will provide feedback during midyear and end-of-year reviews 

with staff, managers and senior leaders, and that it will identify ways to further incentivize staff, 

managers and senior leaders to elevate and address issues. Based on the revisions, the OIG accepted 
18-P-0221 54

this response as meeting the intent of Recommendation 4. The recommendation is resolved pending 

completion of corrective actions. 

Recommendation No. 5

OIG recommends Region 5 provide the public with all results from EPA reviews of Michigan’s 

Safe Drinking Water Act program, and track the progress of identified corrective actions. 

Region 5 concurs with this recommendation and has already made information publicly 

available. The 2010 and 2016 Michigan Drinking Water Program Review Reports are currently 

available on EPA’s website (https://www.epa.gov/mi). In addition, Region 5’s FY 2010 – 2016 

End-of-Year Evaluation Reports for the State of Michigan’s PWSS Program are available to the 

public through FOIA on-line 

(https://foiaonline.regulations.gov/foia/action/public/view/request?objectId=090004d281731e1c)

. 

Region 5 ensures that issues found in previous data and enforcement program reviews of the 

State’s PWSS implementation are included in the following year’s annual PWSS program 

workplan and tracked for progress. Region 5 and MDEQ are finalizing a Corrective Action Plan 

that has been developed from the recommendations in the 2016 Program Review Report, which 

Region 5 released in October 2017 (https://www.epa.gov/mi/2016-michigan-drinking-waterprogram-review). Once final and approved by Region 5, Region 5 will post the Corrective 

Action Plan to the Agency’s website and provide progress updates on a quarterly basis. In 

addition, the Michigan Corrective Action Plan will be attached to the FY 2018 and subsequent 

PWSS grant workplans so that both State and EPA commitments are clear. Frequent check-ins 

with the State are planned to ensure progress in implementing EPA’s recommendations to 

strengthen Michigan’s drinking water program. 

Beginning with the FY 2019 PWSS grant, the Region 5 Water Division Director will document 

that EPA recognizes those primacy activities that Region 5 States are not fully implementing and 

will require the States to provide both short-term and long-term plans for implementing these 

activities. 

OIG Disposition of Corrective Actions:

The OIG accepted this response from the EPA as meeting the intent of Recommendation 5. The 

recommendation is resolved pending completion of corrective actions. 
18-P-0221 55

Recommendation No. 6

OIG recommends OECA provide regular training for EPA drinking water staff, managers and 

senior leaders on SDWA tools and authorities; state and agency roles and responsibilities; and 

any SDWA amendments or LCR revisions.

As noted during our May 7, 2018 teleconference with OIG, OECA and OW share responsibility 

for such trainings and plan to work together to implement this recommendation. Accordingly, 

they asked that this recommendation be addressed to both OECA and OW. OECA and OW have 

provided national SDWA training covering a range of topics, including statutory authorities, 

such as SDWA Section 1431 and Section 1414, and LCR requirements. OECA and OW commit 

to expanding their training for states, regions and Headquarters on these SDWA issues.

As part of ongoing Agency efforts to enhance national implementation of the LCR, EPA has 

been providing training on the Rule’s optimal corrosion control treatment and optimal water 

quality parameter requirements. The workshops provide a review of LCR requirements and 

emphasize the tools and authorities drinking water programs can leverage to implement the 

requirements more effectively. The training has been delivered through in-person workshops at 

each of the EPA Regions, as well as through special conference sessions. Since the inaugural 

workshop in FY 2016, the training has reached approximately 1,300 drinking water professionals 

(staff and managerial level) from federal and state drinking water programs, technical assistance 

providers and water utilities.

Supplemental EPA Response and OIG Disposition of Corrective Actions:

The EPA provided supplemental information during a June 5, 2018, meeting with the OIG. In that 

meeting, OECA and the OW clarified that the training described will also be provided to senior 

leaders. Based on the revisions, and subsequent correspondence on June 12, 2018, the OIG accepted 

this response as meeting the intent of Recommendation 6. The recommendation is resolved pending 

completion of corrective actions. 

Recommendation No. 7

OIG recommends OW implement a system to identify management risks in state drinking water 

programs, including elements such as atypical events, emerging public health concerns, 

environmental justice concerns and public health analysis.

OW concurs with this recommendation. EPA has initiated a workgroup with participation from 

OECA, OW and the Regions. The workgroup will explore how best to use drinking water data 

and measures to identify public water systems that present or are likely to present a significant 

risk to public health. The workgroup will develop procedures and strategies to ensure timely and 

effective intervention where risks to public health are identified. Initial findings and the 

workgroup’s proposed framework for action are expected by the end of December 2018. 
18-P-0221 56

OIG Disposition of Corrective Actions:

The OIG accepted this response from the EPA as meeting the intent of Recommendation 7. The 

recommendation is resolved pending completion of corrective actions. 

Recommendation No. 8

OIG recommends OW create a system that tracks citizen complaints and gathers information on 

emerging issues. The system should assess the risk associated with the complaints, including 

efficient and effective resolution.

As explained during our May 7, 2018 teleconference with OIG, OECA and OW also plan to 

work together to implement recommendation no. 8 and, thus, we ask the OIG to address this 

recommendation to both offices. OECA and OW are exploring ways to adapt or leverage 

existing tools. For example, OECA currently supports a public, online Report a Violation (RAV) 

tool (https://echo.epa.gov/report-environmental-violations) that collects general information 

about violations. That tool is currently not specific to drinking water data, but it has been used to 

receive descriptions of potential SDWA violations. EPA may explore possible revisions that 

would capture more precise contaminant information if reporting capabilities within SDWA, 

SDWIS Prime, or STORET data systems cannot be modified to receive citizen drinking water 

contamination data. EPA could use the RAV as the foundation of an improved system that 

captures citizen reports and sorts them into ranked categories to facilitate identification of 

management risks that require EPA response. 

OIG Disposition of Corrective Actions:

The OIG accepted this response from the EPA as meeting the intent of Recommendation 8. The 

recommendation is resolved pending completion of corrective actions. 

Recommendation No. 9

OIG recommends OECA and OW improve oversight by establishing a clear and credible 

escalation policy for EPA intervention in states. The policy should provide steps the EPA will 

take when states do not act. 

OECA and OW concur with this recommendation. On August 15, 2017, Administrator Pruitt 

reaffirmed EPA’s Policy on Elevation of Critical Environmental and Public Health Issues. The 

Administrator directed EPA staff to elevate concerns quickly and directed the Regions to inform 

headquarters of any issues that are elevated under this policy.

OECA is providing training on the use of SDWA Section 1431 authority. In implementing the 

recommendation from the OIG’s SDWA Section 1431 Management Alert in October 2016 for 
18-P-0221 57

OECA to update the 1991 SDWA Section 1431 guidance, over the past year, OECA worked 

with several Regions, OW and OGC to develop updates to the guidance. OECA is also 

conducting trainings on Section 1431 and the updated guidance.

OECA is currently considering the possibility of a national initiative to promote improved 

drinking water compliance. EPA has initiated a workgroup with participation from OECA, OW 

and the Regions. The workgroup will explore how best to use drinking water data and measures 

to identify public water systems that present or are likely to present a significant risk to public 

health. The workgroup will develop procedures and strategies to ensure timely and effective EPA 

intervention where a state’s response to the risk is insufficient to protect the public’s health. 

OECA will seek state input on whether to create a new national initiative to improve drinking 

water compliance starting in June 2018, and then will seek public comment in November 2018. 

OECA expects to make a decision after this engagement process by July 2019.

OIG Disposition of Corrective Actions:

The OIG accepted this response from the EPA as meeting the intent of Recommendation 9. The 

recommendation is resolved pending completion of corrective actions. 

CLARIFYING INFORMATION REGARDING REPORT FINDINGS

EPA appreciates the opportunity to provide some clarifications to inform the Report’s findings. 

EPA has included clarifications below, and Attachment 2 includes a more detailed itemization of 

clarifications and desired corrections.

First, EPA has identified instances where the Report’s simplifications or generalizations result in 

statements that are factually incorrect or otherwise inconsistent with the Lead and Copper Rule’s 

(LCR or Rule) requirements. EPA recognizes and appreciates that OIG’s Draft Report aims to 

simplify and summarize the LCR’s requirements and acknowledges that the Report’s findings 

about the LCR provide important information on EPA’s implementation of the Rule.

Second, we want to highlight EPA’s concerns about the Draft Report’s detailed timeline of 

events; we think additional information needs to be included for it to be complete and accurate. 

This timeline, which involves several different government agencies and several EPA offices, is 

important in understanding the findings and recommendations in the Draft Report. We believe 

that the additional information provided will allow for a more accurate timeline.

The major clarifications that EPA would like to provide on OIG’s Draft Report are as follows:

1. The Report’s use of generalized terminology such as “maintaining corrosion control,”

without including the term “treatment,” adds ambiguity to the audit’s findings by 

implying Flint was or could have complied with the LCR without installing treatment, 

which is factually inaccurate. There are two intentionally distinct terms used in the LCR 

regarding corrosion control; these are “corrosion control” and “corrosion control 
18-P-0221 58

treatment.” The LCR provides that systems can be deemed to have optimized corrosion 

control with or without treatment so there is an intentional distinction between 

“optimized corrosion control” and “optimized corrosion control treatment,” which is 

especially important with respect to Flint. The term “corrosion control treatment” should 

be used throughout the Report when referring specifically to the Flint water system. 

OIG Response:

The OIG reviewed our use of these terms, and we made changes to the report as appropriate. 

2. The Draft Report includes several references suggesting a 5 parts per billion (ppb) 

benchmark is used to determine when corrosion control treatment installation is required. 

EPA would like to clarify that all large systems must install corrosion control treatment, 

regardless of their tap sampling results, unless they meet certain criteria identified in 40 

C.F.R. Section 141.81(b).

EPA would also like to clarify that the LCR’s treatment technique requirements (e.g., 

corrosion control treatment installation, lead service line replacement, public education) 

are triggered when 90th percentile concentrations exceed the lead action level of 15 ppb. 

Average concentrations are not used, as currently suggested in the Report.

OIG Response:

The OIG reviewed our description of the LCR’s use of the PQL, and we made changes to the report to 

clarify the EPA point listed above. 

3. To provide a clear description and timeline of events, additional information is required.

Two areas requiring additional clarity are:

A. Instances in which the Draft Report concludes that EPA had access to timely 

information, when, in fact, EPA believes the state did not provide complete, 

accurate, and timely data to EPA:

o Page 12, 1st paragraph under “Corrosion Control Was Not Maintained”:

“The MDEQ did not require Flint’s public water system staff to 

maintain corrosion control when Flint changed water sources in April 

2014. According to EPA Region 5, the MDEQ concluded that this 

change in source water would classify Flint as a new drinking water 

system.” 
18-P-0221 59

The above sentence conveys that EPA knew of MDEQ’s decision to classify 

Flint as a new water system in 2014; EPA was not aware of this decision until 

2015.

o Page 19, 2nd paragraph under “Region 5 Did Not Have an Effective 

System for Risk Assessment”:

“By compiling and examining these factors, Region 5’s staff and 

managers could have intervened earlier to oversee the drinking water 

source switch and subsequent events. Instead, the federal response 

was delayed while residents continued to be exposed to lead in their 

drinking water.” 

The above paragraph does not accurately characterize the timeline of events. 

The Total Coliform Rule and Disinfectants and Disinfection Byproducts Rule 

maximum contaminant level violations occurred after the source switch. It is 

unclear how violations that occurred after the source switch could have led 

Region 5 to oversee something that had already happened (the source switch).

o Page 24, 1st paragraph:

“Although this is true, regional staff knew of the source switch soon 

after it happened.” 

This sentence overlooks the fact that the LCR was specifically amended to 

require advanced notification of long-term source and treatment changes to 

the State, and to require the State to review and approve of these changes, not 

EPA. Region 5 did not learn of the lack of corrosion control treatment 

maintenance until a year later, on April 24, 2015, when the State 

communicated that Flint did not have corrosion control treatment.

OIG Response:

The OIG included additional text on page 28 noting that Region 5 did not know about the MDEQ 

misclassification until 2015. The OIG did not make substantial changes to the discussion of risk 

assessment. The objective for this discussion is to note that information from various sources came to 

Region 5 over a period of time—both before Flint changed drinking water sources and after the 

change occurred. As information about risks mounted over time, Region 5 may not have known that 

lead contamination existed, but it could have identified Flint as a system with a high level of risk. This

could have enabled the region to focus additional attention, questions, assistance, inspections and, 

where appropriate, enforcement resources on Flint and the MDEQ to forestall a potential drinking 

water incident like the one that occurred in Flint. 
18-P-0221 60

B. Key activities that Region 5 completed between May 2014 and January 2016 to 

respond to citizen complaints are not clearly described in the Report. These 

actions are crucial to understanding how EPA responded to the scope of the 

recognized risks to public health.

o Page 30, February 25, 2015 - Requested insert for timeline: “EPA assigns 

Dr. Michael Wright, an EPA disinfection by-products expert, to participate on 

Flint’s Technical Advisory Committee.”

o Page 31, April 25, 2015 - Requested insert for timeline: “Region 5 staff 

notifies MDEQ staff that CCT should have been maintained with the source 

switch. Moreover, even with MDEQ’s incorrect interpretation of the LCR, the 

July-Dec 2014 LCR compliance results of 6 ppb would have triggered the 

need for CCT since the 90th percentile was above the threshold in 40 C.F.R. 

Section 141.81(b)(3).”

o Page 31, April 27, 2015 – Requested addition to timeline: “Region 5 

scientists meet with [resident]and provide sampling bottles for her to take 

water samples for lead in her home.” 

o Page 31, April 29, 2015 – Requested addition to timeline: “Region 5 meets 

with and informs the MDEQ of the Region’s interpretation of the LCR and 

that Flint should have been doing corrosion control treatment since the source 

switch.”

OIG Response:

The OIG included additional timeline events where the EPA was able to provide documentation. 

4. The Draft Report highlights events that, from OIG’s perspective, indicated an impending

lead crisis in Flint. However, for the following reasons, at the time the events occurred, 

while they indicated problems, they were not clear indications of a lead crisis:

• Bacteriological contamination in public water systems is common in the summer 

months.

• Disinfection by-product levels are typically highest in the summer months and 

exceedances may occur due to higher water temperatures and increased chlorine 

levels used in the summer months.

• The residence with the high lead levels in early 2015 was an atypical situation (i.e., 

not indicative of other homes in the City). The home had an unusually long service 

line and the service line was physically disturbed in two places. Consequently, 

although this situation posed an obvious risk to the residents at that home, the high 

lead levels at that home did not indicate a system-wide concern, especially given that 

the Michigan Department of Environmental Quality (MDEQ) had indicated that the 
18-P-0221 61

system had corrosion control treatment in place at that time. It was not until April 

2015 that EPA learned from MDEQ that Flint did not have corrosion control 

treatment in place.

• The LCR’s 90th percentile compliance standard allows for 10% of homes to exceed 

the action level of 15 ppb. The City’s 90th percentile values were at 6 ppb (December 

2014) and 11 ppb (June 2015). It was not until September 2015 that EPA learned the 

City was not sampling at the required tier 1 (highest risk) sites for LCR compliance 

monitoring.

OIG Response:

The OIG’s discussion on risk assessment is intended to describe how information that Region 5 

accrued over time demonstrated a system at risk. In addition to the information in the bullets, the 

region also received citizen complaints, knew that the MDEQ had disinvested from some SDWA 

requirements, and that the city recently changed drinking water sources. As described above, Region 5 

may not have known there was a specific risk of lead contamination, but it could have identified Flint 

as a system with a high level of risk. The region then could have focused additional attention, 

questions, assistance, inspections and, where appropriate, enforcement resources on Flint and the 

MDEQ to forestall a potential drinking water incident like the one that occurred in Flint. 

5. The Draft Report refers to the LCR’s Section 141.81(b)(3) criteria to allow Flint’s system 

to meet the exemption criteria for corrosion control treatment. However, Flint never met 

the criteria in (b)(3). Flint’s public water system was required to have corrosion control 

treatment; it met that requirement by the 1997 deadline through purchasing water from

Detroit treated with orthophosphate. As EPA noted in its 2016 Michigan Drinking Water 

Program Review Report (https://www.epa.gov/mi/2016-michigan-drinking-waterprogram-review), MDEQ did not correctly review and approve Flint’s source/treatment 

change in 2014.

OIG Response:

The OIG made modifications to the description of Flint’s sampling under the LCR’s Section 

141.81(b)(3). 

6. There is an important clarification needed to the timeline section on page 30 of the Draft 

Report. In February 2015, there were three statements in the email provided to Region 5 

by an MDEQ manager that led EPA to believe corrosion control treatment had been 

maintained. MDEQ stated: (1) Flint has an optimal corrosion control program in place; 

(2) Flint is conducting water quality parameter monitoring; and (3) the system is in 

compliance with all treatment technique requirements. These statements, taken together, 

indicated that MDEQ believed that Flint was in compliance with the LCR requirement to 
18-P-0221 62

maintain corrosion control treatment and that the corrosion control treatment was being 

monitored using the required water quality parameter monitoring.

OIG Response:

The OIG’s description on page 20 provides a summary of this point. 

CONTACT INFORMATION

If you have any questions regarding this response, please contact Gwendolyn Spriggs (OECA) at 

(202) 564-2439, Steven Moore (OW) at (202) 564-0992, and Eric Levy (Region 5) at (312) 353-

3611.

Attachments
18-P-0221 63

OIG Report: Management Weaknesses Delayed Response to Flint Water Crisis

Corrective Action Plan (CAP)

Supplemental EPA Response and OIG Disposition of Corrective Actions:

The EPA provided supplemental information on proposed corrective actions during a June 5, 2018, 

meeting with the OIG. Based on the revisions, the OIG accepted EPA responses as meeting the intent 

for eight of the nine recommendations. Eight recommendations are resolved pending completion of 

corrective actions. Recommendation 1 is unresolved.

Recommendation Lead 

Office

CA Target Date Corrective Action

1. Establish controls 

to annually verify that 

the states are 

monitoring 

compliance with all 

Lead and Copper Rule 

requirements, 

including accurately 

identifying tier 1 

sampling sites and 

maintaining 

continuous corrosion 

control.

OECA 

OW

1 PWSS Reviews: 

Beginning in 4th

Quarter FY 2019 

(September 30, 

2019) and then 

ongoing. 

OECA national 

drinking water 

oversight 

approach 

recommendations: 

June 30, 2019. 

EPA will continue to focus additional 

attention on metrics related to LCR 

implementation that can be incorporated 

into the protocol that Regions will use 

when conducting their annual Public 

Water System Supervision program 

reviews. The Annual Program Review 

template is being implemented in the FY 

2018 and will continue to be adjusted for 

future reviews to meet oversight goals. 

For compliance monitoring and 

enforcement programs, OECA will 

continue to explore options for creating a 

national oversight approach for the 

drinking water programs and present 

recommendations to its senior managers 

by June 2019.

Revised Corrective Action:

OECA agrees on the value of national 

oversight for compliance monitoring and

enforcement of the Drinking Water 

program, but it is vital that we evaluate 

and develop it in a collaborative manner 

with our State partners. Accordingly, we 

plan to work with the States to develop 

an approach or a pilot for implementing 

a national compliance monitoring and 

enforcement oversight program for the 
18-P-0221 64

Recommendation Lead 

Office

CA Target Date Corrective Action

drinking water, as appropriate, by June 

2019

2. Include in the 

revised Lead and 

Copper Rule the most 

protective protocols 

for monitoring and 

corrosion control.

Revised 

recommendation:

Revise the Lead and 

Copper Rule to 

improve the 

effectiveness of 

monitoring and 

corrosion control 

protocols.

OW 2 The estimated 

publication 

schedule for 

proposed 

revisions to the 

LCR is February 

28, 2019.

The Agency is evaluating input we 

recently received from our state, local 

and tribal partners as well as the best 

available peer-reviewed science to 

ensure the Rule reflects the best ways to 

improve public health protection.

3. Publicly document 

clear expectations, 

roles and 

responsibilities 

between the EPA and 

the state of Michigan 

in an official 

document, such as a 

memorandum of 

understanding or a 

supplemental primacy 

document.

Region 

5

3 FY 2019 Annual 

Workplan which 

will be posted by 

October 1, 2018.

Region 5 documents clear expectations, 

roles and responsibilities between the 

EPA and each of our states in the annual 

workplan for the Public Water System 

Supervision (PWSS) program grant. To 

implement this recommendation, Region 

5 will post the annual Michigan PWSS 

program workplan and end of year 

evaluation on EPA’s website so that the 

information is publicly available.

Revised Corrective Action:

Region 5 will document clear 

expectations, roles and responsibilities 

between the EPA and each of our states 

in the annual workplan for the Public 

Water System Supervision (PWSS) 

program grant. To implement this 

recommendation, Region 5 will post the 

annual Michigan PWSS program 

workplan and end of year evaluation on 

EPA’s website so that the information is 

publicly available.
18-P-0221 65

Recommendation Lead 

Office

CA Target Date Corrective Action

4. Implement a system 

for regional drinking 

water staff, managers 

and senior leaders, 

which incentivizes 

staff elevating and 

management 

addressing important 

and emerging issues in 

accordance with the 

EPA’s Policy on 

Elevation of Critical 

Environmental and 

Public Health Issues.

Region 

5

4 PARS end-ofyear for FY 2018, 

which must be 

completed by 

October 31, 2018.

Within Region 5, staff are encouraged to 

participate and share concerns in a 

variety of meetings including team, 

section, branch, division, and regional 

meetings. These regular check-in

meetings among managers and staff 

allow for information to flow from 

regional leaders down to staff and vice 

versa. Region 5 agrees to explore ways 

to incentivize staff to elevate issues of 

concern during these engagement 

opportunities, including providing 

feedback during mid-year and end-ofyear reviews with staff, specifically on 

the customer service critical element 

present in all staff PARS agreements. 

Region 5 will further explore ways to 

incentive staff and management 

elevating and addressing important and 

emerging issues including the use of 

current awards, both recognition and 

monetary. 

Revised Corrective Action:

Within Region 5, staff are encouraged to 

participate and share concerns in a 

variety of meetings including team, 

section, branch, division, and regional 

meetings. These regular check-in 

meetings among managers and staff 

allow for information to flow from 

regional leaders down to staff and vice 

versa. Region 5 agrees to incentivize 

staff, managers, and senior leaders to 

elevate and address issues of concern 

during these engagement opportunities, 

including providing feedback during 

mid-year and end-of-year reviews, 

specifically on the customer service 

critical element present in all staff, 

managers, and senior leaders PARS 

agreements. Region 5 will incentive 

staff, management and senior leadership 
18-P-0221 66

Recommendation Lead 

Office

CA Target Date Corrective Action

to elevate and address important and 

emerging issues including the use of 

current awards, both recognition and 

monetary.

5. Provide the public 

with all results from 

EPA reviews of 

Michigan’s Safe 

Drinking Water Act 

program, and track the 

progress of identified 

corrective actions.

Region 

5

5 Will post the 

corrective action 

table by 

September 30, 

2018, and provide 

updates on 

progress by April 

30 and September 

30 [f]or each year 

thereafter.

The 2010 and 2016 Michigan Drinking 

Water Program Review Reports are 

currently available on-line. The FY 

2010-2016 End-of-Year Evaluation 

Reports by Region 5 are available to the 

public through FOIA online. 

Region 5 and MDEQ are finalizing a 

Corrective Action Plan that has been 

developed from the recommendations in 

the 2016 Program Review Report, which 

Region 5 released in October of 2017. 

Once final and approved by Region 5, 

Region 5 will post the corrective action 

to the Agency’s website and provide 

updates on a quarterly basis. In addition, 

the Michigan Corrective Action Plan will 

be attached to the FY 2018 and 

subsequent PWSS grant workplans so 

that both State and EPA commitments 

are clear. Frequent check-ins with the 

State are planned to ensure progress in 

implementing EPA’s recommendations 

to strengthen Michigan’s drinking water 

program.

6. Provide regular 

training for EPA 

drinking water staff, 

managers and leaders 

on Safe Drinking 

Water Act tools and 

authorities; state and 

agency roles and 

responsibilities; and 

any Safe Drinking 

Water Act 

amendments or Lead 

and Copper Rule 

revisions.

OECA

OW

6 State/Regional 

staff LCR 

trainings 

conducted in all 

EPA Regions by 

May 31, 2018; 

SDWA Section 

1431 training 

provided on May 

23, 2018; 

Training efforts 

will be ongoing.

EPA has provided and will continue to 

provide regular training nationally about 

SDWA tools and authorities, like 

Sections 1414 and 1431, and various 

NPDWRs, including LCR. 

As part of ongoing Agency efforts to 

enhance national implementation of the 

LCR, EPA has been providing training 

on the Rule’s optimal corrosion control 

treatment and optimal water quality 

parameter requirements. The workshops 

provide a review of LCR requirements 

and emphasize the tools and authorities 

drinking water programs can leverage to 
18-P-0221 67

Recommendation Lead 

Office

CA Target Date Corrective Action

EPA will 

reevaluate 

training needs by 

September 30, 

2019.

implement the requirements more 

effectively. The training has been 

delivered through in-person workshops 

at each of the EPA Regions, as well as 

through special conference sessions. 

Revised Corrective Action:

EPA has provided and will continue to 

provide regular training nationally to 

staff and managers about SDWA tools 

and authorities, like Sections 1414 and 

1431, and various NPDWRs, including 

LCR. EPA will also make these trainings 

available to senior leaders.

As part of ongoing Agency efforts to 

enhance national implementation of the 

LCR, EPA has been providing training 

on the Rule’s optimal corrosion control 

treatment and optimal water quality 

parameter requirements. The workshops 

provide a review of LCR requirements 

and emphasize the tools and authorities 

drinking water programs can leverage to 

implement the requirements more 

effectively. The training has been 

delivered through in-person workshops 

at each of the EPA Regions, as well as 

through special conference sessions.

7. Implement a system

to identify 

management risks in 

state drinking water 

programs, including 

elements such as 

atypical events, 

emerging public 

health concerns, 

environmental justice 

concerns and public 

health analysis.

OW 7 Initial findings 

and the 

workgroup’s 

proposed 

framework for 

action are 

expected by 

December 31, 

2018.

EPA has initiated a workgroup with 

participation from OECA, OW and the 

Regions. The workgroup will explore 

how best to use drinking water data and 

measures to identify public water 

systems that present or are likely to 

present a significant risk to public health. 

The workgroup will develop procedures 

and strategies to ensure timely and 

effective intervention where risks to 

public health are identified.
18-P-0221 68

Recommendation Lead 

Office

CA Target Date Corrective Action

8. Create a system that 

tracks citizen 

complaints and 

gathers information on 

emerging issues. The 

system should assess 

the risk associated 

with the complaints, 

including efficient and 

effective resolution.

OW

OECA

8 4th Quarter FY 

2019; September 

30, 2019.

Identify potential enhancements to 

existing systems and/or identify new 

system requirements that can support 

tracking of citizen complaints.

9. Improve oversight 

by establishing a clear 

and credible 

escalation policy for 

EPA intervention in 

states. The policy 

should provide steps 

the EPA will take 

when states do not act. 

OECA

OW

9 Training efforts 

will be ongoing.

EPA will 

reevaluate 

training needs by 

September 30, 

2019.

Seek state input: 

June 30, 2018;

Seek public 

comment: 

November 30, 

2018;

Decision on 

policy:

July 31, 2019.

OECA will continue to provide training 

on SDWA authorities, including the use 

of SDWA Section 1431 when state and 

local authorities have not acted to protect 

public health.

EPA has initiated a workgroup with 

participation from OECA, OW and the 

Regions. The workgroup will develop 

procedures and strategies to ensure 

timely and effective EPA intervention 

where a state’s response to the risk is 

insufficient to protect the public’s health.
18-P-0221 69

Appendix D

Distribution

The Administrator 

Deputy Administrator

Special Advisor, Office of the Administrator

Chief of Staff 

Agency Follow-Up Official (the CFO)

Agency Follow-Up Coordinator 

General Counsel 

Assistant Administrator for Enforcement and Compliance Assurance

Assistant Administrator for Water

Regional Administrator, Region 5

Associate Administrator for Congressional and Intergovernmental Relations

Associate Administrator for Public Affairs

Principal Deputy Assistant Administrator for Enforcement and Compliance Assurance

Deputy Assistant Administrator for Enforcement and Compliance Assurance

Deputy Assistant Administrator for Water

Principal Deputy Assistant Administrator for Water

Deputy Regional Administrator, Region 5

Director, Office of Continuous Improvement, Office of the Administrator

Director, Office of Children’s Health Protection, Office of the Administrator

Director, Office of Compliance, Office of Enforcement and Compliance Assurance

Director, Office of Criminal Enforcement, Forensics and Training, Office of Enforcement and 

Compliance Assurance

Director, Office of Ground Water and Drinking Water, Office of Water

Director, Office of Water, Region 5

Audit Follow-Up Coordinator, Office of the Administrator

Audit Follow-Up Coordinator, Office of Enforcement and Compliance Assurance

Audit Follow-Up Coordinator, Office of Water

Audit Follow-Up Coordinator, Region 5

Public Affairs Coordinator, Region 5