Final Flint Water Advisory Task Force Report 21march2016

Flint Water Advisory Task Force
March 21, 2016

Governor Rick Snyder
Office of Governor
P.O. Box 30013
Lansing, Michigan 48909

Dear Governor Snyder:
We, the Flint Water Advisory Task Force (FWATF), offer in this report our findings and recommendations
regarding the Flint water crisis. We have come to our conclusions largely through interviews of
individuals involved and review of related documents now available in the public record. Our report
includes 36 findings and 44 recommendations, offered to fulfill our charge of determining the causes of
the Flint water crisis, identifying remedial measures for the Flint community, and safeguarding Michigan
residents.
We hope that our report serves three fundamental purposes:
1. Clarify and simplify the narrative regarding the roles of the parties involved, and assign
accountability clearly and unambiguously.
2. Highlight the causes for the failures of government that precipitated the crisis and suggest
measures to prevent such failures in the future.
3. Prescribe recommendations to care for the Flint community and to use the lessons of Flints
experience to better safeguard Michigan residents.
We are encouraged by your focus and expressed commitment to address the Flint communitys needs,
and to learn from the failures that have transpired. This commitment is appropriate because, though it
may be technically true that all levels of government failed, the states responsibilities should not be
deflected. The causes of the crisis lie primarily at the feet of the state by virtue of its agencies failures
and its appointed emergency managers misjudgments.
Given the extensive investigative reporting on the Flint water crisis (from which we have benefited
greatly), we have limited our explanatory narrative. Rather, our report builds on the ample public record
and information yielded through over 60 interviews and discussions to prescribe recommendations that,
we hope, will ultimately safeguard and benefit Michigan residents for years to come. We have
approached our work with a solemn commitment to the charge you invested in us: to place Michigan
residents well-being first.

Respectfully,

Matthew M. Davis, MD, MAPP Chris Kolb

Eric Rothstein, CPA

Ken Sikkema
Lawrence Reynolds, MD
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March
2016

FINAL REPORT

C o m m i s s i o n e d b y t h e O f f i c e o f G o v e r n o r R i c k S n y d e r
S t a t e o f M i c h i g a n

FLINT WATER ADVISORY TASK FORCEFINAL REPORT

MARCH 2016
Table of Contents

Executive Summary ........................................................................................................................... 1
Summary Statement ............................................................................................................................... 1
A Series of Government Failures ............................................................................................................. 1
FWATF Membership, Charge and Scope of Review ................................................................................ 2
Acknowledgements ................................................................................................................................. 5
Findings of the Task Force ...................................................................................................................... 6
Recommendations of the Task Force .................................................................................................... 10
Background ..................................................................................................................................... 15
Flint, Michigan ...................................................................................................................................... 15
Water Crisis .......................................................................................................................................... 15
Summary Timeline of Key Events .......................................................................................................... 16
Regulatory Context ............................................................................................................................... 22
Public Health Context ........................................................................................................................... 23
Roles of Government Entities in the Flint Water Crisis ..................................................................... 26
Michigan Department of Environmental Quality (MDEQ) .............................................................. 26
Defined Role .......................................................................................................................................... 26
Discussion ............................................................................................................................................. 27
Findings ................................................................................................................................................. 28
Recommendations ................................................................................................................................ 29
Michigan Department of Health and Human Services (MDHHS) .................................................... 30
Defined Role .......................................................................................................................................... 30
Discussion ............................................................................................................................................. 31
Findings ................................................................................................................................................. 33
Michigan Governors Office ........................................................................................................... 35
Defined Role .......................................................................................................................................... 35
Discussion ............................................................................................................................................. 36
Findings ................................................................................................................................................. 38
State-Appointed Emergency Managers ......................................................................................... 39
Defined Role .......................................................................................................................................... 39
Discussion ............................................................................................................................................. 39
Findings ................................................................................................................................................. 40
City of Flint ................................................................................................................................... 42
Defined Role .......................................................................................................................................... 42
Discussion ............................................................................................................................................. 43
Findings ................................................................................................................................................. 44
Genesee County Health Department (GCHD) ................................................................................ 46
Defined Role .......................................................................................................................................... 46
Discussion ............................................................................................................................................. 46
Findings ................................................................................................................................................. 48
U.S. Environmental Protection Agency (EPA) Oversight and the Lead and Copper Rule ................. 48
Defined Role .......................................................................................................................................... 48
Discussion ............................................................................................................................................. 50


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Findings ................................................................................................................................................. 52
Issues Presented by the Flint Water Crisis ........................................................................................ 53
The Reality of Environmental Injustice .......................................................................................... 54
Discussion ............................................................................................................................................. 54
Findings ................................................................................................................................................. 55
Perspectives from Flint ................................................................................................................. 55
Flint Recovery / Remediation ........................................................................................................ 56
State-Wide Initiatives ................................................................................................................... 58
Conclusions ..................................................................................................................................... 62
APPENDIX I: Flint Water Advisory Task Force (FWATF)
APPENDIX II: FWATF Letters
APPENDIX III: Interviewee Listing
APPENDIX IV: Questions of Lockwood, Andrews, & Newnam
APPENDIX V: Detailed Timeline
APPENDIX VI: Abbreviations and Acronyms
Executive Summary
Summary Statement
The Flint water crisis is a story of government failure, intransigence, unpreparedness, delay,
inaction, and environmental injustice. The Michigan Department of Environmental Quality
(MDEQ) failed in its fundamental responsibility to effectively enforce drinking water regulations.
The Michigan Department of Health and Human Services (MDHHS) failed to adequately and
promptly act to protect public health. Both agencies, but principally the MDEQ, stubbornly
worked to discredit and dismiss others attempts to bring the issues of unsafe water, lead
contamination, and increased cases of Legionellosis (Legionnaires disease) to light. With the City
of Flint under emergency management, the Flint Water Department rushed unprepared into full-
time operation of the Flint Water Treatment Plant, drawing water from a highly corrosive source
without the use of corrosion control. Though MDEQ was delegated primacy (authority to enforce
federal law), the United States Environmental Protection Agency (EPA) delayed enforcement of
the Safe Drinking Water Act (SDWA) and Lead and Copper Rule (LCR), thereby prolonging the
calamity. Neither the Governor nor the Governors office took steps to reverse poor decisions by
MDEQ and state-appointed emergency managers until October 2015, in spite of mounting
problems and suggestions to do so by senior staff members in the Governors office, in part
because of continued reassurances from MDEQ that the water was safe. The significant
consequences of these failures for Flint will be long-lasting. They have deeply affected Flints
public health, its economic future,1 and residents trust in government.
The Flint water crisis occurred when state-appointed emergency managers replaced local
representative decision-making in Flint, removing the checks and balances and public
accountability that come with public decision-making. Emergency managers made key decisions
that contributed to the crisis, from the use of the Flint River to delays in reconnecting to DWSD
once water quality problems were encountered. Given the demographics of Flint,2 the
implications for environmental injustice cannot be ignored or dismissed.
The Flint water crisis is also a story, however, of something that did work: the critical role played
by engaged Flint citizens, by individuals both inside and outside of government who had the
expertise and willingness to question and challenge government leadership, and by members of a
free press who used the tools that enable investigative journalism. Without their courage and
persistence, this crisis likely never would have been brought to light and mitigation efforts never
begun.
A Series of Government Failures

Flint water customers were needlessly and tragically exposed to toxic levels of lead and other
hazards through the mismanagement of their drinking water supply. The specific events that led
to the water quality debacle, lead exposure, heightened Legionella susceptibility, and

1
Direct and indirect economic impacts of the Flint water crisis include, for example, financial consequences to
individuals and homeowners; impacts on economic development opportunities and on the revenue base for public
services; and the costs of exacerbated requirements for water infrastructure repair and rehabilitation as well as long-
term public health and social services.

MARCH 2016
infrastructure damage are a litany of questionable decisions and failures related to several issues
and events, including, but not limited to:
Decisions related to the use of the Flint River as an interim water supply source.
Inadequate preparation (for example, staffing, training and plant upgrades) for the switch
to full-time use of the Flint Water Treatment Plant using the Flint River as the primary
water supply source.
Inadequate and improper sampling of distribution system water quality, potentially in
violation of the Safe Drinking Water Act.
Intransigent disregard of compelling evidence of water quality problems and associated
health effects.
Callous and dismissive responses to citizens expressed concerns.
Persistent delays in coordinating appropriate responses to the resultant public health
crises once irrefutable evidence of exposure and poisoning was presented.
We cannot begin to explain and learn from these eventsour chargewithout also highlighting
that the framework for this decision-making was Michigans Emergency Manager Law. This law
replaces the decision-making authority of locally elected officials with that of a state-appointed
emergency manager. While one must acknowledge that emergency management is a mechanism
to address severe financial distress, it is important to emphasize that the role of the emergency
manager in Flint places accountability for what happened with state government.
Our complete findings and recommendations are provided throughout this report and also are
summarized at the close of this Executive Summary. They are formulated to offer specific
measures to better safeguard public health, enhance critical water system infrastructure,
improve governmental decision-making and regulatory oversight, and mitigate the many negative
health and economic effects facing the people of Flint. We hope that our findings and
recommendations serve as a guide and template for remediation and recovery in Flint, and for
safeguarding the health and well-being of residents across our state.
FWATF Membership, Charge and Scope of Review

The FWATFcomposed of five members with experience and backgrounds in public policy, public
utilities, environmental protection, public health, and health carewas appointed by Governor
Rick Snyder on October 21, 2015.3 We were charged with conducting an independent review of
the contamination of the Flint water supply: what happened, why it occurred, and what is
needed to prevent a reoccurrence in Flint or elsewhere in the state. We assessed ongoing
mitigation efforts to help assure that short and long-term public health issues and water
management concerns will be properly addressed to safeguard the health and well-being of the
Flint community. We have developed findings and offer recommendations on the following:
Roles of Government Entities in the Flint Water Crisis

o State of Michigan
Michigan Department of Environmental Quality (MDEQ)
Michigan Department of Health and Human Services (MDHHS)
Michigan Governors Office
State-Appointed Emergency Managers
Paragraph summaries of the FWATF members backgrounds and experience are provided as Appendix I.

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o City of Flint
o Genesee County Health Department (GCHD)
o United States Environmental Protection Agency and the Lead and Copper Rule
Issues Presented by the Flint Water Crisis
o The Reality of Environmental Injustice
o Perspectives from Flint
o Flint Recovery
o State-Wide Recommendations
Before completing this report, the Task Force issued three interim letters to Governor Snyder
offering findings and recommendations requiring immediate response, as follows:4
1. The first letter, issued December 4, 2015, identified our concerns about coordination of
response measures and the need for a framework to measure results and clearly
delineate responsibilities for continuing actions to protect public health.
2. The second letter, issued December 29, 2015, addressed the critical and urgent need to
establish responsibility and ensure accountability for what happened in Flint.
3. Our third letter, issued January 21, 2016, addressed the need for the state to engage the
scientific experts who overcame state and federal agency intransigence to expose the lead
poisoning, and similarly to engage trusted, scientific experts drawn from independent
institutions to address the implications of the Legionellosis outbreak.
In conducting our interviews, we have had complete independence and largely5 unfettered
access to local, state and federal government personnel. Interview subjects were not compelled
to participate in our review, and the FWATF held no subpoena or judicial enforcement powers.
We are grateful to the parties involved for their forthright willingness to discuss the events that
transpired and their perspectives.
We acknowledge that other reviews and investigations are taking place, some with tools that the
FWATF did not have, such as the subpoena and judicial enforcement powers mentioned above.
We appreciate and support these reviews because the magnitude of this tragedy warrants deep
and detailed investigation. It is our hope that these or other reviews examine certain issues we
had neither the time nor investigative tools to fully explore, and that fell outside our immediate
scope given the accelerated timeframe for our information gathering and rendering of
judgments. These issues include, but are not limited to:
State approval and permitting of the Karegnondi Water Authority (KWA) in a region that
had ample water supply and treatment capacity, yet faced economic distress sufficient to
warrant emergency management in its two largest urban centers.
The appropriate role of regulatory agencies and the water utility industry in addressing
the dangers presented by widespread use of lead in public and private plumbing systems.
The FWATFs interim letters to Governor Snyder are provided as Appendix II.
The FWATF was not successful in scheduling an interview with representatives of the firm Lockwood, Andrews, &
Newnam (LAN) despite several requests. LAN requested that questions be submitted to them in writing, and the
questions we submitted are included in Appendix IV. As of the time of publication, the FWATF has not received
responses to these questions.


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Historically, regulatory agencies and the water utility industry at large have been
reluctant to address these dangers beyond use of corrosion control treatment.6 Though
the industry now endorses strengthening of the Lead and Copper Rule and ultimate
replacement of lead service lines (LSLs),7 the industry has not (with notable exceptions)
been proactive in reducing risk through full LSL replacement programs and has
highlighted utility customers obligations to manage lead risks on private property. While
the recommendations of the National Drinking Water Advisory Council (NDWAC) advance
objectives of full LSL replacements, enhanced monitoring, and improved public
education, concerns persist about accountability, oversight and enforcement.8, 9
Protocols for environmental compliance enforcement when EPA has delegated primacy
(authority to enforce federal law) to state agencies, yet retains ultimate responsibility for
protection of public health and management of environmental risks.
Budgets for public health activities at federal, state, and local levels to ensure that highly
skilled personnel and adequate resources are available. The consequences of under-
funding include insufficient and inefficient responses to public health concerns, which
have been evident in the Flint water crisis.
The need for greater clarity on local and state processes and procedures for declaring
emergencies in response to man-made catastrophes (in contrast to natural disasters). The
efforts of local, state, and federal emergency operations teams in Flint beginning in

Historically, water industry groups have maintained that removing lead from water and plumbing systems is not
necessary and would involve significant difficulty and expense (see, for example, Controlling Lead in Drinking
Water, Water Research Foundation, 2015). Notably, when EPAs Lead and Copper Rule (LCR) was published in 1991,
it required replacement of entire LSLs, and in 1994 the water industry sought in court to limit this requirement to
only the publicly owned portions of service lines (40 F.3d 1266, AWWA vs. EPA, 1994). In response, EPA revised the
LCR in 2000 to allow for partial service line replacementa practice the CDC later maintained was associated with
increases in blood lead levels (Important Update: Lead-Based Water Lines, Howard Frumkin, MD; CDC, May 2010).
The water industry historically has focused on controlling lead exposure risks through use of chemical corrosion
control methods and has offered a number of related studies (as compiled in Lead and Copper Corrosion: An
Overview of WRF Research, Jonathan Cuppett, Water Research Foundation, updated January 2016). The American
Water Works Association (AWWA) also has published communications guides on lead-in-water issues (see, for
example, Communicating About Lead Service Lines: A Guide for Water Systems Addressing Service Line Repair and
Replacement, AWWA, 2014; and Strategies to Obtain Customer Acceptance of Complete Lead Service Line
Replacement, AWWA, 2005). Yet industry guidance has taken the position that managing lead-related risks
associated with LSLs and plumbing fixtures on private property is largely the utility customers responsibility. Many
water utilities have not informed customers proactively (if at all) about the presence of LSLs. As a result, customers
generally have limited awareness of the potential need to take action to protect themselves from lead in drinking
water.
7
See, for example, AWWA press release: AWWA Board supports recommendation for complete removal of lead
service lines, March 8, 2016.
8
For example, there are concerns that the voluntary, customer-initiated sampling approach recommended by the
NDWAC will substantially decrease public water systems ability to track presence of lead over time, identify
emerging public health threats, and inform LSL replacement programs. For more information on additional concerns,
see, for example, Strength of New EPA Lead Rule Depends on Accountability, by Brett Walton, Circle of Blue,
February 10, 2016, www.circleofblue.org/2016/world/strength-of-new-epa-lead-rule-depends-on-accountability/.
9
NDWAC and water utility industry representatives have highlighted concerns about the significant financial
resources and time required to effect full LSL replacement, suggesting the need to support reasonable yet aggressive
scheduling of LSL replacement through both enforcement measures (within the LCR) and resource commitments of
local, state and federal entities.

MARCH 2016
January 201610 have demonstrated that emergency operations can be deployed

appropriately and with multi-level coordination. However, delays in Flint occurred due to
reluctance to elevate concerns, confusion and disagreement among authorities about
how and what levels of emergency status were appropriate, and extensive application
requirements.
We also note and acknowledge that additional information will continue to be revealed as other
investigations and reviews of the crisis are conducted. The narrative, findings and
recommendations in this report are based on our interviews and the public record available
through February 2016. We believe this information alone warrants urgent and thorough
response and supports our recommendations.
We hope that our earlier letters and this report contribute to the collective understanding of
what transpired, evoke thoughtful consideration of our recommendations, andmost
importantlyfurther motivate sustained response and support for the Flint community and more
earnest and effective protection of all Michigan residents.
Acknowledgements
The FWATF would not have been able to complete its work without the support of many
individuals and organizations that dedicated their time, resources and passion to facilitate our
review. We are indebted to the Michigan State Universitys Center for Local Government Finance
and Policy for their administrative support and insights, particularly with regard to Michigans
emergency manager laws; and to Chris DeWitt of DeWitt Communications for keeping the task
force informed regarding media coverage. We have been aided by technical insights from
individuals in the water utility and public health communities, too numerous to name individually
here, who have educated us on a broad range of issues. Where we have accurately stated the
technical attributes of specific issues, it reflects on their guidance. We are responsible for any
technical inaccuracies or unintentional misstatements of fact.
Perhaps most notably, we are deeply indebted to the members of the Flint community and safe
drinking water and public health advocates who ultimately entrusted us with profound
expressions of their frustrations, concerns, perspectives and hopes for the future. We are
especially thankful to Flint residents for giving voice to the searing personal costs that are too
often muted in the discourses about public policy implications. We are acutely aware that as we
are a task force commissioned by the State of Michigan, their forthrightness was a leap of faith
given what happened in Flint. We hope that our report honors their trust, advances their hopes
for the future, and helps ensure that Michigan communities are safer.

10
The FWATF recommended to the Governors office that an emergency be declared as early as November 2015 and
issued its first letter to the Governor on December 4, 2015 noting the acute need for more effective coordination of
activities.


MARCH 2016
Findings of the Task Force

Note: Footnotes and text supporting these findings and recommendations are provided in the
individual sections of the report. The footnotes and text provide substantive detail and important
context for our findings and recommendations. Also please note that the findings and
recommendations are independent lists; the findings do not correlate one-to-one to the
recommendations.
Michigan Department of Environmental Quality (MDEQ):
F-1. MDEQ bears primary responsibility for the water contamination in Flint.
F-2. MDEQ, specifically its Office of Drinking Water and Municipal Assistance (ODWMA),
suffers from cultural shortcomings that prevent it from adequately serving and protecting
the public health of Michigan residents.
F-3. MDEQ misinterpreted the LCR and misapplied its requirements. As a result, lead-in-water
levels were under-reported and many residents exposure to high lead levels was
prolonged for months.
F-4. MDEQ waited months before accepting EPAs offer to engage its lead (Pb) experts to help
address the Flint water situation and, at times, MDEQ staff were dismissive and
unresponsive.
F-5. MDEQ failed to move swiftly to investigate, either on its own or in tandem with MDHHS,
the possibility that Flint River water was contributing to an unusually high number of
Legionellosis cases in Flint.
Michigan Department of Health and Human Services (MDHHS):
F-6. MDHHSs lack of timely analysis and understanding of its own data on childhood blood
lead levels, along with its reliance on MDEQ and reluctance to share state data with Dr.
Mona Hanna-Attisha and Professor Marc Edwards, prolonged the Flint water crisis.
F-7. MDHHS bears ultimate responsibility for leadership and coordination of timely follow-up
efforts in Flint and across the state regarding childhood lead poisoning. While local
entities (for example, healthcare professionals, GCHD, health insurance plans) are
partners in efforts to protect children from lead poisoning, MDHHS has the lead role and
failed to exercise its responsibility.
F-8. The consequences of lead exposure for Flint residents are expected to be long-term and
will necessitate sustained investments in education, public and mental health, juvenile
justice, and nutrition needs over the next 10 to 20 years.
F-9. Too few children in Michigan are screened for lead through routine blood tests as
recommended for children ages 1 and 2. Statewide screening goals for children enrolled in
Medicaid are met in very few instances at the county level or within Medicaid health
plans. This lack of information leaves parents, healthcare professionals, and local and
state public health authorities uninformed about the possibility of lead poisoning for
thousands of Michigan children.
F-10. Coordination between MDEQ and MDHHS was inadequate to properly address the public
health issues related to water quality in Flint. Communication was infrequent, and when it
did occur, the default position was to conclude that the health problems were not related


MARCH 2016
to the water supply switch rather than to assume that the problems might be related to
the switch.
F-11. Communication and coordination among local and state public health staff and leadership
regarding Legionellosis cases in 2014-2015 was inadequate to address the grave nature of
this outbreak. The fact that these cases occurred while there were several simultaneous
concerns about quality and safety of water in Flint should have caused public health staff
and leadership at local and state levels to coordinate their actions to ensure a prompt and
thorough investigation.
Michigan Governors Office:
F-12. Ultimate accountability for Michigan executive branch decisions rests with the Governor.
F-13. The Governors knowledge, and that of Governors office staff, of various aspects of the
Flint water crisis was compromised by the informationmuch of it wrongprovided by
MDEQ and MDHHS.
F-14. The Governors office continued to rely on incorrect information provided by these
departments despite mounting evidence from outside experts and months of citizens
complaints throughout the Flint water crisis, only changing course in early October 2015
when MDEQ and MDHHS finally acknowledged the extent of the problem of lead in the
public water supply.
F-15. The suggestion made by members of the Governors executive staff in October 2014 to
switch back to DWSD should have resulted, at a minimum, in a full and comprehensive
review of the water situation in Flint, similar to that which accompanied the earlier
decision to switch to KWA. It was disregarded, however, because of cost considerations
and repeated assurances that the water was safe. The need to switch back to DWSD
became even more apparent as water quality and safety issued continued and lead issues
began to surface in 2015, notwithstanding reassurances by MDEQ.
F-16. The Flint water crisis highlights the risks of over-reliancein fact, almost exclusive
relianceon a few staff in one or two departments for information on which key
decisions are based.
F-17. Official state public statements and communications about the Flint water situation have
at times been inappropriate and unacceptable.
State-Appointed Emergency Managers:
F-18. Emergency managers, not locally elected officials, made the decision to switch to the Flint
River as Flints primary water supply source.
F-19. Treasury officials, through the terms of the local emergency financial assistance loan
executed by the Flint emergency manager on April 29, 2015, effectively precluded a
return to DWSD water, as Flint citizens and local officials were demanding, without prior
state approval.
F-20. The role of the emergency managers in Flint (in combination with MDEQs failures) places
primary accountability for what happened with state government.

MARCH 2016
F-21. Emergency managers charged with financial reform often do not have, nor are they
supported by, the necessary expertise to manage non-financial aspects of municipal
government.
F-22. Michigans Emergency Manager Law and related practices can be improved to better
ensure that protection of public health and safety is not compromised in the name of
financial urgency.
City of Flint:
F-23. Flint Public Works personnel were ill-prepared to assume responsibility for full-time
operation of the Flint WTP and distribution system.
F-24. The Flint Water Treatment Plant (WTP) and installed treatment technologies were not
adequate to produce safe, clean drinking water at startup of full-time operations. Flints
lack of reinvestment in its water distribution system contributed to the drinking water
crisis and ability to respond to water quality problems.
F-25. Flint Public Works personnel failed to comply with LCR requirements, including the use of
optimized corrosion control treatment and monitoring for lead. Flint personnel did not
identify residences with LSLs, secure an adequate number of tap water samples from
high-risk homes, or use prescribed sampling practices (for example, line and tap flushing
methods and sample bottle sizes).
F-26. Flint Public Works acted on inaccurate and improper guidance from MDEQ.
F-27. Many communities similarly rely on MDEQ to provide technical assistance and guidance
on how to meet regulatory requirements. In the case of Flint, MDEQ assistance was
deeply flawed and lax, which led to myopic enforcement of regulations designed to
protect public health.
F-28. The emergency manager structure made it extremely difficult for Flint citizens to alter or
check decision-making on preparations for use of Flint River water, or to receive
responses to concerns about subsequent water quality issues.
Genesee County Health Department (GCHD):
F-29. Communication, coordination and cooperation between GCHD, the City of Flint and
MDHHS were inadequate to protect Flint residents from public health threats resulting
from inadequately treated Flint River water.
F-30. The rate of follow-up on children with elevated blood lead levels through January 2016
was unacceptable, illustrating a low level of coordination between GCHD and MDHHS and
insufficient resources devoted to this task.
F-31. Management of the Flint River-sourced water supply may have contributed to the
outbreaks of Legionellosis in 2014 and 2015 in Genesee County. Although the definitive
cause of the outbreaks is uncertain at the time of publication, GCHD and MDHHS did not
notify the public of the outbreaks in a timely fashion in order to urge caution.
United States Environmental Protection Agency (EPA):
F-32. EPA failed to properly exercise its authority prior to January 2016. EPAs conduct casts
doubt on its willingness to aggressively pursue enforcement (in the absence of

MARCH 2016
widespread public outrage). EPA could have exercised its powers under Section 1414 and
Section 1431 of the SDWA or under the LCR, 40 CFR 141.82(i).
F-33. Despite the clear intent of the LCR, EPA has accepted differing compliance strategies that
have served to mute its effectiveness in detection and mitigation of lead contamination
risks. These strategies have been adopted at water systems and primacy agencies across
the country. Though there may be some ambiguity in LCR rule, none of it relates to what
MDEQ should have done in Flint. There was and remains no justification for MDEQ not
requiring corrosion control treatment for the switch of water source to the Flint River.
F-34. EPA was hesitant and slow to insist on proper corrosion control measures in Flint. MDEQ
misinformation notwithstanding, EPAs deference to MDEQ, the state primacy agency,
delayed appropriate intervention and remedial measures.
F-35. EPA tolerated MDEQs intransigence and issued, on November 3, 2015, a clarification
memo on the LCR when no such clarification was needed.
Issues Presented by the Flint Water Crisis:
F-36. The Flint water crisis is a clear case of environmental injustice.


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Recommendations of the Task Force

Note: Footnotes and text supporting these findings and recommendations are provided in the
individual sections of the report. The footnotes and text provide substantive detail and important
context for our findings and recommendations. Also please note that the findings and
recommendations are independent lists; the findings do not correlate one-to-one to the
recommendations.
Michigan Department of Environmental Quality (MDEQ):
R-1. Implement a proactive, comprehensive cultural change program within MDEQ, specifically
its ODWMA, to refocus the department on its primary mission to protect human health
and the environment. MDEQ should aspire to become a national leader through a
proactive program designed to detect and address contaminants in public water supplies
in a timely manner.
R-2. Establish an apprenticeship/certification program for MDEQ ODWMA employees that
requires direct, hands-on experience with public water system operations. MDEQ
ODWMA employees responsible for water system regulation and SDWA enforcement
should be, or have access to, certified operators and subject matter experts (including, for
example, those at EPA).
R-3. Strengthen SDWA enforcement, most notably for the LCR. The state has the ability to
strengthen its own enforcement of the SDWA and not wait for action to occur at the
federal level.
R-4. Participate in the Flint Water Inter-Agency Coordinating Committees (FWICCs) work
team established to oversee conversion from DWSD-supplied to KWA-delivered water.
MDEQ should draw from that work to revise its policies and procedures for approval of
water treatment and distribution system operating regimens, particularly when source
water changes are contemplated.
R-5. Participate in EPAs ongoing review and revision of the LCR, conveying lessons learned
from the Flint water crisis.
Michigan Department of Health and Human Services (MDHHS):
R-6. Establish policies and procedures at MDEQ and MDHHS to ensure input by health experts
and scientists when permit decisions may have a direct impact on human health.
R-7. Establish and maintain a Flint Toxic Exposure Registry to include all the children and adults
residing in Flint from April 2014 to present.
R-8. Re-establish the Michigan Childhood Lead Poisoning Prevention and Control Commission.
R-9. Ensure that MDHHS is transparent and timely in reporting and analysis of aggregate data
regarding childrens blood lead levels. MDHHS data regarding lead levels shall be provided
to individuals and organizations, based on their expertise, upon request and in cases
when the interpretation of data by MDHHS is questioned.
R-10. Establish a more aggressive approach to timely clinical and public health follow-up for all
children known to have elevated blood lead levels, statewide. MDHHS should expand its
local efforts and partnerships to accomplish this goal. Whenever possible, routine
10

MARCH 2016
screening for lead and appropriate follow-up should occur in childrens primary care
medical homes.
R-11. Strive to be a national leader in monitoring and responding to exposure of children to lead
by converting the Childhood Lead Poisoning Prevention Program (CLPPP) from passive
collection of test results into an active surveillance and outreach program.
R-12. Improve screening rates for lead among young children through partnerships with county
health departments, health insurers, hospitals, and healthcare professionals.
R-13. As the state authority on public health, and as the organization that conducted the
epidemiologic study of Legionellosis cases in Genesee County in 2014-15, take
responsibility for coordinating with GCHD and CDC to protect Michigan residents from
further outbreaks of Legionellosis.
R-14. In cases of switches in drinking water supplies in the future, assume that outbreaks of
Legionellosis cases may be related to changes in water source and communicate the
potential risk to the public, rather than assuming and communicating the opposite.
Michigan Governors Office:
R-15. Expand information flow to the Governor so that information providing the foundation for
key decisions comes from more than one trusted sourceand is verified.
R-16. Create a culture in state government that is not defensive about concerns and evidence
that contradicts official positions, but rather is receptive and open-minded toward that
information. View informed opinionseven if critical of state governmentas an
opportunity for re-assessing state positions, rather than as a threat.
R-17. Ensure that communications from all state agencies are respectful, even in the face of
criticism, and sensitive to the concerns of diverse populations.
R-18. The Governor must assume the leadership of, and hold state departments accountable
for, long-term implementation of the recommendations in this report, including but not
limited to the need for cultural changes across multiple state agencies, the need for
health mitigation and LSL replacement in Flint, and the need for a funding strategy to
address replacement of LSLs statewide.
R-19. Review budget requests for MDEQ to ensure adequate funding is provided to the
ODWMA. EPA audit and interviews indicate that Michigans drinking water program might
have one of the lowest levels of financial support within EPA Region V while having one of
the largest, if not the largest, number of community water systems to regulate.
State-Appointed Emergency Managers:
R-20. Review Michigans Emergency Manager Law (PA 436) and its implementation, and identify
measures to compensate for the loss of the checks and balances that are provided by
representative government.
R-21. Consider alternatives to the current emergency manager approachfor example, a
structured way to engage locally elected officials on key decisions; an Ombudsman
function in state government to ensure that local concerns are a factor in decisions made
by the emergency manager; and/or a means of appealing emergency manager decisions
to another body.

11

MARCH 2016
R-22. Ensure proper support and expertise for emergency managers to effectively manage the
many governmental functions of a city. Decisions on matters potentially affecting public
health and safety, for example, should be informed by subject matter experts identified
and/or provided by the state.
City of Flint:
R-23. Establish and fund a team of subject matter experts in water system operations
(treatment and distribution system management) to support and train water system
personnel, guide safe system operation under current conditions, and prepare for
successful conversion to KWA.
R-24. Implement a programmatic approach to Flint WTP and distribution system operations,
maintenance, asset management, water quality, capital improvements and public
engagement (including risk communication) to ensure that the disparate ongoing efforts
to address Flint water system infrastructure needs are coordinated, fully documented,
and structured to sustain high-quality potable water service over the long term.
R-25. Implement a robust public engagement and involvement program in conjunction with the
anticipated conversion to KWA-delivered water and provide for regular reporting to the
Flint Water Inter-Agency Coordinating Committee (FWICC).
Genesee County Health Department (GCHD):
R-26. Improve follow-up on public health concerns between GCHD, MDHHS and the City of Flint
now and in the future, to effect timely, comprehensive, and coordinated activity and
ensure the best health outcomes for children and adults affected.
R-27. Presume that the risk of Legionella may remain elevated in the Flint water distribution
system and must take appropriate steps with public and private partners to monitor and
mitigate that risk as concerns about water quality continue in the City of Flint.
R-28. Coordinate with state officials (MDHHS) and with local healthcare professionals and
healthcare institutions in Genesee County and the City of Flint to mitigate the risk of
Legionellosis in 2016 and beyond.
United States Environmental Protection Agency (EPA):
R-29. Exercise more vigor, and act more promptly, in addressing compliance violations that
endanger public health.
R-30. In collaboration with the NDWAC and other interested partners, clarify and strengthen
the LCR through increased specificity and constraints, particularly requirements related to
LCR sampling pools, sample draw protocols, and LSL replacementsand, more generally,
strengthen enforcement protocols with agencies delegated primacy.
R-31. Engage Michigan representatives in ongoing LCR revisions and development of
enforcement protocols at EPA and MDEQ.

12

MARCH 2016

Environmental Injustice:
R-32. Issue an Executive Order mandating guidance and training on Environmental Justice
across all state agencies in Michigan, highlighting the Flint water crisis as an example of
environmental injustice. The state should reinvigorate and update implementation of an
Environmental Justice Plan for the State of Michigan.
Flint Recovery and Remediation:
R-33. Sustainably fund the Flint Water Inter-Agency Coordinating Committee (FWICC) to provide
adequate resources to engage supporting sub-committees for delivery of public health
and water system services.
R-34. Clarify and effectively communicate the roles, work and expected outcomes of the City of
Flint, FWICC and Mission Flint.
R-35. Through collaboration among MDHHS, GCHD, local healthcare professionals, and health
insurance plans, ensure 100 percent clinical and environmental follow-up with Flint
families whose children have been found to have elevated blood lead levels since April
2014, and work together to ensure that follow-up occurs in childrens medical homes.
R-36. Offer all children listed in the recommended Flint Toxic Exposure Registry timely access to
age-appropriate screening and clinically indicated follow-up for developmental and
behavioral concerns by licensed healthcare professionals, as well as access to early
childhood education and nutrition services.
R-37. Consider establishing a dedicated subsidiary fund in the Michigan Health Endowment
Fund to facilitate funding of health-related services for Flint.
R-38. Establish a comprehensive Flint public health program, coordinated with county and
state-level public health initiatives, that can serve as a model for population health across
the state. This program should provide assessment, interventions, and support not only
regarding the health effects of water contamination but also more broadly regarding the
health effects of chronic economic hardship and other social determinants of poor health.
State-wide Recommendations:
R-39. Conduct an investigative review of the development and approval of the Karegnondi
Water Authority and of the City of Flints commitments to KWA water purchases.
R-40. Institute a school and daycare water quality testing program (which could serve as a
model for the U.S.), administered collaboratively by MDEQ and MDHHS, that includes
appropriate sampling and testing for lead contamination for all schools and childcare
centers in the state and effective reporting of test results.
R-41. Develop a model LSL replacement program and funding mechanisms for financing work
on private property.
R-42. Revise and enhance information distributed by public water systems on the implications
of widespread use of lead in public and private plumbing.
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MARCH 2016
R-43. Use the occasion of the Flint water crisis to prompt local and state re-investment in
critical water infrastructure, while providing mechanisms to advance affordability and
universal access to water services.
R-44. Prioritize health matters across all state agencies with establishment of a new Cabinet-
level post focused on public health.

14

MARCH 2016
Background11
Flint, Michigan
The beleaguered history of Flint, Michigan over the last several decades is well known,12 yet some
facts are particularly important to provide context for our findings and recommendations.
The City of Flint has suffered dramatic declines in population. From a peak of more than 200,000
in 1960, Flints population had fallen below 100,000 residents by 2014. Since 2000, Flint has lost
over 20 percent of its population.13 Of the remaining residents, approximately 57 percent are
Black or African American. 14
Poverty is endemic in Flint, with 41.6 percent of the population living below federal poverty
thresholds2.8 times the national poverty rate. The median value of owner-occupied housing is
$36,700, roughly one-fifth of the national average. 15 Crime plagues the community; for 2013,
Flints crime index was 811 as compared to a national average of 295.16
Even before the Flint water crisis, Genesee County (in which Flint is the largest population center)
exhibited poor health statistics. In a 2015 study, the county ranked 81st out of 82 Michigan
counties in health outcomes. It ranked 78th in length of life, 81st in quality of life, 77th in health
behaviors, 78th in social and economics factors, and 75th in physical environment measures. Only
the quality of clinical care, for which the county ranked 22nd, is not a cause of acute community
concern.17
Water Crisis
The Flint Water System was first organized in 1883 under private ownership, and the City
purchased the water system in 1903. Before 1967, Flint treated Flint River water at its Water
Treatment Plant (WTP). To ensure adequacy and reliability of water supplies, in 1967 Flint signed
a long-term water supply contract with the Detroit Water and Sewerage Department (DWSD).
From 1967 through 2014, the Flint WTP served as an emergency backup to DWSD-supplied
water. As such, the Flint WTP was not operated on an ongoing day-to-day basis, but rather four
times per year to maintain readiness as an emergency backup. The WTP was also upgraded
periodically to keep it ready for use as an emergency backup.

11
The series of events and decisions that led to the Flint water crisis are (now) well documented, thanks to the
tireless efforts of local activists and journalists. In addition, the public record has been supplemented by the release
of e-mails and other documents by the Governors office and key state agencies. We are indebted to this
construction of a substantial public record. We believe that this public record, in combination with insights obtained
through our interview process, provides more than ample basis for our findings and recommendations.
12
For extensive information on Flints economic decline and troubled circumstances, see the report and endnotes
provided in Long-Term Crisis and Systemic Failure: Taking the Fiscal Stress of Americas Older Cities Seriously: Case
Study, Flint Michigan, by Eric Scorsone, Ph.D. and Nicolette Bateson, Michigan State University Extension,
September 2011.
13
BiggestUSCities.com, www.biggestuscities.com/city/flint-michigan
14
U.S. Census, Quickfacts for Flint, Michigan and the United States,
www.census.gov/quickfacts/table/PST045215/00
15
Ibid
16
City-Data.com, www.city-data.com/crime/crime-Flint-Michigan.html
17
County Health Rankings,
www.countyhealthrankings.org/app/michigan/2015/rankings/genesee/county/outcomes/overall/snapshot

15

MARCH 2016
DWSD provided water to Flint under a 35-year contract signed on December 20, 1965. The initial
contract term expired in 2000 and renewed each year unless it was terminated by either party.
As one of DWSDs wholesale customers, Flint was subject to the terms and rate-setting practices
applicable to all of DWSDs wholesale customer communities. During the final 10 years that Flint
received contractual service from DWSD, the average annual increase in water charges to Flint
was 6.2 percent. DWSDs water supply has been treated for corrosion control for over 20 years
and is deemed optimized for corrosion control treatment.
On April 16, 2013, after a symbolic Flint City Council vote that accompanied the Flint emergency
managers decision, the City joined the Karegnondi Water Authority (KWA), which had been
established to develop a raw water supply pipeline from Lake Huron. After being advised of the
City of Flints intent, DWSD notified the City of the termination of its then-current water supply
contract terms, effective April 2014. DWSD and the City of Flint, both under emergency
management, continued unsuccessfully to negotiate alternative water supply terms. Although
the State of Michigan was in control of both cities at the time, efforts to arrive at an agreement
between the parties during the final year of service to the City of Flint ultimately failed.
In April 2014, the City of Flint began treating Flint River water at the Flint WTP on a full-time basis
and distributing the treated water to its customers. A critical element of that treatment
corrosion control, as required under EPAs Lead and Copper Rule (LCR)was (incorrectly)
determined by MDEQ not to be required immediately; instead, Flint could complete two 6-month
monitoring periods and MDEQ would then determine whether corrosion control was necessary.
Soon after the City began distributing treated water from the Flint WTP, Flint residents began to
complain about its odor, taste and appearance. Numerous water quality problems and
operational challenges resulted in water quality violations related to E coli contamination and
disinfection by-products (total trihalomethanes or TTHMs). Ultimately, the corrosiveness of the
drinking water leached lead from pipes and plumbing fixtures, and it may have increased the
likelihood of water contamination with Legionella. 18
Summary Timeline of Key Events

In this economically disadvantaged and ethnically diverse Michigan community, a series of
disastrous decisions and events occurred. Following are the events most critical to development
of our findings and recommendations:19
1. 1967: City of Flint enters into long-term water supply contract with the Detroit Water and
Sewerage Department (DWSD).
2. 1991: U.S. Environmental Protection Agency (EPA) issues the Lead and Copper Rule to
ensure routine local testing of drinking water and assurance of safe levels of lead and
copper.
3. January 23, 2013: Mike Prysby/MDEQ e-mails colleague Liane Shekter Smith and others
about feasibility of Flint switching to the Flint River, highlighting water quality concerns.

18
Bouffard K. Hospital ties Legionellosis to Flint water. Detroit News, January 23, 2016,
www.detroitnews.com/story/news/politics/2016/01/22/legionnaires-bacteria-found-tests-mclaren-medical-centers-
water/79183428/.
19
Appendix V provides a further, more detailed timeline that attempts to synthesize numerous timelines developed
by other sources, including local media and government agencies.

16

MARCH 2016
4. March 26, 2013: Stephen Busch/MDEQ e-mails MDEQ Director Dan Wyant with Liane
Shekter Smith and other MDEQ staff copied, with warnings about public health risks
associated with Flint River water.
5. March 28, 2013: State Treasurer Andy Dillon e-mails Governor Snyder notifying him of his
approval of Flint joining Karegnondi Water Authority (KWA) and MDEQ concurrence.
6. April 16, 2013: Flint Emergency Manager (EM) Ed Kurtz signs agreement with KWA and
informs the State Treasurer that the City will join KWA (decision officially announced May
1, 2013).
7. April 17, 2013: DWSD issues letter to Flint notifying termination of contract to provide
water service. Negotiations continue to establish alternative contractual arrangements for
DWSD service to Flint.
8. June 26, 2013: Flint EM Ed Kurtz authorizes a sole-source contract with the firm of
Lockwood, Andrews, & Newnam (LAN) for professional engineering services to place the
Flint Water Treatment Plant (WTP) into operation using the Flint River as a primary
drinking water source.
9. March 26, 2014: Stephen Busch/MDEQ e-mails Liane Shekter Smith and Richard
Benzie/MDEQ on clarifying what Flint will be required to do before beginning full-time
Flint WTP operation.
10. April 16-17, 2014: Michael Glasgow/Flint Utilities Department e-mails MDEQ, noting
unpreparedness of Flint WTP and apparent political pressure to start distributing water.
11. April 29, 2014: Flint EM Darnell Earley notifies Detroit EM that Flint has switched water
supply sources to the Flint River. Genesee County Drain Commission remains as a non-
contract customer of DWSD.
12. July 1, 2014: Flint begins first 6-month monitoring period for lead and copper in drinking
water.
13. August 15, 2014: E. coli bacteria violation in water sampled from the Flint distribution
system leads to local boil water advisory.
14. September 10, 2014: MDEQ requests pre-emptive operational evaluation for disinfection
byproducts called trihalomethanes (THMs).
15. October 1, 2014: MDEQ submits briefing paper to Governor's office re: City of Flint
drinking water situation (boil water notices). Genesee County Health Department (GCHD)
expresses concern to Flint Public Works regarding increased incidence of cases of
Legionellosis since April 2014, and the possible relationship to use of the Flint River as the
water supply. MDHHS epidemiology staff expresses concern but there is no further state-
level evaluation.
16. October 13, 2014: General Motors (GM) announces that it will cease to use Flint WTP-
sourced water for its Flint Engine Operations facility until the KWA connection is
completed, due to corrosion concerns related to the chloride levels in water from the Flint
WTP. MDEQ notes chloride in Flint WTP-treated water is within public health guidelines.
17. October 14, 2014: Valerie Brader, State Deputy Legal Counsel and Senior Policy Advisor, e-
mails Governors Chief of Staff Dennis Muchmore and other top aides arguing for a return
to DWSD because of water quality problems. Michael Gadola, then the Governors Legal
Counsel, responds by agreeing with Brader. Brader and Rich Baird, another senior aide to

17

MARCH 2016
the Governor, then discuss the idea with Emergency Manager Darnell Earley, who
maintains the water quality problems can be solved and it would be cost-prohibitive to
return to DWSD.
18. December 16, 2014: MDEQ notifies Flint of initial quarterly violation of SDWA Disinfection
Byproducts (total trihalomethane, or TTHM) requirements.
19. December 31, 2014: First 6-month round of LCR monitoring ends. Using 100 samples not
necessarily drawn from highest risk homes (as the LCR intends), the 90th percentile lead
level result is 6 parts per billion with 2 samples above action levels for lead (15 parts per
billion). Given the 6 ppb result, Flint is disqualified from being exempted and will have to
implement corrosion control treatment under the LCR, irrespective of subsequent 6-
month monitoring results. MDEQ fails to properly advise Flint WTP of this regulation.
20. January 12, 2015: In response to water quality concerns, the state installs water coolers in
state offices in Flint, and state employees are given the option in their offices to use
bottled water and provide bottled water to visitors.
21. January 27, 2015: MDHHS epidemiology staff member contacts Genesee County Health
Department (GCHD) to recommend that they construct a map of Legionellosis cases and
correlate them to the Citys water service area.
22. January 2015 (date unclear): Staff from Genesee County hospitals, MDHHS, MDEQ and
GCHD meet, and MDHHS Director Nick Lyon directs GCHD to conduct and complete its
evaluation of the causes of the increased Legionellosis cases that had begun to occur in
2014.
23. January 27, 2015: FOIA request sent by GCHD environmental hygienist James Henry to
Flint DPW and Flint Mayor for information on water treatment to support the countys
investigation of Legionellosis cases.
24. January 30, 2015: Brad Wurfel/MDEQ e-mails Dave Murray, Governor Snyders deputy
press secretary, re: Legionella, saying said he didnt want MDEQ Director Wyant to say
publicly that the water in Flint is safe until we get the results of some county health
department traceback work on 42 cases of Legionellosis in Genesee County since last
May.
25. February 25, 2015: LeeAnne Walters contacts EPA Region V regarding high levels of lead
(104 ppb) found in drinking water at her home.
26. February 26, 2015: Initial EPA-MDEQ correspondence regarding elevated lead in sample
collected from LeeAnne Walters's house. Jennifer Crooks/EPA speculates Flint River water
chemistry is leaching contaminants from pipes; this prompts the EPAs initial query of
MDEQ about whether optimized corrosion control treatment (OCCT) is in place at the Flint
WTP.
27. February 26, 2015: Mike Prysby/MDEQ emails Jennifer Crooks/EPA indicating that all
other samples in the monitoring period for July 1, 2014 through December 31, 2014 are
below the EPA action level of 15 ppb.
28. February 27, 2015: Miguel Del Toral/EPA, in e-mails to MDEQ and EPA staff, mentions
possibility of biasing lead results low by collecting samples after flushing water through
the taps; asks again about Flint OCCT, saying "they are required to have OCCT in place."
18

MARCH 2016
29. February 27, 2015: Stephen Busch/MDEQ e-mails Jennifer Crooks and Miguel Del
Toral/EPA saying that the 90thpercentile is 6 ppb for the monitoring period 7/1/14-
12/31/14 and that Flint has an optimized corrosion control program, and talks about EPA
regulations requiring targeted sample pool to focus on highest risk homes.
30. March 3, 2015: In response to local complaints regarding drinking water quality and
related health effects, Flint EM Ambrose cites $12 million in costs associated with
returning to DWSD.
31. March 12, 2015: Stephen Busch/MDEQ e-mails colleagues stating that there is no
confirmation of Legionella in the water supply. No test data are provided to substantiate
this statement.
32. March 13, 2015: Brad Wurfel/MDEQ e-mails Harvey Hollins/Governors office and Dan
Wyant/MDEQ noting uptick in Legionellosis cases, placing responsibility for follow-up on
GCHD, and discounting GCHD environmental hygienist Jim Henrys concerns about a
possible relationship between uptick in Legionellosis and change in water source.
33. March 13, 2015: Stephen Busch/MDEQ e-mails Jim Henry/GCHD stating there is unlikely
to be Legionella at the Flint WTP, but that water main breaks and leaks may permit entry
of Legionella into the water supply. Busch advises contacting MDHHS, but does not
himself contact MDHHS.
34. March 30, 2015: MDEQ notifies Flint of results of first 6-month lead and copper
monitoring period (July-December 2014) showing 6 ppb result.
35. March 31, 2015: Jennifer Crooks/EPA corresponds with MDEQ regarding a conference call
that focused on increased cases of Legionellosis.
36. April 25, 2015: Miguel del Toral/EPA e-mails Pat Cook/MDEQ, questions how a large water
system can be deemed to have optimal corrosion control without treatment, cites federal
regulations that provide the only two scenarios for large systems to be deemed to have
optimized corrosion control, and shows that Flint does not meet either of the two
scenarios.
37. April 27, 2015: Miguel Del Toral/EPA e-mails Tom Poy/EPA and other colleagues stating
that Pat Cook/MDEQ has confirmed the Flint WTP has no corrosion control treatment
(CCT), which is very concerning given the likelihood of lead service lines in the city.
38. April 27, 2015: Laurel Garrison/CDC e-mails GCHD stating that the Legionellosis outbreak
in Genesee County is very large, one of the largest in the past decade.
39. April 27, 2015: Miguel Del Toral/EPA visits LeeAnne Walterss house to inspect plumbing
and deliver sampling bottles.
40. April 27, 2015: Pat Cook and Stephen Busch/MDEQ exchange e-mails complaining about
Del Toral/EPA's questions on corrosion control treatment.
41. May 29, 2015: MDHHSs Surveillance of Infectious Diseases and Epidemiology team
produces a report regarding Legionellosis cases in Genesee County in 2014-2015; the
conclusion of the report is that the outbreak is over.20

20
Of the Legionellosis cases in 2014-2015, 42 percent had healthcare (hospital) contact; 47 percent had contact
with the Flint water supply. The report indicates that the lack of clinical specimens from patients prohibited
19

MARCH 2016
42. June 24, 2015: Miguel Del Toral (EPA) provides Tom Poy/EPA his Interim Report: High
Lead Levels in Flint, Michigan, summarizing information and concerns about lead levels in
drinking water in Flint.
43. June 10, 2015: EPA/MDEQ conference call includes discussion of the fact that Flint does
not have CCT in place.
44. June 25, 2015: Adam Rosenthal/MDEQ e-mails Mike Glasgow and Brent Wright/Flint
Utilities Department (copying Mike Prysby and Stephen Busch/MDEQ) reminding them
that 61 more lead and copper samples need to be collected and sent to the lab by June
30, 2015, and that they are will be [sic] below the AL [action level] for lead. As of now
with 39 results, Flints 90th percentile is over the AL for lead.
45. July 7, 2015: MDEQ is contacted by the American Civil Liberties Union regarding a draft
letter from Miguel Del Toral/EPA to LeeAnne Walters that raises concerns about possible
leaching of lead from service lines without appropriate corrosion control.
46. July 10, 2015: Susan Hedman/EPA Region 5 (based in Chicago) writes to Flint Mayor
Walling to say that EPA will work with MDEQ on issues related to lead in water.
47. July 22, 2015: Governor Snyders chief of staff Dennis Muchmore e-mails director of
MDHHS expressing that many members of the Flint community are raising concerns about
water but feel they are not being heard.
48. July 23, 2015: Linda Dykema/MDHHS e-mails Deputy Director of Population Health and
Community Services Susan Moran and others at MDHHS (though not Director Lyon)
stating that she has corresponded with MDEQ and that there has been no change in
compliance regarding Flint water quality and appropriate state and federal law, and that
Miguel Del Toral/EPA acted outside of his authority (these are MDEQ talking points).
49. July 24, 2015: In response to Muchmore e-mail, Brad Wurfel/MDEQ writes, The bottom
line is that the residents of Flint do not need to worry about lead in the water supply, and
MDEQ recent sampling does not indicate eminent [sic] health threat from lead.
Muchmore responds, Thanks.
50. July 28, 2015: MDHHS epidemiologist Cristin Larder finds that childrens blood lead tests
conducted in summer 2014 lie outside the control limit compared with prior years and
that this finding does warrant further investigation. On the same day, CLPPP data
manager Robert Scott analyzes the data over a 5-year period and concludes that water
was not a major factor. Later that day, CLPPP manager Nancy Peeler concludes that the
lack of persistently elevated blood lead levels in children in Flint beyond the summer
months indicates no connection to the change in water in Flint in 2014. Larder then
receives email communication from Peeler: Peeler has concluded from CLPPP data and
communicated with MDHHS leadership that there is no problem with children's lead
levels in Flint.
51. August 27, 2015: Virginia Tech professor Marc Edwards releases his first set of findings
regarding tests of water in Flint. Over half of 48 samples have lead levels of more than 5
parts per billion (ppb) and 30 percent of samples have lead levels greater than 15 ppb.

testing that could have made a definitive link to the water supply as a source of Legionella. It indicates that there
should be vigilance in 2015 regarding possible new cases of Legionellosis, including collection of clinical
specimens.

20

MARCH 2016
52. August 31, 2015: EPA/MDEQ conference call: second 6-month monitioring test results for
January 1-July 31, 2015 indicate 90th percentile at 11 ppb. It is determined that CCT is
needed and implementation steps are delineated.
53. August 31, 2015: Brad Wurfel/MDEQ raises concerns about Professor Edwardss tests and
accompanying media coverage to MDEQ, Muchmore, Harvey Hollins, Dave Murray and
Sara Wurfel of Governors office. There is no apparent communication with MDHHS
regarding this issue.
54. September 8, 2015: Virginia Tech posts to FlintWaterStudy.org sample testing results on
252 samples of 300 sample kits provided. The Virginia Tech researchers concluded that:
mathematically, even if the remaining 48 samples returned have non-detectable lead...
FLINT HAS A VERY SERIOUS LEAD IN WATER PROBLEM. Of the 252 water samples, 101
have lead in excess of 5 ppb. Flints 90th percentile in Edwards survey was 25 ppb.
Several samples were over 100 ppb and one of the samples as over 1,000 ppb.
55. September 9-12, 2015: MDHHS begins to develop educational program materials for the
public regarding reducing the risk of lead exposure for children, in response to media
coverage of Professor Edwardss water testing results.
56. September 22, 2015: Dr. Mona Hanna-Attisha, director of the pediatric residency program
at Hurley Medical Center, contacts Robert Scott/MDHHS to request access to the states
childhood lead testing records. This is a similar request to one filed by Professor Edwards
several weeks before, to which the state had yet to respond. No data are shared.
57. September 23, 2015: Nancy Peeler/MDHHS, director of the states Childhood Lead
Poisoning Prevention Program (CLPPP), e-mails Robert Scott/MDHHS to consider re-
running the analysis that had been conducted in July, and asks for formal epidemiologic
help. Later that day, Mikelle Robinson/MDHHS writes to colleagues that the Governors
office briefing maintains that Flint water does not represent an imminent public health
problem.
58. September 24, 2015: Dr. Hanna-Attisha presents her findings about children tested for
lead in a press conference at Hurley Medical Center, reporting that the proportion of
children with elevated blood lead levels has increased since the switch to the Flint River
water source in April 2014. MDHHS issues comments emphasizing differences between
the Hurley analysis and preceding internal analyses by MDHHS that were not shared
publicly. That same day, Robert Scott/MDHHS writes in an internal memo that he sees
patterns in blood lead levels similar to what Dr. Hanna-Attisha has reported.
59. September 28, 2015: MDHHS Director Nick Lyon calls for analysis of the blood lead levels
in order to make a strong statement with a demonstration of proof that the blood lead
levels seen are not out of the ordinary. No such analysis is ever provided. Later that day,
Governor Snyder is briefed by staff that the Flint water system is in compliance.
60. September 29, 2015: The Detroit Free Press publishes an analysis of Flint blood lead tests,
concluding that Dr. Hanna-Attishas analysis is correct. GCHD issues a health advisory
regarding the water quality. Governor Snyders office contacts Director Wyant and
Director Lyon to consider emergency responses.
61. October 1, 2015: MDHHS issues a statement confirming Dr. Hanna-Attishas analysis.
62. October 16, 2015: Flint switches back to DWSD as source of drinking water for the city.

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MARCH 2016
Regulatory Context
The federal Safe Drinking Water Act21 (SWDA) was enacted in 1974 and governs regulation of
drinking water throughout the United States. It has been amended multiple times since its
enactment, most recently in 2015. From the United States Environment Protection Agency (EPA)
website:
The Act authorizes EPA to establish minimum standards to protect tap water
and requires all owners or operators of public water systems to comply with
these primary (health-related) standards. The 1996 amendments to SDWA
require that EPA consider a detailed risk and cost assessment, and best available
peer-reviewed science, when developing these standards. State governments,
which can be approved to implement these rules for EPA, also encourage
attainment of secondary standards (nuisance-related).22
Michigan enacted the state Safe Drinking Water Act (PA 399) in 1976. It establishes state
authority for regulating drinking water supplies in Michigan. It also provides the statutory basis
for the EPAs delegation to the Michigan Department of Environmental Quality (MDEQ) to
implement the federal SWDA, including the Lead and Copper Rule (LCR).
Lead and Copper Rule
The Lead and Copper Rule (LCR), promulgated in 1991,23 falls under the SDWA. Short-term
revisions, prompted following the incidence of elevated lead levels in the District of Columbias
water distribution system, were published in the Federal Register in 2007.24 From the guidance to
the states on the rule:
The goal of the LCR is to provide maximum human health protection by reducing
lead and copper levels at consumers' taps to as close to the [Maximum
Contaminant Level Goals] MCLGs as is feasible. To accomplish this goal, the LCR
establishes requirements for community water systems (CWSs) and non-transient
non-community water systems (NTNCWSs) to optimize corrosion control and
conduct periodic monitoring. Systems are required to perform public education
when there are lead action level exceedances at more than 10 percent of the taps
that are sampled, treat source water if it contributes significantly to lead and
copper levels at the tap, and replace lead service lines in the distribution system if
the lead level at the tap continues to exceed the action level after optimal
corrosion control and/ or source water treatment has been installed.25
The MCLG for lead in water is 0 milligrams per liter (mg/L); the action level requiring public
notification of exceedance is 0.15 mg/l (also expressed as 15 parts per billion).
Large water systems, defined as those serving over 50,000 people, were required to have optimal
corrosion control treatment (OCCT) by 1997. The rule requires large water systems that have met

21
42 U.S.C. 300f et seq., 1974

www.epa.gov/laws-regulations/summary-safe-drinking-water-act
23
56 FR 26460, June 7, 1991
24
72 FR 57782, October 2007
22
25
LCR Short-Term Revisions State Implementation Guidance-Final June 2008
22

MARCH 2016
the OCCT requirements through the installation of corrosion control treatment to continue to
operate and maintain that treatment.26
Currently, EPA is in the process of reviewing and revising the LCR through its established
rulemaking procedures.
Public Health Context

Flint is now confronted by public health challenges: mitigating the effects of toxic lead exposure
and ensuring an appropriate case-tracking and containment response to the outbreak of
Legionellosis in Flint. Several attributes of these public health challenges are particularly
noteworthy and informed our findings and recommendations:
Lead Exposure
Lead is a potent neurotoxin. For any given exposure, lead has more profound health effects in
children because the exposure is distributed throughout the bodys volume. Childrens smaller
body volumes convey larger risks from lead exposure; these effects are concentrated in brain
cells.
One of the most concerning aspects of lead exposure is that once it has been deposited in the
nervous system, lead cannot be removed. The impact of lead poisoning on neurological
development is permanent. Recent research has indicated that, with each 1 microgram per
deciliter increase in blood lead level, children demonstrate decreasing performance on
intelligence tests.27
Given the neurotoxicity of lead, for many decades medicine and public health experts have
focused on how to reduce lead exposure, particularly for children. Known historical sources of
lead include lead in paint, lead in gasoline, and lead in water sources.28 Major federal laws have
addressed these sources by prohibiting lead in paint, prohibiting lead in gasoline, and requiring
corrosion control and testing of public drinking water sources to identify lead contamination in
water (via the LCR, above).
In Michigan, prior to the Flint water crisis, trends in lead test results for children had told a story
of public health progress. As recently as the late 1990s, almost 50 percent of young children (ages
1 to 2) in Michigan had blood lead levels of 5 micrograms per deciliter or above. By 2013, fewer
than 5 percent of young children in Michigan had levels of 5 micrograms per deciliter or above.29
This downward trend mirrors similar improvements in communities across the United States.

26
40 CFR 141.82 (g) Continued operation and monitoring. All systems optimizing corrosion control shall continue to
operate and maintain optimal corrosion control treatment, including maintaining water quality parameters at or
above minimum values or within ranges designated by the State under paragraph (f) of this section, in accordance
with this paragraph for all samples collected under 141.87(d) through (f).
27
Citations offered in Elevated Blood Lead Levels in Children Associated With the Flint Drinking Water Crisis: A
Spatial Analysis of Risk and Public Health Response, by Mona Hanna-Attisha, MD, MPH; Jenny LaChance, MS;
Richard Casey Sadler, PhD; and Allison Champney Schnepp, MD, American Journal of Public Health, November 2015.
28
For a discussion of the prevalent use of lead in the United States and the lead industrys conduct in light of the
determination of its toxicity, see Lead Wars: The Politics of Science and the Fate of America's Children (2013), by
Gerald Markowitz and David Rosner, who are interviewed on National Public Radios Fresh Air in a March 3, 2016
episode titled, America's 'Lead Wars' Go Beyond Flint, Mich.: It's Now Really Everywhere.
Known as the reference level as stated by the federal Centers for Disease Control and Prevention.
29
23

MARCH 2016
These improvements have largely been attributed to reductions in lead paint in households
rather than reductions in lead exposure through drinking water.
In Michigan, routine blood lead level checks are recommended for children 1 to 2 years old who
live in communities that are known to have historically high proportions of children with levels at
the reference level or higher, and for all children with Medicaid health coverage. For the past
decade, Flint has been one of 14 Michigan communities that have been identified by MDHHS as
focus communities because of historically high levels of children with elevated blood lead
levels. Local and state health agencies are responsible, in coordination with childrens healthcare
providers (physicians, nurse practitioners, etc.), for following up on elevated blood lead levels.
Appropriate follow-up includes:
o Providing advice to families regarding increasing the nutritional quality of the childs diet
to increase the amount of foods with high levels of iron, calcium, and vitamin C;
o Rechecking blood lead levels within 3 to 6 months to see whether the level has decreased
below 5 micrograms per deciliter, and continuing interventions and re-testing at this
interval to assure progress; and
o Performing in-home assessments for environmental sources of lead (for example, lead
paint, lead in dust) for children with blood lead levels of 10 micrograms per deciliter or
more.30
Of note, before the Flint water crisis, in-home assessments did not routinely include testing of
drinking water as a potential source of lead exposure.
Legionella
Infections caused by Legionella bacteria can cause relatively mild illness in generally healthy
adults but can cause life-threatening illness and even death in elderly and immune-compromised
patients. Such infections almost never occur in children. Legionellosis, the name given to
infections caused by Legionella bacteria, has been recognized since the 1970s as often occurring
in environments with self-contained air supply systems (such as healthcare facilities) during non-
winter months when cooling towers for air conditioning can serve as breeding grounds for the
bacteria. Historically, Legionellosis is fatal in approximately 10 percent of cases.
Legionellosis is a reportable disease, meaning that infections with Legionella must be reported to
local and state public health authorities. Public health specialists known as epidemiologists
conduct analyses of cases, especially when the pattern of cases exceeds historical levels in a given
jurisdiction.
Prior to the switch to the Flint River as a source of drinking water in 2014, the number of cases of
Legionellosis in Genesee County had not exceeded 10 cases per year for several years. From June
2014 to March 2015, there were 45 cases of Legionellosis in Genesee County, with 5 deaths. This
was described by an expert from the CDC in 2015 as one of the largest [outbreaks of
Legionellosis] in the past decade. About 40 percent of the cases had known exposure to

30
Prior to the Flint water crisis, environmental assessments were not performed for children with blood lead levels
of 5 to 9 micrograms per deciliter, but only for children with blood lead levels of 10 micrograms per deciliter or
higher.

24

MARCH 2016
possible healthcare sources of Legionella; almost 50 percent of cases had known exposure to
Flint River-sourced water supply.31
According to the MDHHS report issued on May 29, 2015, it was not possible for the state
epidemiologists to draw definitive conclusions that the change in water supply was related to the
outbreak of disease, given the lack of clinical specimens of Legionella from patients diagnosed
with the disease in 2014-15. It is speculated that clinical respiratory specimens (sputum) were not
available because antibiotic treatment was started presumptively after a positive urine test for
Legionella, rendering any subsequent specimens indeterminate. Although urine specimens can
confirm a diagnosis of Legionellosis, urine specimens cannot be used for determining the source
of Legionella.
Subsequent data reported publicly by MDHHS on January 21, 2016, indicated that there were 42
additional cases of Legionellosis from May 2015 through October 2015, with 4 deaths.32 Taking
the 2014-15 data together with additional 2015 data, MDHHS reported that 36 percent of cases
likely were exposed to Flint River-sourced drinking water, and that again there were too few
clinical specimens to draw definitive conclusions about contaminated water as the source of
infection in these cases.
At the time of this report, the pattern of an abrupt increase in cases of Legionellosis in Genesee
County in 2014-15 that occurred after a shift to the Flint River strongly implicates the water
source and treatment of the water as a potential cause of higher Legionellosis case incidence.
EPA experts Del Toral and Lytle have suggested that the treated water from Flint WTP has
disrupted the previously stable lining and biofilm of water lines to such an extent that chlorine
in the water supply has been excessively depleted. Del Toral also suggested that the flushing of
fire hydrants may have stripped the biofilm and released bacteria (Legionella) that the biofilm
had contained. If true, this may have led to a situation where Legionella may grow more
abundantly than in a distribution system conveying properly treated drinking water.
Unfortunately, these are hypotheses. Definitive data for the analysis of cases in 2014 and 2015
are not available, so it is not possible to be conclusive about the cause. Nonetheless, great
concern should remain about the clustering of cases among patients potentially exposed in
healthcare facilities in the City of Flint and cases among individuals whose homes receive water
from the Flint WTP.
MDHHS and GCHD have indicated that they will have a high level of vigilance in monitoring for
cases of Legionellosis in 2016. They have reminded healthcare professionals treating patients in
Genesee County to obtain appropriate clinical (respiratory) specimens in suspected cases of
Legionellosis before initiating treatment. This cooperation between public health and medical
professionals will be crucial to identifying the cause of future Legionellosis cases in Genesee
County and controlling outbreaks in the future. In addition, a team of scientists from multiple

31
Some of these cases had exposure to both Flint River water and to healthcare facilities.
32
Twenty-two of the 42 cases reported from May-October 2015 had known healthcare-related exposures in the two
weeks prior to development of symptoms, and 21 of these were from the same healthcare facility. Sixteen of the 42
cases of Legionellosis in Genesee County from May-October 2015 were in individuals who had neither exposure to a
healthcare facility nor exposure to Flint River-sourced water.
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MARCH 2016
Michigan universities is expected to test Flint drinking water in 2016 to assess whether conditions
in the system created an environment that heightened the likelihood of Legionella
contamination.
Roles of Government Entities in the Flint Water Crisis

Many individuals, agencies and groups participated in the events leading to the Flint water crisis
and the subsequent response. Their various roles and responsibilities have been subjects of
considerable discussion and debate. In the subsequent sections, we describe the defined (or
statutory) roles of many of these parties, as well as the nature of their involvement in the Flint
water crisis. Findings and recommendations are also provided.
The water crisis in Flint is effectively elevating public awareness of the latent dangers associated
with lead in water systems, which regulators and many water utilities historically have been
reluctant to address beyond the addition of corrosion control treatment. As it responds to the
acute crisis in Flint, the State of Michigan is in a position to set important precedents that may
have application well beyond the state, as more utilities and regulatory agencies prepare for
more aggressive approaches to address the problem of lead in water. This opportunity is noted in
several of the recommendations provided below.
Michigan Department of Environmental Quality (MDEQ)

Defined Role
MDEQ is responsible for enforcement of the SDWA (including the Lead and Copper Rule (LCR)),
the Clean Water Act (CWA) and other environmental regulations in the State of Michigan. With
respect to drinking water, MDEQs stated goal is that Michigans water resources are clean and
safe and a measure of success towards that goal is that 100 percent of the population has safe
drinking water with no reported violations of health based standards.33 The agencys
responsibility for SDWA compliance enforcement derives from it, like all other states except
Wyoming, being delegated primacy by the EPA.
Within the MDEQ, the Office of Drinking Water and Municipal Assistance (ODWMA) has
responsibility for SDWA enforcement and lending assistance to public water suppliers. The
ODWMA Community Water Supply Programs primary function is regulatory oversight of
approximately 1,425 community public water supplies in Michigan.34 The Community Water
Supply Program provides capacity development and operator training and certification, operates
certified laboratories, and monitors and reports on public water system violations. ODWMA staff
who regulate compliance with the SDWA are not required to be licensed operators or have
experience with drinking water treatment plant or distribution system operations.
For many communities, ODWMA has been and continues to be relied upon to provide technical
assistance and guidance on water treatment processes, approaches to managing distribution

33
Sustaining Michigans Water Heritage: A Strategy for the Next Generation, Draft for Public Review, June 4, 2015.
Prepared by the Michigan Office of the Great Lakes, in collaboration with Michigan Department of Environmental
Quality, Michigan Department of Natural Resources, Michigan Department of Agriculture and Rural Development,
and Michigan Economic Development Corporation, p. 6.
34
www.michigan.gov/deq/0,1607,7-135-3313_3675_3691---,00.html

26

MARCH 2016
system water quality, and overall utility management. ODWMA historically has taken a
collaborative approach with public water suppliers, offering guidance on technical requirements
for compliance with environmental regulations.
Discussion
MDEQ is responsible for ensuring that community water systems comply with the SDWA.
According to EPA Region V, ODWMA, which was originally within the state Department of
Community Health, has more community water systems to regulate than other Region V states.
Additionally, while all states water system regulators in Region V are stretched financially,
Michigan is particularly challenged because fees to operate the program are generally lower than
fees charged by other states, requiring the state to rely more heavily on general funds and
federal revenue.
For a variety of reasons, MDEQ discounted use of the Flint River as a permanent water source in
2013. However, it did agree to use of the river as a temporary source, conditioned upon
completion of identified improvements to the Flint Water Treatment Plant (WTP). Flint was
granted two permit modifications in April 2014 that allowed the treatment plant to operate full-
time with the Flint River as the water source.
In advance of the City of Flints conversion from DWSD water supply to use of Flint River water,
MDEQ had multiple communications and meetings with Flint Utilities Department staff and their
consultants. A plan of treatment of Flint River water was discussed and covered numerous issues
including dosing of chemicals, use of polymers, and unit process performance. When asked by
Flint water plant personnel about adding phosphate in the treatment process, as DWSD does for
corrosion control, MDEQ said that a corrosion control treatment decision would be made after
two 6-month monitoring periods were conducted to see if corrosion control treatment was
needed. Similarly, distribution system operations requirements were outlined, including sampling
and testing for compliance with the LCR that involved obtaining tap water samples from high-risk
residences. ODWMA anticipated that use of Flint River water would be problematic35 but
deferred to state emergency manager decisions to proceed.36 Subsequently:
o MDEQ advised Flint WTP staff, in contradiction to longstanding federal policy under the
LCR, that corrosion control treatment was not required.
o MDEQ did not require appropriate sampling of tap water quality as mandated by the LCR.
o MDEQ obstinately used water quality test results based on flawed sampling and insisted
on the accuracy of the erroneous data.
o MDEQ dismissed expressed concerns of Flint residents, elected officials, and external
subject matter experts (as well as EPA).

35
Internal March 26, 2013 MDEQ e-mail (Busch to Wyant, Shekter Smith, and others) noting, among other points:
Continuous use of the Flint River at such demand rates would: Pose an increased microbial risk to public health
(Flint River vs. Lake Huron source water), Pose an increased risk of disinfection by-product (carcinogen) exposure to
public health (Flint River vs. Lake Huron source water), Trigger additional regulatory requirements under the
Michigan Safe Drinking Water Act.
36
Internal March 27, 2013 MDEQ e-mail (Sygo to Busch) noting, among other points: As you might guess we are in a
situation with Emergency Financial Managers so its entirely possible that they will be making decisions relative to
cost. The concern in either situation is that a compliant supply of source water and drinking water can be supplied.
27

MARCH 2016
o MDEQ inaccurately reported information about Flints corrosion control to EPA, stating
that Flint had an optimized corrosion control program when, in fact, it was not employing
corrosion control treatment.
o MDEQ deferred requiring Flint to implement CCT until after the second 6-month
monitoring period was completed and showed lead levels of 11 ppb, though EPA advised
MDEQ to require Flint to have CCT as early as April 2015.
o MDEQ waited on legal opinions about SDWA compliance requirements and delayed
admission of its incorrect interpretation of SDWA compliance requirements for (at least) 2
months.
o MDEQ insisted, even after compelling evidence of lead poisoning of children was
presented, that Flint water quality met applicable SDWA standards.
o MDEQ failed (for more than a year) to work with MDHHS leadership and staff to ensure
an appropriate and comprehensive public health response to repeated requests to
address health concerns related to drinking water. MDEQ continued to insist the water
was safe and met all federal requirements, and discouraged any statements that would
imply that the water was not safe.
The obvious question that MDEQ, along with the City and its consultants, should have asked was:
What will happen without corrosion control treatment? Similarly, they could have asked why a
less corrosive source of water (Lake Huron water) would be required to have corrosion control
treatment, but not the more corrosive Flint River source. In Flint, the more corrosive water
source ultimately destroyed the protective scaling on pipes and plumbing that orthophosphate
addition had provided through the water supplied by DWSD.
Findings
The FWATF, as stated in our second letter to Governor Snyder,37 places primary responsibility for
the Flint water crisis on the MDEQ, and specifically its ODWMA. This finding is based on
numerous interviews and reviews of publicly available documents. Nothing in our subsequent
interviews or our review of thousands of pages of related documents has dissuaded us from this
fundamental conclusion. We found that:
F-1. MDEQ bears primary responsibility for the water contamination in Flint.
F-2. MDEQ, specifically its ODWMA, suffers from cultural shortcomings that prevent it from
adequately serving and protecting the public health of Michigan residents.
F-3. MDEQ misinterpreted the LCR and misapplied its requirements. As a result, lead-in-water
levels were under-reported and many residents exposure to high lead levels was
prolonged for months. Specifically:
o MDEQs misinterpretation of the LCR and lack of due caution resulted in the
decision not to require corrosion control upon the switch to the Flint River but,
rather, to begin two consecutive 6-month water quality monitoring periods.
o MDEQ failed to promptly require corrosion control even after the initial 6-month
monitoring period results were received and 90th percentile lead sampling results
were at 6 ppb, which would have disqualified Flint from being exempted from

See Appendix II for copies of the FWATFs letters to Governor Rick Snyder.
37
28

MARCH 2016
having to have corrosion control treatmenteven under MDEQs flawed

interpretation.
o MDEQs guidance to Flint on LCR compliance sampling techniques (calling for pre-
flushing, use of small mouthed bottles, etc.), while possibly technically permissible,
was not designed to detect risks to public health. MDEQ failed to take adequate
steps to correct Flint water operations staffs inaccurate LCR sampling.
o MDEQ ODWMA advised Flint Utilities Department personnel to make sure the rest
of the water samples in the second 6-month monitoring period were clean, since
the samples they had already submitted exceeded EPAs action level for lead.
o MDEQ conveniently, and without adequate investigation, excluded LeeAnne
Walterss water quality test results for purposes of determining whether Flint
sampling results exceeded EPAs action level.
F-4. MDEQ waited months before accepting EPAs offer to engage its lead (Pb) experts to help
address the Flint water situation and, at times, MDEQ staff were dismissive and
unresponsive.
F-5. MDEQ failed to move swiftly to investigate, either on its own or in tandem with MDHHS,
the possibility that the Flint water system was contributing to an unusually high number
of Legionellosis cases in Flint.
MDEQ caused this crisis to happen. Moreover, when confronted with evidence of its failures,
MDEQ responded publicly through formal communications with a degree of intransigence and
belligerence that has no place in government. These failures are not diminished, nor should focus
on them be deflected, by the fact that other parties contributed to the disastrous decisions or the
prolonging of their consequences.
Recommendations
R-1. Implement a proactive, comprehensive cultural change program within MDEQ, specifically
its ODWMA, to refocus the department on its primary mission to protect human health
and the environment. MDEQ should aspire to become a national leader through a
proactive program designed to detect and address contaminants in public water supplies
in a timely manner.38
o ODWMA should heighten its focus on protection of public health and provide
technical assistance to advance public water system performance.
o Technical assistance should not be oriented toward defining minimum requirements
to achieve technical compliance with regulatory requirements.
o In the event that regulatory requirements are ambiguous, ODWMA should default to
public health protection.

38
For example, in the case of lead detection, ODWMAs program should have adopted water quality sampling
procedures that maximized the potential for detection by identifying high-risk homes, prohibiting pre-flushing of
service lines, and improving sample draw procedures.

29

MARCH 2016
o MDEQs program restructuring should address the findings of this and other program
and incident reviews, and commit to transparent, accessible reporting on
implementation of associated recommendations.
R-2. Establish an apprenticeship/certification program for MDEQ ODWMA employees that
requires direct, hands-on experience with public water system operations. MDEQ
ODWMA employees responsible for water system regulation and SDWA enforcement
should be, or have access to, certified operators and subject matter experts (including, for
example, those at EPA).
R-3. Strengthen SDWA enforcement, most notably for the LCR. The state has the ability to
strengthen its own enforcement of the SDWA and not wait for action to occur at the
federal level:
o Reiterate (and clarify where necessary) appropriate sampling procedures, and
establish them in rule revisions or guidelines such that they are clear for all to
understand. Provide resources for public water systems to obtain authoritative
guidance in the event of questions or concerns.
o Make water sample test results required under the Lead and Copper Rule available to
the public while protecting personally identifiable information.
R-4. Participate in the Flint Water Inter-Agency Coordinating Committees (FWICCs) work
team established to oversee conversion from DWSD-supplied to KWA-delivered water.
MDEQ should draw from that work to revise its policies and procedures for approval of
water treatment and distribution system operating regimens, particularly when source
water changes are contemplated.
R-5. Participate in EPAs ongoing review and revision of the LCR, conveying lessons learned
from the Flint water crisis.39
Michigan Department of Health and Human Services (MDHHS)

Defined Role
The Michigan Department of Health and Human Services (MDHHS)40 is responsible for addressing
all matters of public health for the population of the state. MDHHS works to achieve this goal
through a combination of primary preventionpreventing illnesses before they occur41and
secondary preventionreducing the burden of disease once it has occurred.42
Meeting the responsibilities of MDHHS requires constant attention through surveillance
programs and effective communication and coordination with public health partners at multiple
levels of government (city, county, federal). MDHHS conducts surveillance for dozens of diseases

Also applicable for recommendations related to the LCR offered in the report section on the EPA and LCR.
39
40
Created from the combination of the Department of Community Health and Department of Human Services in
2015.
41
For example, promoting and facilitating childhood vaccination against diseases such as measles and influenza.
42
For example, conducting screening programs to identify individuals who have developed cancer so that they can
receive appropriate medical care.
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MARCH 2016
and health conditions through a wide variety of efforts. For instance, MDHHS is recognized for a
high-quality system of tracking childhood vaccination through the Michigan Care Improvement
Registry (MCIR). MCIR allows state officials to assess childrens vaccination levels on a regular
(weekly) basis, and to identify neighborhoods and schools where vaccination levels may be so low
that outbreaks of vaccine-preventable diseases are possible. As a result, MDHHS can then
communicate with healthcare professionals who administer vaccines, and with parents of
children who are not up-to-date on their vaccinations, to encourage them to protect their
children against disease.
MCIR is a very positive example of the public health function of MDHHS. In the case of Flint,
however, MDHHSs response to two public health concerns, related to lead exposure and cases of
Legionella infection, did not meet the agencys own standard of performance.
Discussion
Childrens Exposure to Lead in Drinking Water
MDHHS includes the Childhood Lead Poisoning Prevention Program (CLPPP), which is responsible
for tracking the results of all childrens blood lead tests, and the Healthy Homes program, which
is responsible for coordinating remediation of homes when high levels of environmental lead
exposure are found for a child with an elevated blood lead level. All blood lead tests conducted in
the state must be reported to CLPPP, under state law. For many years, CLPPP has functioned as a
registry of blood lead tests, comparing aggregate results at the state level in the most recent year
to levels in prior yearstypically in annual reports released in the summer following the end of a
given calendar year. The primary outcomes reported have been the proportions of children with
blood lead levels 10 micrograms per deciliter and proportions with blood lead levels 5
micrograms per deciliter. For more than a decade, CLPPP has also specifically tracked local lead
testing results in 14 focus communities known to have higher proportions of children with
elevated blood lead levels than in other communities in Michigan. Flint is one such focus
community.
The CLPPP operated under the assumption that children with elevated blood lead levels were
being managed by their respective healthcare professionals. Therefore, no urgency was given to
performing the comparisons that they published in annual reports, which were posted online
without any public announcements. For this reason, there is no evidence that MDHHS conducted
an analysis of blood lead levels in 2014 prior to late July 2015, after Governor Snyders chief of
staff Dennis Muchmore wrote to MDHHS officials expressing concern about many complaints
from Flint residents about water quality in Flint.
On July 28, 2015, a MDHHS epidemiologist (Larder) performed a classic epidemiologic analysis of
2014 blood lead test data versus prior years and found a concerning pattern of elevated levels in
Flint. On the same day, the CLPPP data manager (Scott) compared data over the preceding 5
years and concluded that the 2014 data were not substantially different than several preceding
years. Scotts analysis was fundamentally flawed because he failed to consider that the
proportions of children with high blood lead were declining over the years 2011-2013, and
therefore 2014 levels represented a clear deviation from the improving trend in previous years.
For unclear reasons, these conflicting conclusions of Scott and Larder were not elevated to higher
levels of authority within MDHHS. Rather, the explanation that there was no difference (from a
data manager rather than an epidemiologist) was allowed to persist for another 2 months.
Messages from other MDHHS officials over that subsequent time period indicated that they were

31

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aware of the MDEQ narrative that the water in Flint was safe and did not present an imminent
public health problem.
By September 2015, Dr. Mona Hanna-Attisha released her analysis of blood lead tests performed
at Hurley Medical Center, showing that childrens blood lead levels were clearly abnormal at a
higher rate than in prior years. Of note, Dr. Hanna-Attisha and Professor Marc Edwards of Virginia
Tech had formally requested release of CLPPP data from MDHHS (Scott) in previous weeks and
months, but had never received such data, leading Dr. Hanna-Attisha to analyze data from Hurley
Medical Center only. When the Hurley data were released, MDHHS issued statements indicating
that the Hurley data were analyzed using different methodology than the state would employ,
and MDHHS did not endorse the Hurley findings. A few days later, MDHHS Director Lyon sent a
memo to MDHHS staff asking them to make a strong statement with a demonstration of proof
that the blood lead levels seen are not out of the ordinary. Within a few days, MDHHS
epidemiologists had re-analyzed the data and reversed course, agreeing publicly with the Hurley-
based analysis by October 1, 2015.
Subsequently, MDHHS changed its approach and began to analyze blood lead level data in the
CLPPP database on a basis closer to real time. In a series of reports released approximately
every 2 weeks since November 2015, MDHHS has communicated with the public regarding the
proportion of children in Flint with blood lead tests 5 micrograms/deciliter. This is a promising
step in transparency and timeliness.
However, excessive and likely harmful lead exposure already has occurred for hundreds and
perhaps thousands of children in Flint, and it is now MDHHSs responsibility to follow up with
comprehensive secondary prevention. MDHHS reports that about 200 children in Flint are known
to have had childhood lead levels 5 micrograms/deciliter when they were tested since April
2014 (the month of the water switch to the Flint River). This number of children is likely a
profound underestimate of the number of children exposed; based on Census estimates and
Medicaid records, the number of children under 6 years old living in the City of Flint is
approximately 10,900. Given the known risks of lead neurotoxicity for young children,
appropriate near-term, middle-term, and long-term follow-up for children exposed to lead in
Flint will include:
Neurodevelopmental assessments,
Timely access to early childhood education,
Behavioral assessments and interventions in preschool years,
Educational assessments in preschool and school years accompanied by appropriate
learning support, and
o Appropriate counseling and medical therapy to address attentional and behavioral
concerns at school age and into adolescence.
Such comprehensive approaches to secondary prevention for children in Flint are consistent with
a model framework for medical and public health response proposed by Dr. Mona Hanna-Attisha
at Hurley Medical Center.
o
o
o
o
Despite the unmistakable connection between the quality of drinking water and public health,
there is no liaison between MDEQ and MDHHS to ensure that complaints or concerns about
water are brought to the attention of MDHHS staff in a timely fashion to prompt investigative
action. The lack of a liaison function within state government also adversely affected the
response to cases of Legionellosis, as described below.

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Cases of Legionella Infection

Legionellosis is an infection with species of bacteria called Legionella, so called because it came to
prominence when many attendees at an American Legion conference fell ill in 1976.
Legionellosis has a broad spectrum of severity, causing relatively mild illness in some individuals
who are generally healthy and causing much more severe illness in seniors and patients whose
immune systems are weakened. It is generally fatal in about 10 percent of cases.
Legionella bacteria live in water supplies and flourish in warmer temperatures and standing
water, present in locations such as cooling towers for air conditioning systems. It is a reportable
disease, meaning that any healthcare professional who makes the diagnosis must report the case
to the local health department. In turn, the local health department reports cases to the state
health department. Fewer than 10 cases of Legionellosis per year were reported by GCHD in
years immediately preceding the switch of water source to the Flint River.
MDHHS assisted GCHD with evaluation of the Legionellosis outbreak that began in 2014 and
extended into early 2015, at GCHDs request. When the initial evaluation report was issued by
MDHHS epidemiology team in May 2015, it is unclear why they asserted the the outbreak is
over; subsequent reports released in January 2016 indicated that additional cases occurred
beginning in May 2015.43 MDHHS indicated in its May 2015 report that data were inconclusive
regarding a community source such as the water supply because of a lack of clinical specimens.
While MDHHSs statement regarding the absence of conclusive evidence of a community source
has scientific merit, it is evident that MDHHS was not calibrating its evaluation for the unusual
circumstance of the switch to the Flint River in April 2014. In fact, although the report mentions it
as a possible source, there is no explicit mention of the switch to a new raw water source in Flint,
and new water treatment protocols, as possible causal factors. Although there was a January
2015 meeting that included MDHHS, MDEQ and GCHD regarding cases of Legionellosis in
Genesee County, subsequent discussions of Legionellosis appear to have occurred within the silos
of MDEQ and MDHHS until late 2015, and remained uncoordinated until the Governors
announcement about ongoing Legionella investigations in January 2016.
Findings
F-6. MDHHSs lack of timely analysis and understanding of its own data on childhood blood
lead levels, along with its reliance on MDEQ and reluctance to share state data with Dr.
Mona Hanna-Attisha and Professor Marc Edwards, prolonged the Flint water crisis.
F-7. MDHHS bears ultimate responsibility for leadership and coordination of timely follow-up
efforts in Flint and across the state regarding childhood lead poisoning. While local
entities (for example, healthcare professionals, GCHD, health insurance plans) are
partners in efforts to protect children from lead poisoning, MDHHS has the lead role and
failed to exercise its responsibility.
F-8. The consequences of lead exposure for Flint residents are expected to be long-term and
will necessitate sustained investments in education, public and mental health, juvenile
justice, and nutrition needs over the next 10 to 20 years.

This may have been related to delays in reporting between local healthcare professionals, GCHD, and MDHHS.
43
33

MARCH 2016
F-9. Too few children in Michigan are screened for lead through routine blood tests as
recommended for children ages 1 and 2. Statewide screening goals for children enrolled in
Medicaid are met in very few instances at the county level or within Medicaid health
plans. This lack of information leaves parents, healthcare professionals, and local and
state public health authorities uninformed about the possibility of lead poisoning for
thousands of Michigan children.
F-10. Coordination between MDEQ and MDHHS was inadequate to properly address the public
health issues related to water quality in Flint. Communication was infrequent, and when it
did occur, the default position was to conclude that the health problems were not related
to the water supply switch rather than to assume that the problems might be related to
the switch.
F-11. Communication and coordination among local and state public health staff and leadership
regarding Legionellosis cases in 2014-2015 was inadequate to address the grave nature of
this outbreak. The fact that these cases occurred while there were several simultaneous
concerns about quality and safety of water in Flint should have caused public health staff
and leadership at local and state levels to coordinate their actions to ensure a prompt and
thorough investigation.
Recommendations
R-6. Establish policies and procedures at MDEQ and MDHHS to ensure input by health experts
and scientists when permit decisions may have a direct impact on human health.
R-7. Establish and maintain a Flint Toxic Exposure Registry to include all the children and
adults residing in Flint from April 2014 to present.
The Flint Toxic Exposure Registry will serve as an authoritative reference source of
information (including contact details [for example, primary contact information, back-up
contact information, and preferred mode of contact]) for purposes of timely health
assessments in the short-term and long-term, as well as subsequent communication
regarding policies and scientific findings. Timely assessments will include clinical
evaluations and re-evaluations in healthcare settings, appropriate follow-up conducted by
public health professionals, and longitudinal assessments of the impact of environmental
exposure on childrens and adults health (including among pregnant women).
R-8. Re-establish the Michigan Childhood Lead Poisoning Prevention and Control Commission.
The Commission would perform a comprehensive review of the states lead poisoning
prevention program; evaluate the effectiveness of the program, including its ability to
satisfy federal law requiring that 100 percent of all young children enrolled in Medicaid be
screened with a blood lead test; and make recommendations for the programs
improvement. The Commission would also conduct public hearings, review information
from other sources, and study other states experiences. The Commission must also
develop short- and long-range strategic recommendations for childhood lead poisoning
prevention and control in Michigan.
R-9. Ensure that MDHHS is transparent and timely in reporting and analysis of aggregate data
regarding childrens blood lead levels. MDHHS data regarding lead levels shall be provided
34

MARCH 2016
to individuals and organizations, based on their expertise, upon request and in cases
when the interpretation of data by MDHHS is questioned.
R-10. Establish a more aggressive approach to timely clinical and public health follow-up for all
children known to have elevated blood lead levels, statewide. MDHHS should expand its
local efforts and partnerships to accomplish this goal. Whenever possible, routine
screening for lead and appropriate follow-up should occur in childrens primary care
medical homes.
R-11. Strive to be a national leader in monitoring and responding to exposure of children to
lead by converting the Childhood Lead Poisoning Prevention Program (CLPPP) from
passive collection of test results into an active surveillance and outreach program.
Performance of the surveillance program should be reported to the public. MDHHS
should be prepared to amplify its efforts if performance targets are not met.
R-12. Improve screening rates for lead among young children through partnerships with county
health departments, health insurers, hospitals, and healthcare professionals.
R-13. As the state authority on public health, and as the organization that conducted the
epidemiologic study of Legionellosis cases in Genesee County in 2014-15, take
responsibility for coordinating with GCHD and CDC to protect Michigan residents from
further outbreaks of Legionellosis.44
R-14. In cases of switches in drinking water supplies in the future, the state must assume that
outbreaks of cases of Legionellosis may be related to changes in water source and should
communicate the potential risk to the public, rather than assuming and communicating
the opposite.
Michigan Governors Office

Defined Role
The Governor of Michigan heads the executive branch of Michigan state government and has the
power to reorganize state departments and appoint department heads. All executive branch
departments of state government report to the Governor, including the three key departments
involved in the Flint water crisis: MDEQ, MDHHS, and Treasury. The Governor also appoints
personal staff to keep him informed of issues and events. Among other responsibilities, the
Governor (through the Michigan Department of Technology, Management and Budget) submits
an annual budget and has a line-item veto for appropriations bills.
Rick Snyder, Michigans 48th Governor, took office in January 2011. He began his second term in
January 2015.

44
Specific steps should include: (a) anticipate the risks of Legionellosis infections going forward; (b) take timely steps
to minimize those risks in Flint drinking water by working with EPA, MDEQ and Flint WTP; (c) coordinate with
healthcare facilities to minimize risks of healthcare facility-acquired Legionellosis; (d) communicate with the public
about steps being taken and cases of Legionellosis that occur.
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MARCH 2016
Discussion
The Flint water crisis occurred during Governor Snyders tenure. The Governor and his office
were directly involved in some aspects of the crisis and briefed on some of the major decisions
surrounding Flint drinking water. Emergency managers that he appointed made key decisions
that led to and prolonged the crisis. He appointed the directors of the three state departments
MDEQ, MDHHS, and Treasurythat bear differing degrees of responsibility for what happened.
The Governor and the Governors office must rely heavily on information from state departments
to make decisions, set directions, and take action. In this case, the individuals and departments
on which the Governor relied for guidance provided wrong information, particularly on the issues
related to lead in the drinking water and elevated blood lead levels in children. In particular, two
state agencies attempted to dismiss and discredit credible evidence of threats to public health.
MDEQ did not acknowledge the true extent of the Flint water problems until late September
2015. Likewise, MDHHS, which misread its own data on childrens blood lead levels in Flint, did
not inform the Governor of lead poisoning related to use of the Flint River as a water source until
late September 2015.
However, Governor Snyder and certain executive staff members were aware before late
September 2015 of several issues that are noteworthy and relevant. For example:
o The Department of Treasury approved the Flint emergency managers decisions
(supported by Flint City Council) to switch to KWA after negotiations across two entities
under emergency management failed. Members of the Governors staffand the
Governor himselfparticipated in some of those discussions.
o The Governors office received citizen complaints and was well aware of numerous press
stories about water quality problems as early as May 2014 and continuing throughout
2015.45,46
o The decision by General Motors (GM) in October of 2014 to use Flint Township water
instead of Flint WTP-sourced water for its Flint Engine Operations facility was not only
known to executive staff members of the Governor, but was also cited as a reason to
switch back to DWSD (see below).
o In late January 2015, at least one member of the Governors office was informed that
concerns were being raised in the MDEQ about the Legionellosis outbreak in Genesee
County and possible connection to the Flint water supply.47
o In March 2015, at least one of the Governors office staff members was advised of the
Legionellosis outbreak in Flint and local health department concerns of a potential link to
the Flint water conversion.48

45
This was subsequent to Department of Treasurys approval of the Flint emergency managers decision to contract
with LAN to upgrade the Flint WTP to treat water from the Flint River as the primary drinking water supply, instead
of purchasing water from DWSD.
46
The October 1, 2014 MDEQ briefing paper to Governor's office regarding City of Flint drinking water situation (boil
water notices) ascribes problems to aged, inadequately maintained, cast iron pipe in the distribution system.
47
See January 30, 2015 e-mail from Brad Wurfel/MDEQ to Dave Murray, Governor Snyders deputy press secretary,
re: Legionella.

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MARCH 2016
o In March 2015, the Governors chief of staff proposed buying and distributing bottled
water in Flint because of citizen concerns about water quality.
o In mid-summer 2015, an aide to Governor Snyder arranged for the donations of water
filters to be distributed in Flint to address concerns about water quality.
o In mid-summer 2015, the Governor and senior staff discussed Flint water issues; lead was
apparently part of those discussions.
The switch to the Flint River as the primary source of drinking water for the City of Flint occurred
in late April 2014. On October 14, 2014, after citizen complaints about the waters odor, color
and taste49 and the decision by GM to leave the Flint water system, two key executive staff
members traded emails suggesting that, given these problems, it was time to switch back to
DWSD for Flints drinking water. Other executive staff members received these emails, and
according the Governors chief of staff at the timethe Governor was informed of the concern
and the suggestion. A phone conversation occurred between key staff members Valerie Brader
and Rich Baird and the Flint emergency manager about the suggestion. The emergency manager
assured these Governors office staff members that the water quality problems were not of a
permanent nature and asserted that it would be too costly to switch back to DWSD. That
conversation ended any serious discussion about switching back to DWSD at that time.
The suggestion to switch back to DWSD was revisited in mid-summer 2015. However, MDEQ
continued to provide reassurances that the treated water reaching homes in Flint was both safe
and in compliance with SDWA requirements. These continuing reassurances, as well as the cost
issue, apparently prevented any systemic or comprehensive review of the water situation in Flint.
According to Governor Snyder, it was not until after September 28, 2015, that he was personally
advised that MDEQ and MDHHS had been wrong for months about the reality of lead in the
water and childrens blood lead levels.
Discussions about the Flint water situation were also conducted in the context of overarching
discussions about financially distressed cities served by emergency managers, and Flint in
particular. Flint water issues were a focal point for senior staff and were discussed with the
Governor. Considerable frustration was apparent due to new issues arising just as immediate
problems seemed on the road to improvement. Continued reliance on MDEQ drove poor
decisionsor the lack of decisions.
As the Flint water crisis unfolded, certain state agencies perceived need to defend the original
decision to switch to the Flint River and resist a return to DWSD resulted in public relations and
communications efforts that have, at times, been inappropriate. In the spring and summer of
2015, for example, this perceived need to defend a flawed decision manifested itself in attempts
by MDEQ and MDHHS to discredit accurate information on lead in drinking water and elevated
blood lead levels provided by outside experts. Citizen concerns were at times derided and
dismissed, in spite of the fact that various members of the Governors staff had expressedand
were expressingconcerns about the water situation in Flint at the same time.

48
See March 13, 2015 E-mail from Brad Wurfel/MDEQ to Harvey Hollins/Governors office.
Though not, at that time, related to lead or TTHMs.
49
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MARCH 2016
To some extent, inappropriate official public relations efforts continue to this day. Even as the
state is aggressively engaged in mitigation efforts in Flint, the statement that the Flint water crisis
was a local, state, and federal failure implies that blame is attributable equally to all three levels
of government. Primary responsibility for the water contamination in Flint lies with MDEQ. In
addition, at the time of the water crisis, Flint was under the control of state-appointed
emergency managers, who made key decisions that contributed to the crisis. Because of these
two facts, the state is fundamentally accountable for what happened in Flint.
Though delayed, we acknowledge and support the many steps the Governor has taken to date to
address the implications of lead in the Flint water supplythe state declaration of emergency,
the establishment of both the Flint Water Inter-Agency Coordinating Council and Mission Flint,
additional funding for addressing the health issues faced by lead-poisoned children in Flint,
partial reimbursement for water bills paid during the time of lead contamination, and progress on
a plan to replace LSLs.
Findings
F-12. Ultimate accountability for Michigan executive branch decisions rests with the Governor.
F-13. The Governors knowledge, and that of Governors office staff, of various aspects of the
Flint water crisis was compromised by the informationmuch of it wrongprovided by
MDEQ and MDHHS.
F-14. The Governors office continued to rely on incorrect information provided by these
departments despite mounting evidence from outside experts and months of citizens
complaints throughout the Flint water crisis, only changing course in early October 2015
when MDEQ and MDHHS finally acknowledged the extent of the problem of lead in the
public water supply.
F-15. The suggestion made by members of the Governors executive staff in October 2014 to
switch back to DWSD should have resulted, at a minimum, in a full and comprehensive
review of the water situation in Flint, similar to that which accompanied the earlier
decision to switch to KWA. It was disregarded, however, because of cost considerations
and repeated assurances that the water was safe. The need to switch back to DWSD
became even more apparent as water quality and safety issued continued and lead issues
began to surface in 2015, notwithstanding reassurances by MDEQ.
F-16. The Flint water crisis highlights the risks of over-reliancein fact, almost exclusive
relianceon a few staff in one or two departments for information on which key
decisions are based.
F-17. Official state public statements and communications about the Flint water situation have
at times been inappropriate and unacceptable.
Recommendations
R-15. Expand information flow to the Governor so that information providing the foundation
for key decisions comes from more than one trusted sourceand is verified.
R-16. Create a culture in state government that is not defensive about concerns and evidence
that contradicts official positions, but rather is receptive and open-minded toward that
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MARCH 2016
information. View informed opinionseven if critical of state governmentas an

opportunity for re-assessing state positions, rather than as a threat.
R-17. Ensure that communications from all state agencies are respectful, even in the face of
criticism, and sensitive to the concerns of diverse populations.
R-18. The Governor must assume the leadership of, and hold state departments accountable
for, long-term implementation of the recommendations in this report, including but not
limited to the need for cultural changes across multiple state agencies, the need for
health mitigation and LSL replacement in Flint, and the need for a funding strategy to
address replacement of LSLs statewide.
R-19. Review budget requests for MDEQ to ensure adequate funding is provided to the
ODWMA. EPA audit and interviews indicate that Michigans drinking water program might
have one of the lowest levels of financial support within EPA Region V while having one of
the largest, if not the largest, number of community water systems to regulate.
State-Appointed Emergency Managers

Defined Role
The role of the emergency manager (EM) under the Emergency Manager Law, PA 436, is clear
and unambiguous. Though they report directly to the Department of Treasury, EMs have
complete authority and control over municipal decisions. In that context, the EMs had the
responsibility to ensure that Flint water system operations were adequately resourced and
supported by personnel and consultants with adequate training and expertise.
Discussion
Owing to significant declines in economic vitality and substantial outmigration since (at least) the
1990s, Flint was first placed in financial receivership under an emergency financial manager
between 2002 and 2004.50 Since 2011, the City has been under some form of state-ordered and
controlled emergency financial management.51 During this time, four different EMs have served
for varying lengths of time, one serving twice.52
Our interviews confirmed the EMs reported to and interacted regularly with Treasury officials.
They discussed issues such as public safety, staffing requirements, and financial matters. The
EMs, working through Treasury, also would contact other state agencies for assistance on a
regular basis, such as the State Police on law enforcement matters.

50
Imposed under PA 72 of 1990.
51
In 2011, PA 72 was replaced by PA 4, which amplified the powers of an appointed EM. The voters repealed PA 4 in
November 2012, but a subsequent statute was passed by the legislature in December 2012: PA 436 of 2012. That
statute is not subject to a voter referendum and has been in effect since March 2013.
52
Ed Kurtz served as Flints emergency financial manager under PA 72 of 1990 from May 2002 to 2004; Michael
Brown was appointed in December 2011 under PA 4; Ed Kurtz became EM again in August 2012; Michael Brown was
reappointed again in June 2013; Darnell Earley replaced Brown In October 2013; Jerry Ambrose replaced Earley in
January 2015; and Ambrose left in April 2015 when control over the citys finances was assigned to a city
administrator under the supervision of a Receivership Transition Advisory Board.

39

MARCH 2016
Numerous decisions were made between December 2011 and April 2015 that had some impact
on the decision to use the Flint River as the primary source of drinking water for the City of Flint.
Various state-appointed EMs served during this timeframe and it was these EMs who made these
decisions, not locally elected officials. Although it is true that some locally elected officials
supported, acknowledged, embraced, and even celebrated some of the decisions, the decisions
were not theirs to make. The state-appointed EMs made the decisions.
Specifically, Flint EM Ed Kurtz authorized use of the Flint River as a water source for Flint, as
clearly indicated by his approval of a sole-source contract for the engineering firm Lockwood,
Andrews, & Newnam (LAN) to prepare the Flint WTP for full-time treatment of Flint River water.
Darnell Earley was the incumbent Flint EM and presided over the switch of water sources in April
2014. He and later EM Jerry Ambrose were in place during periods when citizens requested a
return to DWSD because of health problems they were experiencing. Neither Darnell Earley nor
Jerry Ambrose seriously considered a return to DWSD in part because MDEQ, local staff and their
consultants assured the EMs that the water quality problems were manageable and that there
was nothing seriously wrong with the water.53 In March 2015, nearly one year after the source
water conversion, Jerry Ambrose stated that a reconnection to DWSD would cost the City $10.1
million per year and that water purchases could be as high as $1 million per monthessentially
asserting that it was unaffordable.54
In any event, the facts in this case point to the reality that state government, as the entity in
charge of Flint decision-making, failed to protect the health of the citys residents. Regardless of
any successes of the EM process in other Michigan cities, this failure must force us to review the
EM law and the general approach to financial problems. Government approaches to cities in fiscal
distress must balance fiscal responsibility with the equally important need to address quality of
life, economic development, and infrastructure maintenance and provision.
Findings
F-18. Emergency managers, not locally elected officials, made the decision to switch to the Flint
River as Flints primary water supply source.
F-19. Treasury officials, through the terms of the local emergency financial assistance loan
executed by the Flint emergency manager on April 29, 2015, effectively precluded a
return to DWSD water, as Flint citizens and local officials were demanding, without prior
state approval.
The Emergency Manager Law is predicated on the provision that any ongoing
accumulated local government deficit is resolved prior to the termination of receivership
(P.A. 436 of 2012). As the city of Flint neared the end of its Emergency Manager status in
March 2015, the city still retained an $8 million accumulated deficit in the General Fund.
To resolve this accumulated deficit, the state and the Flint EM, with the concurrence of
Flints City Council, signed an emergency loan agreement between the City of Flint and

53
See, for example, "City of Flint Water System Update with Questions and Answers," February 16, 2015, posted to
City of Flint website at www.cityofflint.com/wp-content/uploads/Water-Sysytem-FAQ-Update-2-16-151.pdf, as
confirmed in FWATF interviews of Flints former EMs.
54
Memorandum dated March 3, 2015, to Deputy State Treasurer Wayne Workman.
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MARCH 2016
Michigans Local Emergency Financial Assistance Loan Board for nearly $8 million.55 This
emergency loan included a provision that the City of Flint could not, without prior state
approval, return to DWSD or lower water rates.
F-20. The role of the EMs in Flint (in combination with MDEQs failures) places primary
accountability for what happened with state government.
Trying to assign responsibility to an individual EM for the decision to use the Flint River is
pointlessand the answer ambiguous. One EM set it in motion, another presided over
the actual event, and two EMs did not seriously entertain reversing the decision in the
face of public protest. The latter refusals were for simple reasons: they received expert
advice that the water was safe to drink, and they concluded that switching back to DWSD
would be too costly.
We believe the larger issue is one of accountability. Who is accountable for the decisions
made by the EMs in Flint? We believe the state must assume that accountability. If the
state does not assume that responsibility, given the role the state has in both the
appointment of EMs and the line of accountability to the Department of Treasury, then no
accountability exists at all.
F-21. EMs charged with financial reform often do not have, nor are they supported by, the
necessary expertise to manage non-financial aspects of municipal government.
F-22. Michigans Emergency Manager Law and related practices can be improved to better
ensure that protection of public health and safety is not compromised in the name of
financial urgency.
The EM Law is predicated on the concept that a local financial crisissuch as that which
occurred in Flint in 2011is due to the inability of local officials to address the problem.
The EM is supposed to be able to better handle the situation, make better and faster
decisions, and resolve the crisis. The EM law states [t]hat the fiscal stability of local
governments is necessary to the health, safety, and welfare of the citizens of this state
and it is a valid public purpose for this state to assist a local government in a condition of
financial emergency.56 The EM is deemed necessary not only to resolve the fiscal
problem but also to protect the public health and safety.
Yet in the case of Flint, while other state and local officials were involved, EMs were at the
heart of decision-making processes that prolonged lead exposure occasioned by MDEQs
failure to prescribe appropriate treatment for the Flint water system.
Recommendations
R-20. Review Michigans Emergency Manager Law (PA 436) and its implementation, and
identify measures to compensate for the loss of the checks and balances that are
provided by representative government.

55
Note that the Resolution presented to Flint City Council by the Flint EM, Resolution 150302.1, contained no
information regarding the DWSD and water rates conditions contained in the emergency loan.
56
Michigan Public Act 436 of 2012, Section 3 (c).
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MARCH 2016
Although we acknowledge that controversy will always accompany state receivership in

whatever form, we recommend a review of PA 436. While some of the checks and
balances inherent in democratic decision-making are necessarily and by definition absent
under emergency managementas is also true under bankruptcyproper and efficient
checks and balances per se should not be a casualty of state receivership. Neither should
avenues for citizens to voice their concerns, particularly regarding matters of public health
and safety.
R-21. Consider alternatives to the current EM approachfor example, a structured way to
engage locally elected officials on key decisions; an Ombudsman function in state
government to ensure that local concerns are a factor in decisions made by the EM;
and/or a means of appealing EM decisions to another body.
R-22. Ensure proper support and expertise for EMs to effectively manage the many
governmental functions of a city. Decisions on matters potentially affecting public health
and safety, for example, should be informed by subject matter experts identified and/or
provided by the state.
EMs are asked to ensure the protection of the public health and safety and yet are not
provided adequate tools and resources to achieve this objective. EMs are empowered to
effect cost-cutting measures such as the ability to terminate contracts and restructure
budgets. However, they are given little or no priority access to state or federal resources
or assistance in undertaking the complex activities of running a municipality. Other states
take different approaches that may do a better job of balancing the need for fiscal
discipline with the need to provide basic public services, especially when scientific, health,
and/or engineering expertise is involved.
City of Flint
Defined Role
As the owner of its public water system, the City of Flint has responsibility for compliance with
the SDWA under Act 399. These responsibilities include ensuring proper design, construction,
operations and maintenance, so that contaminants in tap water do not exceed the standards
established by law. The City is required to employ properly certified water operators that are
trained and experienced to operate the treatment and distribution system.
The City must test its water routinely for specified contaminants and report the results to
MDEQ. If a water system is not meeting these standards, it is the water suppliers responsibility
to notify its customers when there is a problem with water quality.57 With a planned change in
water source, it is the Citys responsibility to carefully plan and test water treatment techniques,
ensure staff is knowledgeable about treatment protocols, and monitor distribution system water
quality. We note that decisions affecting these responsibilities, particularly those that had
financial implications, were ceded to Flints EMs throughout the course of the Flint water crisis.

57
Quotes are from the MDEQs Outline of Flint Drinking Water Issues for Flint Water Task Force, p.3.

42

MARCH 2016
Discussion
City of Flint Public Works executive leadership and staff were immediately responsible for
treating Flint River water and for monitoring water quality in the distribution system. SDWA
compliance is the obligation of the public water supplier, and it is their hands that public trust is
placed. Flint was responsible for ensuring that its WTP was adequately upgraded and tested to
perform full-time operations, that operations staff members were adequately trained and
familiar with treatment processes, that the treatment technologies used were adequate to
produce safe drinking water, and that the water quality throughout the distribution system (all
the way to consumers taps, in the case of the LCR) was in compliance with regulatory
requirements, as confirmed using appropriate sampling procedures. These standards of practice
were not met in Flint.
The City relied on Flint Utilities Department staffs limited experience, consultant advice, and
most substantially MDEQ for technical support. In this respect, Flint was similar to many
communities in Michigan that rely on MDEQ for technical assistance and advice on regulatory
compliance requirements. However, in Flint, that reliance was tragically misplaced.
Our interviews underscored several troubling aspects of the inexorable drive to leave the DWSD
system and use the Flint River as an interim supply source for drinking water. Most obviously, the
parties simply failed to adequately appreciate (or signal) the complexities involved in treating
Flint River water, or the potential implications of water chemistry changes to the citys water
distribution network. We note that Flint endured a series of water quality threatsfrom E coli
contamination to high total trihalomethane (TTHM) levelsthat could have been prevented.
Increased lead exposure and increased incidences of Legionellosis likely are the most serious
health consequences of a sustained period of water quality problems that clearly overwhelmed
Flint staff. At best, consultant support for Flint River water treatment, and later for redress of
distribution system water quality problems, focused on specific issues without adequate
consideration for latent public health dangers.
The Flint Utilities Department personnel were under-trained, inexperienced with full-time plant
operations, and ill-prepared to manage complex water chemistry issues. We note that selected
staff members conveyed concerns as events unfolded, only to have those concerns discounted.
Several aspects of the situation are particularly troubling.
o Less than one month before startup of full-time Flint WTP operation, MDEQ was uncertain
about its requirements for the transition. MDEQ staff noted internally that Flint would
face complexities in treating Flint River water and challenges with full-time operation of
the dated WTP.58
o It is not clear that Flints resident consulting engineers, LAN, had adequate expertise and
experience with river water treatment, yet the firm was engaged through a sole-source
contract.59

58
See, for example, Stephen Busch e-mail of March 26, 2014 and his e-mail of exactly one year earlier.
59
LAN representatives were not made available for interview. Questions were provided in writing and sent to LAN
(and are included in Appendix IV); responses were not received prior to publication of this report.

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MARCH 2016
o Flint WTP operators were hired too late in plant ramp-up efforts to enable full-time
staffing, which precluded adequate training on plant operations.
o MDEQ misinterpreted the Lead and Copper Rule (LCR) in determining that corrosion
control treatment was not necessary with commencement of full-time WTP operation.
Neither Flint Utilities Department staff nor their consulting engineers were given either to
question this misinterpretation, or to institute rigorous distribution system water quality
monitoring to safeguard against corrosion-causing water quality issues.
We note that Flint WTP supervisory personnels expressed concerns regarding readiness to begin
full time operationsincluding appropriate LCR-mandated samplingand these concerns went
unheeded.60 However, it seems clear that these concerns were voiced in an environment that
was unreceptive to reconsideration of the Citys chosen course, mandated by its EMs.61
We also are dismayed by the inadequate and technically flawed efforts Flint Utilities Department
personnel undertook, based on MDEQs instructions, to assess distribution system water quality.
As a result, Flints water quality sampling was fundamentally flawed, giving false assurances and
an untenable basis for MDEQs claims that Flints system was delivering safe water. The series of
missteps and outright errors is well documented,62 including sampling of pre-flushed lines, use of
narrow-mouthed bottles, and perhaps most egregiously failure to select high-risk homes for
testing, as required by the LCR. It is hard not to attribute this conduct to a misguided objective of
securing nominal LCR compliance irrespective of what conditions might actually exist in the
homes of Flint residents.
Also troubling, though not altogether uncommon among U.S. water systems, is Flints admission
that it had not conducted a census of LSLs as required by the LCR. Without this information, Flint
was not in a position to identify high-risk homes to properly monitor lead levels and comply with
the LCR.
In summary, while we cannot begin to explain or excuse MDEQs transgressions in its oversight of
the conversion to the Flint River water supply, the Flint Public Works role in the crisis appears
attributable to an inexperienced and poorly resourced organization struggling to take on
enormous, untenable responsibilities. Flints EM, relying on sole-sourced consultant support, held
responsibility for ensuring adequate staffing, training, and preparation for conversion of Flints
drinking water source. Those responsibilities were not met.
Findings
F-23. Flint Public Works personnel were ill-prepared to assume responsibility for full-time
operation of the Flint WTP and distribution system.

60
April 17, 2014 e-mail from Flint Utilities Departments Michael Glasgow to Adam Rosenthal, Mike Prysby, and
Stephen Busch at MDEQ.
61
See, for example, April 24, 2014 e-mail from Daugherty Johnson, City of Flint Utilities Administrator, and Mike
Prysby and Stephen Busch/MDEQ, including Flint Public Works Director Howard Croft.
62
See, for example, COMMENTARY: MDEQ Mistakes and Deception Created the Flint Water Crisis, September 30,
2015, Siddhartha Roy, Flintwaterstudy.org, and February 27, 2015 e-mail from Miguel Del Toral/EPA to MDEQ: If
systems are pre-flushing the tap the night before collection of LCR compliance samples (MDEQ still provides these
instructions to public water systems) this clears particulate lead out of the plumbing and biases the results low by
eliminating the highest lead values.

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F-24. The Flint WTP and installed treatment technologies were not adequate to produce safe,
clean drinking water at startup of full-time operations. Flints lack of reinvestment in its
water distribution system contributed to the drinking water crisis and ability to respond
to water quality problems.
F-25. Flint Public Works personnel failed to comply with LCR requirements, including the use of
optimized corrosion control treatment and monitoring for lead. Flint personnel did not
identify residences with LSLs, secure an adequate number of tap water samples from
high-risk homes, or use prescribed sampling practices (for example, line and tap flushing
methods and sample bottle sizes).
F-26. Flint Public Works acted on inaccurate and improper guidance from MDEQ.
F-27. Many communities similarly rely on MDEQ to provide technical assistance and guidance
on how to meet regulatory requirements. In the case of Flint, MDEQ assistance was
deeply flawed and lax, which led to myopic enforcement of regulations designed to
protect public health.
F-28. The EM structure made it extremely difficult for Flint citizens to alter or check decision-
making on preparations for use of Flint River water, or to receive responses to concerns
about subsequent water quality issues.
Recommendations
R-23. Establish and fund a team of subject matter experts in water system operations
(treatment and distribution system management) to support and train water system
personnel, guide safe system operation under current conditions, and prepare for
successful conversion to KWA.
In addition to creating water quality problems, the switch to the Flint River may have
precipitated conditions in Flints water system that increase the potential for Legionella to
occur. With warmer temperatures in 2016, there is a heightened need for multi-agency
coordination on testing of the Flint water system for the presence of Legionella, and on
public health monitoring for the incidence of Legionellosis and determinations of sources.
R-24. Implement a programmatic approach to Flint WTP and distribution system operations,
maintenance, asset management, water quality, capital improvements and public
engagement (including risk communication) to ensure that the disparate ongoing efforts
to address Flint water system infrastructure needs are coordinated, fully documented,
and structured to sustain high-quality potable water service over the long term.
Though not the subject of the FWATFs review, it is apparent that the Flint water utility
faces acute financial challenges due to earlier financial management practices, as well as
successful challenges to EM-ordered rate increases. These circumstances impose an
unprecedented context for establishing defensible water rates and collection practices in
a community that was already facing difficult water affordability challenges. Careful
financial planning and management will be required to secure and effectively deploy
external funding assistance, and to gradually stabilize water system revenues to sustain
water utility operations over the long term. This must be complemented by an effective
public education and engagement program, and innovative water affordability strategies
to advance universal access to potable water service.
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R-25. Implement a robust public engagement and involvement program in conjunction with the
anticipated conversion to KWA-delivered water and provide for regular reporting to the
Flint Water Inter-Agency Coordinating Committee (FWICC).
Genesee County Health Department (GCHD)

Defined Role
As a local health department, the Genesee County Health Department (GCHD) is responsible for
all government public health functions for residents in their jurisdiction, including the City of
Flint. Like the vast majority of cities in Michigan, Flint does not have its own public health officials
and instead relies on its county health department (GCHD) to perform public health functions.
GCHD must coordinate and communicate effectively with city officials and the public. Specific to
the Flint water crisis, GCHD responsibilities include investigating outbreaks of reportable diseases
such as Legionellosis and conducting timely in-home assessments of potential sources of lead
exposure for children found to have elevated blood lead levels.
Importantly, the functions of local health departments also include cooperative coordination with
state public health authorities (MDHHS), and in turn with federal public health authorities (for
example, Centers for Disease Control and Prevention [CDC]) as needed. The expectation is that
local health departments manage issues that arise in their jurisdictions. State public health
authorities become involved at the request of local authorities and/or when events such as an
outbreak involve more than one jurisdiction (that is, more than one local health department). In
turn, MDHHS requests help from the CDC as needed. This local-to-state-to-federal sequence is
designed to facilitate communication, coordination, and follow-up among officials at multiple
levels of authority, and it requires mutual trust, collaboration and effective communications
across agencies.
Discussion
In summer 2014, after the change of water source for the City of Flint, there were two public
health problems that arose within the jurisdiction of GCHD: exposure to lead and exposure to
Legionella.
Exposure to Lead
In contrast to Legionellosis, which has involved GCHD as a front-line responder, GCHD was not
extensively involved in responding to exposure of children to lead from the Flint water supply.
Elevated blood lead level records are maintained as part of a regularly updated listing of test
results by MDHHS in the statewide Childhood Lead Poisoning Prevention Program (CLPPP). GCHD
was involved as a coordinating organization for conducting tests and relaying test results to the
state.
Clinicians are responsible for testing childrens blood for lead in early childhood on a routine
basis. Health insurance plans (especially those that contract with state Medicaid) are responsible
for encouraging families and clinicians to have children screened at the appropriate ages and
then following up with children whose blood lead levels are elevated. GCHD would get involved
for children with elevated lead levels that prompted in-home assessments of possible sources of
environmental lead exposure.
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Since the switch to the Flint River, a higher proportion of children in Flint have had elevated lead
levels that would prompt in-home assessments. Several aspects of the GCHD-MDHHS response
are noteworthy:
o GCHD was overwhelmed with the need for in-home assessments, and MDHHS
supported training and placement of outreach nurses in GCHD to supplement its
workforce.
o GCHD had been asked only to reach out to pregnant women who might have had lead
exposure, rather than performing their usual in-home assessment duties. MDHHS
tasked an outside firm with performing the in-home assessments.
o As of late January 2016, only about one-fifth of children known to have had elevated
blood lead levels in Flint since April 2014 had received in-home environmental
assessments (including water testing).
Legionella
After the switch to the Flint River in 2014, the Flint Utilities Department began flushing water
mains citywide to address brown-colored water resulting from corrosion of pipes in the
distribution system. Many fire hydrants ran for days, which may have disrupted the biofilm, a
slime coating (which is distinct from the scaling provided by corrosion control treatment) on the
inside surface of the water mains and water service lines. When the biofilm was disrupted,
Legionella and other bacteria may have been released. In addition, EPA experts Del Toral and
Lytle believe that corroding pipes likely absorbed chlorine in the water, leading to extremely low
chlorine levels that were insufficient to kill Legionella in the water. Also, given the small
population in Flint compared to the large water distribution system developed to serve the citys
larger population in decades past, water likely pooled in the system for excessively long periods,
providing an ideal environment for bacterial growth.
As noted above, several cases of Legionellosis occurred in patients who likely were exposed to
Legionella in healthcare facilities. McLaren Medical Center in Flint responded to the incident by
hiring a Legionella expert, spending $300,000 for systems to eliminate the bacteria, and changing
practices on their wards to instruct patients not to take showers (because aerosols can spread
Legionella).
During this timeframe, the City of Flint (Mayor Dayne Walling, EM Jerry Ambrose and others)
asserted the water was safe. Even while outbreak investigations were ongoing, GCHD and
MDHHS did not issue a bulletin to the medical community or the public. The Legionella expert
hired by the hospital and other water quality experts cannot dismiss the possibility of a link
between the Legionellosis outbreaks and lack of proper corrosion control and disinfection in the
Citys water system.
In Flint, neither the Flint EM nor his appointed City Administrator, GCHD, or MDHHS fully
disclosed the Legionellosis outbreak to local medical professionals or the general public.
Moreover, this outbreak, which is always associated with water supplies, was not communicated
by MDEQ with sufficient urgency to the Governors office.
In contrast, New York City experienced an outbreak of Legionellosis attributed to several hospital
cooling systems in different parts of the city in summer 2015. Public health officials made
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announcements to City residents about the cases and the outbreak was reported in the media,
along with health advice for the public.
Findings
F-29. Communication, coordination and cooperation between GCHD, the City of Flint and
MDHHS were inadequate to protect Flint residents from public health threats resulting
from inadequately treated Flint River water.
F-30. The rate of follow-up on children with elevated blood lead levels through January 2016
was unacceptable, illustrating a low level of coordination between GCHD and MDHHS and
insufficient resources devoted to this task.
F-31. Management of the Flint River-sourced water supply may have contributed to the
outbreaks of Legionellosis cases in 2014 and 2015 in Genesee County. Although the
definitive cause of the outbreaks is uncertain at the time of publication, GCHD and
MDHHS did not notify the public of the outbreaks in a timely fashion in order to urge
caution.
Recommendations
R-26. Improve follow-up on public health concerns between GCHD, MDHHS and the City of Flint
now and in the future, to effect timely, comprehensive, and coordinated activity and
ensure the best health outcomes for children and adults affected.
R-27. Presume that the risk of Legionella may remain elevated in the Flint water distribution
system and must take appropriate steps with public and private partners to monitor and
mitigate that risk as concerns about water quality continue in the City of Flint.
R-28. Coordinate with state officials (MDHHS) and with local healthcare professionals and
healthcare institutions in Genesee County and the City of Flint to mitigate the risk of
Legionellosis in 2016 and beyond.
It is not clear whether the switch back to DWSD in October 2015 and subsequent addition
of corrosion control will change the conditions for Legionella growth in the Flint water
distribution system. In addition, the strong predominance of cases linked to healthcare
exposure at one particular hospital in Flint underscores the critical importance of
appropriate and timely antiseptic use by healthcare facilities to reduce the risk of
Legionellosis.
To facilitate appropriate collection of Legionella specimens that will permit tracing of
Legionella species in the setting of any further outbreaks, healthcare professionals in
Genesee County should be vigilant and err on the side of collecting respiratory specimens
before initiating therapy in cases of presumed Legionellosis.
U.S. Environmental Protection Agency (EPA) Oversight and the Lead and
Copper Rule
Defined Role
EPA has responsibility under the Safe Drinking Water Act to set and enforce health-based
drinking water quality standards. EPA establishes National Primary Drinking Water Regulations
that set enforceable maximum contaminant levels in drinking water and prescribe treatment

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requirements. Each standard also includes requirements for water systems to test for
contaminants in the water to make sure standards are achieved.
EPA regulates public water systems through its Public Water System Supervision (PWSS) program.
From the description of that program:
EPAs and states primary means of monitoring public water system compliance with the
SDWA and its implementing regulations is the review and evaluation of analytical results
of water samples collected by public water systems. These reports provide the water
systems and regulators with the data they need to ensure that drinking water monitoring
is ongoing and that the drinking water standards are being met. When results indicate
that a contaminant is present at a level that exceeds standards, states and EPA work with
public water systems to take steps to prevent or remove the contaminants, and notify
consumers so that they can make informed choices.63
EPA is required to oversee the regulatory actions of state and local agencies and ensure that local
public water suppliers adhere to the standards set under the SDWA.64 The SDWA authorizes the
EPA to delegate primary enforcement responsibilities to the states. Forty-nine states, including
Michigan, have this delegated authority.
While the states are delegated regulatory primacy, there are two sections of the SDWA that give
EPA authorization to act:
a. Sec. 1414 of the Act says that when the agency finds a public water system out of
compliance, the EPA must notify the state and public water system of the violation. If
after 30 days the state has not commenced enforcement action, then the EPA must issue
an order to comply. In the case of Flint, EPA did not use this authority as required by the
SDWA.
b. Sec. 1431 of the Act grants emergency powers to the EPA when the Administrator is
aware of a contaminant or threat which may present an imminent and substantial
endangerment to the health of persons, and that appropriate state and local authorities
have not acted to protect the health of such persons, the EPA Administrator may take
such actions as he or she may deem necessary in order to protect the health of such
persons. The EPA used this authority when it issued its emergency order on January 21,
2016.
Lead and Copper Rule:
The Lead and Copper Rule (LCR) is intended to protect public health by reducing lead and copper
in drinking water at customers taps. For the rule to be effective, and for lead and copper
contamination to be detected, water sampling practices must be rigorous. Ample industry
guidance65 emphasizes the requirements for this rigor, which include selecting residences at high

63
64
www.epa.gov/compliance/safe-drinking-water-act-sdwa-compliance-monitoring
Before the federal EPA was established, states regulated drinking water. The SDWA kept that regulatory structure
in place and assigned EPA oversight responsibility for state regulatory activities.
65
See, for example, A Field Comparison of Sampling Protocols for Measuring Lead in Drinking Water, Porter, A., M.
Del Toral, and M. Schock. In Proceedings, Water Quality Technology Conference, Long Beach, CA, November 3-7,
2013, American Water Works Association, Denver, CO (2013).

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risk for lead exposure, prohibiting pre-flushing and aerator removal, and observing minimum
stagnation times. More fundamentally, public water systems must identify the LSLs in their
service areas, advise customers of their presence and potential implications, and facilitate full
service line replacements in the event of action level exceedances. The LCR also requires public
water systems to minimize lead and copper levels in drinking water by controlling corrosion in
the distribution system, which is achieved by implementing corrosion control treatment (CCT).
Unfortunately, despite the clarity of its intent, the LCRs language has been subject to various
interpretations from one state, and one water system, to another. Though MDEQs
misinterpretations may be among the most egregious examples of lax and myopic compliance
practices, there are pronounced concerns that the effectiveness of the rule has been
compromised.66 EPA is in the process of reviewing and revising the LCR through its established
rulemaking procedures.
While the states are delegated regulatory primacy, 40 CFR 141.82(i) gives the EPA Regional
Administrator authority to review treatment decisions made by a state and issue federal
treatment determinations consistent with the LCR.
Discussion
Prior to Flints water supply conversion, EPAs delegation of primacy for enforcement of the
SDWA in Michigan had been challenged by a series of disagreements and concerns over
compliance requirements and sampling practices.67 These were heightened with the series of
events that precipitated the water crisis. EPA Region V was first notified of a potential problem in
Flint by resident LeeAnne Walters, who called to inform them of the high lead level (104 ppb)
found in her drinking water. In early 2015, EPAs Miguel Del Toral worked with Walters to
diagnose water quality problems at her residence. During this time, EPA inquired (repeatedly)
about CCT at the Flint WTP, advised MDEQ that the LCR unambiguously requires CCT, and were
told incorrectly that Flint had an optimized corrosion control program.
In this timeframe, EPA was trying to determine whether the high lead levels at LeeAnne Walterss
house represented an isolated or system-wide problem. Ultimately, it required LeeAnne
Walterss inquiry of Flint Utiliites Department personnel for EPA to learn that Flint did not have
CCT in place. It took 2 months from EPAs first inquiry for MDEQ to acknowledge that Flint was
not implementing CCT.
Given this information, EPA tried to convince MDEQ by persuasion and forthright referencing to
the LCR that Flint needed to add CCT (as DWSD had been doing for decades) However, MDEQ was
entrenched in its (incorrect) position that two 6-month monitoring periods are allowed before a
decision on CCT is required. MDEQ forestalled imposing the requirement for CCT pending
issuance of a legal opinion.

66
See, for example, Dr. Yanna Lambrinidous dissenting opinion on long-term revisions for the LCR, submitted to the
EPA National Drinking Water Advisory Council in October 2015 (EPA NDWAC LCR WG, Dissenting Opinion, Oct.
2015), www.epa.gov/sites/production/files/2015-11/documents/ndwaclcrstatementofdissent.pdf; and the
Northeast-Midwest Institutes Elin Betanzos article, Clarifications Needed to Strengthen the Lead and Copper Rule
Working Groups Recommendations for Long Term Revisions to the Federal Lead and Copper Rule, November 17,
2015, www.nemw.org/wp-content/uploads/2015/11/NEMWI-LCR-recommendations.pdf.
67
FWATF interviews with Miguel Del Toral. Also see April 27, 2015, e-mail exchanges among MDEQs Cook, Busch
and Prysby regarding Del Torals question on corrosion control treatment.

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EPA was similarly hampered by poor information derived from Flints flawed water quality
sampling for LCR compliance. Not only did MDEQ persist in prescribing sampling methods that
limited opportunities for detection of lead contamination, it did not ensure that a proper sample
pool was obtained from the Flint system. The first 6-month monitoring period results showed the
90th percentile lead level results to be 6 ppb, and the second 6-month monitoring period results
showed the 90th percentile to be 11 ppb. Both of these outcomes fell beneath the lead action
level of 15 ppb. Unfortunately, because of the flawed sampling pool and sampling techniques, the
extent of the lead problem was under-reported. It came to light in September 2015 with the
results of Dr. Marc Edwardss lead sampling program. After testing 252 water samples taken in
Flint, the 90th percentile68 of Dr. Edwards samples was found to be 25 ppb, and more than 100
samples had lead over 5 ppb.
Even given the Citys flawed sampling program, EPA staff did become aware of the potential risks
in April 2015 when MDEQs failure to require CCT was revealed, and EPA leadership was advised
of acute concerns in an interim report by Miguel del Toral in June 2015:
In effect, the City of Flint stopped providing treatment used to mitigate lead and copper
levels in the water. In accordance with the Lead and Copper Rule (LCR), all large systems
(serving greater than 50,000 persons) are required to install and maintain corrosion
control treatment for lead and copper. In the absence of any corrosion control treatment,
lead levels in drinking water can be expected to increase.
The lack of mitigating treatment is especially concerning as the high lead levels will likely
not be reflected in the City of Flint's compliance samples due to the sampling procedures
used by the City of Flint for collecting compliance samples.69
However, with the exception of the strident e-mails and interim report by Del Toral,70 EPA
refrained from elevating concerns or taking action. EPA did not insist on implementation of CCT
between the end of April 2015, when it learned CCT was not in place, and July 21, 2015, when the
second round of LCR monitoring results ended MDEQs misinformed interpretaton of the LCR.
Only after broad public revelation of the magnitude of the crisis and of MDEQs multiple
failuresand, not coincidentally, the opportunity to garner positive recognitiondid EPA
exercise its authority under the SDWA and issue its Emergency Order on January 21, 2016.
EPA did not cause the problem in Flint, and it was EPA employees (in particular Del Toral) who
asserted the need for Flint to have CCT in place. Unfortunately, EPA was not insistent or forceful
enough to prompt MDEQ to require Flint to add CCT for almost 3 months after EPA was aware of
its absence. This needlessly extended the time during which Flint residents were exposed to
corrosive drinking water with potentially high levels of lead.
Finally, EPA entertained and acquiesced to MDEQs request for a legal opinion regarding the long-
standing and well-understood requirement for corrosion control, ultimately issuing a clarification
memo on LCR compliance requirements that suggested ambiguities.

68
th
For a discussion of the arithmetic related to calculation of the 90 percentile, see the YouTube video: How to
calculate Flint's 90th percentile lead level with EMU math professor Chris Gardiner,
www.youtube.com/watch?v=9pql00zr700&feature=em-share_video_user.
69
Interim Report: High Lead Levels in Flint, Michigan, by Miguel del Toral, transmitted to Thomas Poy, Chief,
Ground Water and Drinking Water Branch, on June 24, 2015; p. 2.
70
See, for example, Miguel Del Torals e-mail to Jennifer Crooks MDEQ dated April 25, 2015.

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Findings
F-32. EPA failed to properly exercise its authority prior to January 2016. The agencys conduct
casts doubt on its willingness to aggressively pursue enforcement (in the absence of
widespread public outrage). EPA could have exercised its powers under Section 1414 and
Section 1431 of the SDWA or under the LCR, 40 CFR 141.82(i).
F-33. Despite the clear intent of the LCR, EPA has accepted differing compliance strategies that
have served to mute its effectiveness in detection and mitigation of lead contamination
risks. These strategies have been adopted at water systems and primacy agencies across
the country. Though there may be some ambiguity in LCR rule, none of it relates to what
MDEQ should have done in Flint. There was and remains no justification for MDEQ not
requiring corrosion control treatment for the switch of water source to the Flint River.
F-34. EPA was hesitant and slow to insist on proper corrosion control measures in Flint. MDEQ
misinformation notwithstanding, EPAs deference to MDEQ, the state primacy agency,
delayed appropriate intervention and remedial measures.
F-35. EPA tolerated MDEQs intransigence and issued, on November 3, 2015, a clarification
memo on the LCR when no such clarification was needed.
Recommendations
R-29. Exercise more vigor, and act more promptly, in addressing compliance violations that
endanger public health.
R-30. In collaboration with the NDWAC and other interested partners, clarify and strengthen
the LCR through increased specificity and constraints, particularly requirements related to
LCR sampling pools, sample draw protocols, and LSL replacementsand, more generally,
strengthen enforcement protocols with agencies delegated primacy.71
The LCR should be modified to address a host of issues that have been the subject of
ongoing debate and were tragically exemplified by the Flint water crisis. In particular, the
LCR should be revised to:
o Unambiguously require optimized corrosion control treatment as a default practice for
all large public works systems, and consider extending this requirement to small and
medium-sized public water systems.72 EPA should remove any loopholes or flexible
provisions that could be misinterpreted as allowing utilities to defer or avoid corrosion
control, as was done in Flint. Optimized corrosion control will continue to be
important in the long term, even after LSLs are replaced, due to other sources of lead
in the distribution system such as lead solder and brass fixtures.

71
For a further discussion of opportunities to strengthen the LCR, see Dr. Yanna Lambrinidous dissenting opinion on
long-term revisions for the LCR, submitted to the EPA National Drinking Water Advisory Council in October 2015
(EPA NDWAC LCR WG, Dissenting Opinion, Oct. 2015), www.epa.gov/sites/production/files/2015-
11/documents/ndwaclcrstatementofdissent.pdf.
72
The current LCR language requires corrosion control for small and medium-sized systems only if water testing
indicates action level exceedances, and it allows cessation of treatment if subsequent testing is below action levels.
EPA should define procedures for small and medium-sized systems to safeguard public health and water quality
through evaluation of corrosion control treatment requirements.

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o Reiterate (and clarify) lead-in-water tap monitoring and sampling protocols to ensure
that lead sampling will capture the worst-case lead levels in the highest risk homes, as
the LCR intends.
o Clarify requirements for full LSL replacement, avoiding or eliminating language that
allows utilities to count a LSL as replaced if water from a service line tests under the
lead action limit in a one-time sample.
o Ban partial LSL replacements, which have been found by the CDC to increase risks of
elevated blood lead levels.
In addition, the 15 ppb lead action level in the LCR should be revisited given that It is
widely acknowledged that no lead is safe, and that the CDC recently lowered its 10
micrograms/deciliter blood lead level of concern to a 5 micrograms/deciliter reference
level.
Also, the LCR should call for frequent and accessible public outreach and education on
lead-in-water risks, including instructions on steps consumers can take to protect
themselves. The LCR should require utilities to provide customers with explicit and urgent
public notification of lead risks associated with activities that may cause physical
disturbance of LSLs; inform customers when a LSL is present at their home; and provide
customers clear information on how to request testing of lead-in-water levels in their
homes.
Perhaps most fundamentally, the LCR should mandate proactive, full replacement of
LSLs73 in a manner that appropriately balances risks and financial impacts. The LCR should
require LSL replacements to be explicitly incorporated into water utilities renewal and
replacement programs with required (and monitored) timelines that preclude undue
(multi-decade) delays in replacements.
R-31. Engage Michigan representatives in ongoing LCR revisions and development of
enforcement protocols at EPA and MDEQ.
EPA is conducting a process to define revisions to the LCR, which provides an opportunity
to clarify ambiguities in requirements and to strengthen measures to protect public health
and safety. State and local representatives, chastened by Flints experience, should
participate in this revision process and ensure lessons learned are clearly and effectively
communicated to decision-makers, including the National Drinking Water Advisory
Council and EPA.

While our review has enabled us to draw a number of findings and conclusions about respective
roles, it also occasions us to speak to issues and consequences that transcend the accountabilities
assigned to individual agencies or entities. These issues convey many of the lessons learned from

73
This recommendation is consistent with recommendations of the Lead and Copper Rule Working Group: Report of
the Lead and Copper Rule Working Group To the National Drinking Water Advisory Council, August 24, 2015.
https://www.epa.gov/sites/production/files/2016-01/documents/ndwaclcrwgfinalreportaug2015.pdf

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the Flint water crisis, evoke collective empathy for the Flint community, and speak to the
opportunties for the crisis to improve the conduct and performance of government.
The Reality of Environmental Injustice

Discussion
Environmental justice embraces two fundamental principles: (1) the fair, non-discriminatory
treatment of all people; and (2) the provision for meaningful public involvement of all people
regardless of race, color, national origin or incomein government decision-making regarding
environmental laws, regulations and polices.74 Environmental justice or injustice, therefore, is not
about intent. Rather, it is about process and resultsfair treatment, equal protection, and
meaningful participation in neutral forums that honor human dignity.
Environmental injustice is not about malevolent intent or deliberate attacks on specific
populations, nor does it come in measures that overtly violate civil rights. Environmental
injustices as often occur when parties charged with the responsibility to protect public health fail
to do so in the context of environmental considerations.
The facts of the Flint water crisis lead us to the inescapable conclusion that this is a case of
environmental injustice. Flint residents, who are majority Black or African American and among
the most impoverished of any metropolitan area in the United States, did not enjoy the same
degree of protection from environmental and health hazards as that provided to other
communities. Moreover, by virtue of their being subject to emergency management, Flint
residents were not provided equal access to, and meaningful involvement in, the government
decision-making process.
The occurrence of environmental injustice in the Flint water crisis does not indict or diminish
other public and private efforts to address Flints many challenging circumstances. However,
irrespective of the intent of the parties involved, the simple reality is that the Flint water crisis is a
case of environmental injustice.75

74
From the Environmental Justice Plan for the State of Michigan and Department of Natural Resources and
Environment, December 17, 2010:
The term "environmental justice" is defined in Executive Directive No. 2007-23 as follows:
Environmental justice means the fair, non-discriminatory treatment and meaningful involvement of
Michigan residents regarding the development, implementation, and enforcement of environmental
laws, regulations, and policies by this state. The two "pillars" of environmental justice, thus, are the
fair treatment of all people and providing for meaningful public involvement in government decision-
making.
From the U.S. EPA (www3.epa.gov/environmentaljustice):
Environmental Justice is the fair treatment and meaningful involvement of all people regardless of
race, color, national origin, or income with respect to the development, implementation, and
enforcement of environmental laws, regulations, and policies. EPA has this goal for all communities
and persons across this Nation. It will be achieved when everyone enjoys the same degree of
protection from environmental and health hazards and equal access to the decision-making process
to have a healthy environment in which to live, learn, and work.
75
There is ample evidence that the lead poisoning crisis is one in a series environmental injustices visited on the
citizens of Flint. See, for example, The Racist Roots of Flints Water Crisis, by Julia Craven and Tyler Tynes,

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Findings
F-36. The Flint water crisis is a clear case of environmental injustice.
Recommendations
R-32. Issue an Executive Order mandating guidance and training on Environmental Justice
across all state agencies in Michigan, highlighting the Flint water crisis as an example of
environmental injustice. The state should reinvigorate and update implementation of an
Environmental Justice Plan for the State of Michigan.
Perspectives from Flint

The FWATF believes that by characterizing some of the prevailing perspectives of Flint residents,
its members can provide valuable context for effectively implementing the recommendations
herein.
From the viewpoint of medical services providers charged with responsibility to mitigate heath
consequences, there is both depression and anxiety associated with understanding what is
occurring in Flint. The Flint water crisis is a chronic toxic exposure of an entire population in a
sharply demarcated geographic area. Several key aspects point to the long-term health and social
consequences:
a. The manifestations of this toxic exposure depend on where along the life course a person
may be. At different ages, critical structures and functions are injured or altered to
different degrees. These changes may not manifest in functional derangements for
months or years after exposure. The science of epigenetics addresses the interaction
between genes and the environment, suggesting that some of these changes can be
passed on from one generation to the next.
b. Blood lead levels do not indicate peak lead exposures beyond a 30- to 35-day window.
The damage from lead toxicity may be done months before the first blood lead level is
taken or after the last is drawn, especially for newborns and children younger than 6 years
of age. This suggests that the findings related to elevated lead levels measured in Flint
children are merely the tip of the iceberg of actual exposure across children living in Flint.
c. Documented risks of learning, behavioral, and cognitive problems are present for all
potentially exposed children in Flint. Aggressive and impulsive behaviors that can emerge
in adolescence related to lead exposure put children in the crosshairs of the criminal
justice system, unemployment and underachievement.
d. The risk of kidney problems, hypertension, gout and stillbirths may affect exposed adults
in Flint over the coming years and decades.
For those serving in Flints already distressed schools and mental health agencies, new and
unprecedented challenges derive from balancing the need to track children and adults in a toxic
exposure registry for preventative and supportive services, while being mindful of the stigma of
low expectations for those listed in the registry.

Huffington Post, February 3, 2016, www.huffingtonpost.com/entry/racist-roots-of-flints-water-
crisis_us_56b12953e4b04f9b57d7b118.

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For well-intentioned parents, there is a need for significant sensitivity and expertise as they
struggle to address and understand the guilt and depression that derive from unknowingly
exposing their children, based on the hollow reassurances of those appointed and elected at city
and state levels that the water was safe.
For non-English-speaking Flint residents, equally subject to the toxic effects of lead and related
psychological trauma, communications and instructions regarding water use were not available,
especially for those not literate in their native language. The sight of uniformed state troopers
and National Guardsmen entering neighborhoods in convoys with flashing lights frightened many
who did not open their doors to accept filter or water distributions. Initial requirements for
identification scared many families away from distribution sites. There has been no provision for
necessary medical and behavioral services for undocumented residents, regardless of age. There
is fear that those presenting for extensive medical services will be deported, potentially dividing
families. While there are several organizations that provide services regardless of status, it is
essential that trusted members of the community can vouch for those organizations and help
with appropriate documents which are unfamiliar to local service providers.
Among African American seniors, the protracted Flint water crisis echoes the tragic Tuskegee
syphilis study and the decision not to treat smallpox among freedmen in the aftermath of the
American Civil War. From this perspective, it is noted that measuring blood lead levels without
removing the sources of lead from the environmentin this case, lead-tainted waterappears
the equivalent of using Flints children (and adults) as human bioassays.
From the perspective of Flint community leaders, these consequences are traumatic and
contribute to a dynamic that requires care and interventions as for any survivors of a traumatic
event. These interventions must occur for individuals, neighborhoods and the community.
Leaders must work to counter the doubtful views of many residents that public health and
political systems do not have the will to sustain primary prevention but, rather, are willing to
consign some people by virtue of their home address to the long-lasting neurodevelopmental and
health impacts of lead exposure. Flint will have to engage in self-care and healing as it dissects
the implications of what has occurred and is reminded of how much further we must go to
become a just society.
Flint Recovery / Remediation

In light of the damage done, and the long-term health, economic, and social consequences for
the Flint population, the Flint Water Advisory Task Force endorses the visions of responsive
model public health and infrastructure renewal programs outlined by Dr. Mona Hanna-Attisha,
Professor Marc Edwards and Miguel Del Toral. Flints population, exposed to toxic levels of lead,
must be provided mitigating health services, public health infrastructure and skilled personnel.
Flints water system, damaged by corrosive water, must be renewed and rehabilitated with high-
risk LSL replacements prioritized. The State of Michigan must bear the primary responsibility for
funding and securing federal funding for mitigation efforts in light of the responsibilities of state
agencies, as well as the fact that state-appointed emergency managers governed Flint as key
decisions were made that led to the water crisis.
As our initial letter to Governor Snyder called for a coordinated response to the Flint water crisis,
we are gratified to see the efforts, now coordinated through emergency management personnel,
to the immediate problems imposed by uncertainty regarding the safety of Flints tap water.

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Recommendations
Our final recommendations look beyond the most immediate challenges of the unsustainable and
expensive bottled water and filter distribution program that was needed, but clearly must serve
as an interim emergency response. We offer the following mid-term and long-term Flint-specific
recommendations:
R-33. Sustainably fund the Flint Water Inter-Agency Coordinating Committee (FWICC) to
provide adequate resources to engage supporting sub-committees for delivery of public
health and water system services.
The FWICC has been charged with developing an incident action plan; reviewing our
recommendations; establishing routine protocols for communications at the local,
executive and legislative levels; making recommendations regarding the health impacts of
the affected population; and assessing the status of infrastructure and determining
feasible actions for upgrading Flints water system.76 The FWICC also should ensure
transparent, public reporting of the status of various Flint-related measures, including the
sources and uses of local, state and federal funds. Charitable organizations should be
asked to provide accounting of their Flint-related activities to facilitate comprehensive
reporting and information dissemination on available services.
R-34. Clarify and effectively communicate the roles and work of the City of Flint, Flint Water
Inter-Agency Coordinating Council and Mission Flint.
While many of the current efforts and investigations are critically important to safeguard
Flint residents, address immediate challenges, and further establish accountability, the
FWICC and Mission Flint are now in place to work with the City of Flint in coordinating
sustained service delivery and remediation measures. These entities, and accompanying
committees and work teams, have complementary roles and responsibilities that should
be clearly delineated and communicated to all Flint residents. Communication must
include efforts to reach Flint residents for whom English is not the primary language, and
residents whose literacy in any language is limited. The status of the projects and
programs that these entities are shepherding should be clearly communicated and
measured against aspirational goals and objectives.
R-35. Through collaboration among MDHHS, GCHD, local healthcare professionals, and health
insurance plans, ensure 100 percent clinical and environmental follow-up with Flint
families whose children have been found to have elevated blood lead levels since April
2014, and work together to ensure that such follow-up occurs in childrens medical
homes.
For the majority of >200 children residing in Flint and known to have elevated blood lead
levels (5 micrograms per deciliter) from April 2014 to present, appropriate clinical and
public health follow-up has not been timely. Such limitations in follow-up reflect a lack of
coordination among state and county public health authorities, health insurance plans,
local healthcare professionals, and parents. These children, and others who have elevated

76
Drawn from January 11, 2016 Press Release: Gov. Rick Snyder: Flint Water Interagency Coordinating Committee
will support long-term needs in Flint.
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blood levels on testing after this report is issued, will need long-term monitoring and
access to a support services that include focused public health, nutrition and educational
services.
R-36. Offer all children listed in the recommended Flint Toxic Exposure Registry timely access to
age-appropriate screening and clinically indicated follow-up for developmental and
behavioral concerns by licensed healthcare professionals, as well as access to early
childhood education and nutrition services.
Importantly, all children in the recommended Flint Toxic Exposure Registry are at risk for
toxic lead exposure, even if they were not screened for blood lead levels during the time
period of April 2014 to present. Therefore, all children listed should have access to the
same screening and appropriate follow-up services as children who were found to have
elevated blood lead levels.
R-37. Consider establishing a dedicated subsidiary fund in the Michigan Health Endowment
Fund to facilitate funding of health-related services for Flint.
The Michigan Health Endowment Fund (MHEF) statute created eight areas of focus for the
fund, including several that are pertinent to the Flint water crisis. The MHEF focuses on
access to healthy food (known to offset childrens absorption of environmental lead),
wellness programs (such as those known to encourage primary and secondary
prevention), access to mental health services (such as behavioral therapy for children
adversely affected by lead exposure), and foodborne illness prevention (such as averting
exposure to lead in food prepared with lead-contaminated drinking water). Given the
substantial overlap between the focus areas of the fund and the areas of short- and long-
term activity for the people of Flint, it is appropriate to establish a subsidiary fund that
would be administered to facilitate funding of health-related services for children and
adults in the Flint Toxic Exposure Registry. Because Michigan has been successful in
securing federal funds to expand Medicaid coverage for persons under age 21 years in
Flint, the subsidiary MHEF Fund would be designed to focus on facilitating and supporting
services not explicitly covered by Medicaid. The Fund should also provide funding to
support timely and transparent evaluation of the health impact of these supplementary
services for the people of Flint.
R-38. Establish a comprehensive Flint public health program, coordinated with county and
state-level public health initiatives, that can serve as a model for population health across
the state. This program should provide assessment, interventions, and support not only
regarding the health effects of water contamination but also more broadly regarding the
health effects of chronic economic hardship and other social determinants of poor health.
State-Wide Initiatives
Beyond remediation of the impacts inflicted upon Flint, outstanding issues and lessons learned
from the Flint water crisis provide an opportunity to improve public water supplies and
coordination of institutions charged with safeguarding public health.
Recommendations
Our recommendations include:

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R-39. Conduct an investigative review of the development and approval of the Karegnondi
Water Authority and of the City of Flints commitments to KWA water purchases.
The development of the KWA and the decision by the City of Flint to join it is complicated
by an array of factors related to regional water system capacities, utility capital project
contracting and financing, and local control over the implementation of facilities to
promote economic development. As noted, issues related to state approval and
permitting of the KWA are beyond the scope of our review.77 However, the specific
attributes of the decisions related to KWA warrant investigative review. We note:
o State and local officials repeatedly characterized Genesee County and Flint leadership,
including Flints emergency managers, as adamant in their promotion of KWA and
desire for independence from DWSD.
o Several firms, each with ties to the respective and effectively competing parties,
issued conflicting studies as to the merit of KWA. Independent review was requested
of MDEQ, an agency ill-equipped to render judgments regarding economic feasibility.
o Contracting related to Flints water purchase commitments and to use of the Flint
WTP on an interim basis were effected through action of Flints emergency managers.
An entity with proper tools and resources, such as the Michigan Attorney General or the
U.S. Attorneys office, should do a complete and thorough review of the development and
approval of KWA and of the City of Flints commitments to KWA water purchases.
R-40. Institute a school and daycare water quality testing program (which could serve as a
model for the U.S.), administered collaboratively by MDEQ and MDHHS, that includes
appropriate sampling and testing for lead contamination for all schools and childcare
centers in the state and effective reporting of test results.
Drinking water and water available for food preparation in schools and may be sources of
lead and other hazards for school children. Currently, federal and state regulations do not
require city, county or state authorities to routinely test water in school buildings.
Furthermore, there is no state law, guidance or regulation regarding testing of drinking
water in various childcare and pre-school settings (children below kindergarten-age).
Michigan should institute a school and day care water quality testing program,
administered collaboratively by MDEQ and MDHHS, that includes appropriate sampling
and testing for lead contamination in all schools and childcare centers in the state.
Findings from such testing should be made available to all parents of children enrolled in
the facilities where testing is performed. If lead is discovered through this testing,
immediate remediation of the situation (for example, replacement of LSLs and lead-
containing fixtures) must be required.
School testing requirements also should be applied to licensed day care settings across
the state, given that young children are at the highest risk of profound health effects from
lead exposure.

77
These issues may (and perhaps should) prompt general inquiry into how utility regulation may better promote
regional optimization of infrastructure investments.

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MARCH 2016
A Safe Water in Schools for Health (SWISH) program78 would include regular testing
(and re-testing) of tap water at school and licensed day-care facility faucets and water
fountains for regulated contaminants and for bacteria growth (like Legionella) known to
be contained in plumbing systems. For schools found to have unsafe water, the program
would provide funding and implementation support for either lead pipe replacements or
installation of filters capable of treating the water to federal standards. The program
could establish goals to install high-quality water fountains that facilitate effective water
quality monitoring (as well as student use with refillable bottles). For some schools, this
program could include the participation of science programs and students, working with
independent testing laboratories. In any event, all water quality testing results should be
posted both at the facilities and online, and communicated to parents.
R-41. Develop a model LSL replacement program and funding mechanisms for financing work
on private property.
Notwithstanding the water industrys historical reluctance to advocate for full LSL
replacements, the state should develop a funding mechanism and program to evaluate
and replace LSLs statewide, recognizing that some communities already have replaced
their LSLs.79 The state should develop a model statewide LSL replacement program that
could serve as a national model, in collaboration with EPA, with the following attributes:
Requirement for developing censuses of LSLs in utility service areas that are accessible
on utility systems computerized Geographical Information Systems (GIS) and asset
management systems. Censuses should be comprehensive, covering full lengths of
service lines and ownership status, and be made publicly available to facilitate
satisfaction of customer queries.
Evaluation of lead line conditions and associated risks (placing high priority on
replacements of lines to high-risk properties (for example, schools, childcare centers,
hospitals, older neighborhoods and residences of vulnerable populations).
Programming of full LSL replacements in federal- and state-sponsored public housing.
Provision of health risk information to customers with LSLs when homeowners are
presented with the option to pay for the private part of their LSL replacement.
Explicit incorporation of LSL risk considerations in utility renewal and replacement
programs to enable orderly, yet expeditious, full LSL replacement (including
replacement of LSLs on private property).
Establishment or enhancement of funding mechanisms to facilitate full LSL
replacements by:
o Reviewing strategies used by other communities and approaches to addressing
funding of improvements on private property;

78
These recommendations are drawn from (and reflect our substantive concurrence with) recommendations offered
by Peter Gleick, president of the Pacific Institute, and Professor Marc Edwards, Virginia Tech. See One step to help
restore trust in Flint, Detroit Free Press, March 6, 2016.
79
Information on industry experience and perspectives is provided in Strategies to Obtain Customer Acceptance of
Complete Lead Service Line Replacement, American Water Works Association, 2005.

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MARCH 2016
o Facilitating public water systems access to LSL replacement funding, including

through provisions in drinking water state revolving loan fund program
administration;
o Facilitation of public water system customer funding for replacement of LSLs and
lead-containing fixtures on private property;
o Review of LCR-established authority to require full service line replacements; and
o Mitigation of low-income water affordability challenges through financial
assistance and innovative financing mechanisms.
The program should provide for MDEQ to require annual reporting and tracking of the
census of LSLs as part of regular reporting requirements. MDEQ should compile, analyze
and publicly report on the submitted data, enabling state legislature and the general
public to readily access information on progress of LSL replacements throughout the state
while protecting personal information.
R-42. Revise and enhance information distributed by public water systems on the implications
of widespread use of lead in public and private plumbing.
Independently, or in conjunction with the model LSL replacement program recommended
above, the state should improve dissemination of accurate information on the dangers
presented by lead in water systems and plumbing. Readily accessible information should
be broadly provided about potential sources of high levels of lead in water, including, for
example, the potential for the release of lead particulates from piping disturbed by
construction activities, as well as lead solder, galvanized plumbing, and brass fixtures.
Consider and model successful public engagement (and, more generally, LSL replacement)
programs used in countries such as the Netherlands that have more successfully managed
lead risks.80
R-43. Use the occasion of the Flint water crisis to prompt local and state re-investment in
critical water infrastructure, while providing mechanisms to advance affordability and
universal access to water services.
Nationally, water system infrastructure renewal and rehabilitation requirements are
expected to exceed $1 trillion over the next generation.81 Michigan is no exception in
facing a significant infrastructure funding gap, even without prospective funding of full LSL
replacements. State and local decision-makers, water utility representatives, and
community groups should partner to garner support for water system re-investment
(through local service rates and state funding mechanisms), while balancing potential

80
Refer to Water production and distribution in the Netherlands, Andr. Struker, Waternet, Jan Vreeburg, KWR, Jan
Peter van der Hoek, Delft University, Waternet, February 2016 presentation to Flint Water Inter-Agency
Coordinating Committee.
81
See, for example:

Report Card for Americas Infrastructure, American Society of Civil Engineers (ASCE), 2013,
www.infrastructurereportcard.org/a/#p/grade-sheet/americas-infrastructure-investment-needs
Buried No Longer: Confronting Americas Water Infrastructure Challenge, AWWA, 2012,
www.awwa.org/Portals/0/files/legreg/documents/BuriedNoLonger.pdf
Drinking Water Infrastructure Needs Survey and Assessment, Fifth Report to Congress, U.S. EPA, 2011,
www.epa.gov/sites/production/files/2015-07/documents/epa816r13006.pdf
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MARCH 2016
impacts on low-income populations. Stakeholders should work to define new and

innovative water service pricing and funding approaches82 to advance water affordability
and universal access to service.
R-44. Prioritize health matters across all state agencies with establishment of a new Cabinet-
level post focused on public health.
The Flint water crisis illustrates that MDEQ and MDHHS failed to coordinate and
collaborate in responding to multiple health-related concerns raised by members of the
Flint community and by public health partners such as GCHD. Governor Snyder indicated
that there is no liaison function at the Cabinet level in Michigan state government to
connect inter-agency actions regarding health matters. Although the FWICC is designed to
function in an inter-agency manner, its purpose is Flint-centric. There is a strong argument
that such inter-agency functionality for health should be instituted at the state level, to
help safeguard the health of all Michigan residents.
The sheer size of the current MDHHS potentially dilutes the role of the state in important
public health matters. The Task Force recommends that a physician or nurse with public
health and/or health policy credentials serve on the Governor's Cabinet, and be
supported by a staff and budget appropriate for the activities of this role. This person
would serve an overall supervisory and inter-agency liaison role for all activities that have
a bearing on health for Michiganders. Given the suboptimal health status of the Michigan
public on a wide array of matters (for example, infant mortality, obesity, life expectancy,
smoking), not to mention the health concerns that are now paramount in Flint, this
person would have a broad mandate.
Conclusions
The conclusion we made in December 2015 that primary responsibility for causing the Flint water
crisis rests with the MDEQ has only been substantiated by our subsequent interviews and
research. This final report, however, documents the failings, shortcomings and problems in other
agencies and entities as well, such as MDHHS, GCHD, the local water treatment plant, the EM
structure, the Governors office, and the U.S. EPA. These failures reflect the discounting of
profound public health concerns and indifference to Flint residents plight.
The value in documenting what went wrong is not to ascribe blame for blames sake, but to
establish the foundation for moving forward, both in Flint and throughout the state. The state
clearly must respond with dedicated and systematic attention to health concerns for people of
Flint. But it also has the opportunity to demonstrate that lessons have been learned from the
Flint experienceas traumatic as it has been and will continue to beand develop model
infrastructure renewal and public health programs that will serve all Michigan residents for
generations to come.
Flint residents and their fellow Michigan citizens deserve no less.

82
See, for example, Blue Ribbon Panel on Affordability Final Report, City of Detroit, 2016,
www.detroitmi.gov/brpa.

62
APPENDIX I: Flint Water Advisory Task Force (FWATF)

Flint Water Advisory Task Force (FWATF)

Matthew Davis, MD, MAPP, is professor of pediatrics and internal medicine at the University of
Michigan Health System and professor of public policy at the Gerald R. Ford School at the
University of Michigan, having joined the faculty in 2000. Davis also is a professor of health
management and policy at the School of Public Health. He previously served as the chief medical
executive of the Michigan Department of Community Health/Department of Health and Human
Services.
Chris Kolb (Co-Chair) is president of the Michigan Environmental Council, a statewide coalition of
70 environmental, public health and faith-based nonprofit groups. Before joining the MEC, Kolb
represented Ann Arbor in the state House for six years and served six years on the Ann Arbor City
Council. He has been president of the MEC for seven years and has more than 12 years of
experience in the environmental management field.
Lawrence Reynolds, MD, is a pediatrician in Flint who serves as president of the Mott Childrens
Health Center. He received his medical degree from Howard University College of Medicine and
has been in practice for 36 years. He has served as president of the Genesee County Medical
Society and the Michigan Chapter of the American Academy of Pediatrics. He has been honored
for his humanitarian and advocacy efforts on behalf of children from the Community Foundation
of Greater Flint.
Eric Rothstein is a national water issues consultant and principal at the Galardi Rothstein Group.
He served as an independent advisor on the creation of the Great Lakes Water Authority.
Rothstein also has served as Jefferson County, Alabamas rate consultant and municipal adviser
for litigation related to the countys bankruptcy and issuance of $1.7 billion in sewer warrants
and led strategic financial planning for the City of Atlantas Department of Watershed
Management. He has more than 30 years of experience in water, wastewater and stormwater
utility finance and rate-making assessments.
Ken Sikkema (Co-Chair) is a senior policy fellow at Public Sector Consultants, where he specializes
in public finance, environment, and energy policy. Prior to joining the firm, Sikkema served in
both the Michigan House and Senate, culminating with four years as Senate majority leader. He
has also served as both an adjunct and visiting professor at Grand Valley State University.

APPENDIX II: FWATF Letters

December 7, 2015
On Wednesday, November 18, 2015, the Flint Water Advisory Task Force met with representatives of
the Michigan Department of Environmental Quality (MDEQ) and the Michigan Department of Health
and Human Services (MDHHS) to discuss elements of the 10-point Action Plan designed to address
various issues related to the ongoing public health protection challenges precipitated by lead in the Flint
water supply. These discussions were held at our request as part of our task to make recommendations
to prevent a similar occurrence in Flint or elsewhere, and also to monitor ongoing mitigation efforts.
Subsequent to those meetings, on Tuesday, November 24, 2015, members of the Task Force
participated in a conference call with yourself, members of the Administration, and representatives of
these agencies to discuss the progress to date on the 10-point Action Plan, as well as several other
related issues.
We want to acknowledge the steps that have already been taken to implement the action plan,
specifically in the areas of outreach efforts to facilitate blood lead testing for children, communication
with health care providers in the Flint community about the importance of testing children for lead, and
the training of additional public health nurses in the Genesee County Health Department. We do
believe, however, that additional steps need to be taken to reach additional children for blood lead
testing, assure proper follow-up with children found to have elevated blood lead levels, and to continue
water testing. We will continue to assess state and local efforts and make recommendations regarding
specific steps that we believe are warranted.
One primary concern we have at this point is that the current efforts appear to be taking place in the
absence of a larger project coordination framework that measures results and clearly delineates
responsibilities for continuing actions to protect public health. We believe the state is best positioned to
facilitate this larger framework, which should address the following:
1. The need for MDHHS and MDEQand, possibly, other state agencies--to set goals for actions in
collaboration with local and federal agencies and organizations.
2. The need for a set of corresponding timelines for the goals.
3. The need to establish responsibility for meeting the goals in a timely fashion and for
contingency plans for the state if the goals are not being met.
4. The need for clear, regular communication with the Flint community and stakeholder groups
regarding action steps and updates.
We also believe it important that a single person or entitypotentially independent of any one
particular state agency and mutually agreeable to this Task Force and you, Governorbe established to
provide effective coordination of ongoing activities and reporting on the status of mitigation measures.
For this, we also believe a readily understood dashboard should be developed that reports on the
goals, timelines and assignments. This will enable members of the Flint community, public health
providers, and state agencies to know about the status of the Flint water crisis mitigation program, as
well as promote coordination and accountability. The Task Force is prepared to assist in the
development of that dashboard.
We believe it is vitally important that trusted members of the Flint community be engaged in
communication on this issue, as well as the distribution of information conveyed by our suggested
dashboard reporting. Accordingly, in advance of our final report, we would like to ensure the
independent coordinator suggested above engage trusted community groups to begin rebuilding
community trust in state actions.
We appreciate your personal interest in this issue, commitment to assisting the Task Force in our
review, andmost importantlycommitment to ensuring that the full measure of state resources are
brought forward to protect the public health in Flint and throughout the state.
Respectfully yours,
Flint Water Advisory Task Force:

Dr. Matt Davis
Chris Kolb
Dr. Larry Reynolds
Eric Rothstein
Ken Sikkema
December 29, 2015

The Flint Water Advisory Task Force, which you appointed on October 21, 2015, has devoted
considerable effort and countless hours to our review of the contamination of the Flint water supply:
what happened, why it occurred, and what is needed to prevent a recurrence in Flint or elsewhere in
the state. We have also been assessing ongoing mitigation efforts to help assure that short- and long-
term public health issues and water management concerns will be properly addressed to safeguard the
health and well being of the Flint community.
Shortly after we began our work, we recognized the immediate need for better coordination of the
states response to the ongoing public health issues in Flint, and for assignment of a single person to
provide this coordination. We addressed these concerns in a letter to you on December 7, 2015, and you
responded with immediate adoption of these recommendations. We thank you for the commitment
your response demonstrates.
In our continuing efforts, we have now interviewed numerous individuals at state and local levels;
reviewed many documents, articles, and emails; and deliberated repeatedly as a group. Both individually
and as a group, we have visited Flint several times during the past several weeks to meet with citizens,
public health officials and healthcare providers, individuals who have water management
responsibilities at the city and county levels, and other public officials.
It is clear to us, particularly as we listen to the people of Flint, that it is both critical and urgent to
establish responsibility for what happened in their community and to ensure accountability. This is a
first step in a long process to re-establish the trust they no longer have in their government and the
agencies whose responsibility it is to protect their health. It is urgent because this deep distrust of
government continues to compromise the effective delivery of protective services designed to address
ongoing public health issues. It is for these reasons that we are sending this letter at this time.
We believe the primary responsibility for what happened in Flint rests with the Michigan Department
of Environmental Quality (MDEQ). Although many individuals and entities at state and local levels
contributed to creating and prolonging the problem, MDEQ is the government agency that has
responsibility to ensure safe drinking water in Michigan. It failed in that responsibility and must be
held accountable for that failure.
The Safe Drinking Water Act (SDWA) places responsibility for compliance with its requirements on the
public water system. In this instance, the City of Flint had the responsibility to operate its water system
within SDWA requirements, under the jurisdiction of the MDEQ. The role of the MDEQ is to ensure
compliance with the SDWA through its regulatory oversight as the primary agency having enforcement
responsibility for the Flint water system.
The MDEQ failed in three fundamental ways.
Regulatory Failure
We believe that in the Office of Drinking Water and Municipal Assistance (ODWMA) at MDEQ, a culture
exists in which technical compliance is considered sufficient to ensure safe drinking water in Michigan.
This minimalist approach to regulatory and oversight responsibility is unacceptable and simply
insufficient to the task of public protection. It led to MDEQs failure to recognize a number of indications
that switching the water source in Flint wouldand didcompromise both water safety and water
quality. The MDEQ made a number of decisions that were, and continue to be, justified on the basis that
federal rules allowed those decisions to be made. ODWMA must adopt a posture that is driven not by
this minimalist technical compliance approach, but rather by one that is founded on what needs to be
done to assure drinking water safety.
A culture change must occur within ODWMA. It must be driven by a mission that is aspirational
regarding the role of the MDEQ in ensuring the safety and the quality of Michigans drinking water. We
believe, and have expressed to MDEQ Director Dan Wyant, that as a Great Lakes State, Michigan should
aspire to have the safest drinking water in the nation, rather than merely aiming for technical
compliance with regulatory requirements.
Failure in Substance and Tone of MDEQ Response to the Public
Throughout 2015, as the public raised concerns and as independent studies and testing were conducted
and brought to the attention of MDEQ, the agencys response was often one of aggressive dismissal,
belittlement, and attempts to discredit these efforts and the individuals involved. We find both the tone
and substance of many MDEQ public statements to be completely unacceptable. In a real way, the
MDEQ represents the public, including the very individuals it treated dismissively and disrespectfully in
public statements. We recognize that the agency might disagree with the opinions of others on a variety
of issues, including testing protocol, interpretation of testing results, the requirements of federal law
and rules, and other matters. What is disturbing about MDEQs responses, however, is their persistent
tone of scorn and derision. In fact, the MDEQ seems to have been more determined to discredit the
work of otherswho ultimately proved to be rightthan to pursue its own oversight responsibility.
Failure in MDEQ Interpretation of the Lead and Copper Rule
The federal Lead and Copper Rule (LCR) is central to what happened in Flint, because that rule, at least
theoretically, is designed to prevent lead and copper contamination of drinking water. The federal LCR
calls for optimized corrosion control treatment, which the MDEQ did not require in the switch to the
Flint River. Prior to the switch, MDEQ staff instructed City of Flint water treatment staff that corrosion
control treatment (CCT) was not necessary until two six-month monitoring periods had been conducted.
The need for CCT would be evaluated after the results from those two monitoring periods were
reviewed. The decision not to require CCT, made at the direction of the MDEQ, led directly to the
contamination of the Flint water system.
The MDEQ seems to have taken different positions on whether it faithfully followed the LCR in the Flint
situation. It first maintained that it followed the LCR, then stated that it did not follow the rule properly,
and most recently claimed that a federal memorandum issued by the US EPA in early November 2015
suggests that the original MDEQ interpretation was possibly correct.
We are not convinced. Even the MDEQs latest interpretation of the US EPAs November memorandum
is overly legalistic and misunderstands the intent of the LCR, which is to minimize risks of lead and
copper exposure for human health.
We believe ODWMAs single-minded legalistic focus is the heart of the problem, and it is part of the
technical compliance culture described above. ODWMA should not be basing its actions solely on a

legally possible interpretation of the LCR. It should be focusing on how to protect Michigans citizens
from lead in drinking water.
We met with MDEQ Director Wyant on December 16, 2015, to discuss these issues, as well as many
others. We note his substantial agreement with many of our conclusions, particularly as it relates to the
regulatory failure and the abysmal public response of his agency. It is our understanding that he has
drawn similar conclusions in his own evaluation of the MDEQs role in the Flint water crisis. At the same
time, it was disappointing to hear his weak defense of the CCT decision based on the EPAs November
2015 memorandum.
We are not finished with our work. Other individuals and entities made poor decisions, contributing to
and prolonging the contamination of the drinking water supply in Flint. As an example, we are
particularly concerned by recent revelations of MDHHSs apparent early knowledge of, yet silence
about, elevated blood lead levels detected among Flints children. We also feel it important to further
review local government decision processes under emergency management. Our final report will
highlight and discuss those concerns, among many others, to provide some context to a comprehensive
series of recommendations. As stated earlier in this letter, however, we believe that establishing
responsibility is a critical and urgent need, and one that should not wait for our final report in 2016.
Individuals and agencies responsible must be held accountable in a timely fashion.
It is our hope that the heightened awareness of the dangers of lead poisoning can be an opportunity to
make Michigan safer, particularly for its children. Drinking water must be recognized as a potential
source of health risk exposure when water lines and fixtures containing lead are disturbed or
compromised. Proper testing, not only in high-risk areas but also in facilities serving children (e.g.,
schools), must be considered. Facilitating long-term financing of a model public health program, and
also replacement of lead-containing water service lines and fixtures, would enable Michigan to realize a
positive lasting legacy from the tragedy of the Flint water crisis. Our final report will address some of
these issues.
The City of Flints water customersfellow Michigan citizenswere needlessly and tragically exposed to
toxic levels of lead through their drinking water supply. They deserve a commitment to properly assess
responsibility and ensure accountability. They also deserve a commitment to needed mitigation in both
the short and long term. The Flint water crisis never should have happened. Having failed to prevent it,
state government should coordinate a sustained, public-health-focused response to remedy, to the
fullest extent possible, the impacts on the Flint community.
Respectfully yours,

Flint Water Advisory Task Force:
Matt Davis
Chris Kolb
Larry Reynolds
Eric Rothstein
Ken Sikkema

January 22, 2016

Governor Rick Snyder
Office of Governor
P.O. Box 30013
Lansing, Michigan 48909
The Flint Water Advisory Task Force (FWATF) appreciates your recent efforts to secure federal
and mobilize state emergency response resources to address the immediate water supply
issues in Flint.
This letter is to encourage a similarly robust response to the challenges of re-establishing a
reliable, trusted potable water distribution system in Flint. This is required as soon as possible
to replace the unsustainable and expensive bottled water and filter distribution program that
has been necessitated, but which clearly must serve as an interim, emergency response.
Consistent with the priorities identified in the Safe Drinking Water Emergency Order issued by
the EPA on January 21, 2016, we recommend the following actions to address scientifically
grounded concerns that the water system in Flint remains unsafe because of lead
contamination and Legionella. Public trust in the safety of the water supply may only begin to
be re-established through the states forthright engagement of the scientific experts who
overcame state and federal agency intransigence to expose the lead poisoning.
Our recommendations are:
Engage US EPA staff experts versed in Lead and Copper Rule (LCR) requirements
specifically Miguel del Toral, Darren Lytle and Michael Shock. These individuals should
be empowered to guide implementation of a comprehensive LCR sampling program in
Flint that will monitor lead levels now and throughout the conversion to raw water
supply by the Karegnondi Water Authority (KWA) and full-time use of the Flint Water
Treatment Plant.
Establish an inter-disciplinary work group comprising subject matter experts drawn from
respected public utility associations and institutions of higher learning in Michigan and
elsewhere (including Marc Edwards of Virginia Tech), to oversee the conversion to KWAsupplied raw water.
Commission and/or contract with an unbiased third-party organization or consortium

(hereafter: Flint water safety scientific assessment team [FWSSAT]) that will be
responsible for assessing the quality and safety of drinking water in residences, schools
and child care settings in Flint, and hospitals and other healthcare facilities served by the
Flint water system. The explicit focus of FWSSAT activities will be lead and Legionella;
however, the FWSSAT may include other considerations in its work.
The FWSSAT will be invested with the responsibility of declaring when the public water
supply in Flint is safe for routine consumption. The FWSSAT will employ the most
rigorous scientific standards, using a sampling strategy that is designed to optimize
detection of water contamination in home, school, and child-care settings, and
healthcare environments. All schools and healthcare facilities must be included in the
sampling approach. Rigorous sampling of residences and child-care settings (whether
centers or in-home) will also be implemented, using any and all available information
about lead water service lines. In addition, if a homeowner or renter whose dwelling
has not been included in sampling wishes to have the dwelling included, they will also
be sampled. The sampling efforts and reporting process of the FWSSAT will be fully
transparent to the public; results of testing should be published on local, state, and
federal (EPA) websites.
To assure the re-building of community trust and assure sufficient expertise for future
water quality and safety, the FWSSAT should partner with local (Flint Water Treatment)
and state (MDEQ) personnel in its activities. The FWSSAT should have an interdisciplinary advisory committee that includes local community leaders, local and state
officials, national scientific authorities regarding water quality and safety and public
health, and the leader of the interagency state effort regarding the Flint water crisis.
When the FWSSAT advisory committee is satisfied that the FWSSAT scientific
procedures have thoroughly assessed water quality and safety in Flint residences,
schools and child care settings, and healthcare facilities and found the water to be
sufficiently free of contamination, then the committee will advise the public of the
findings. The FWSSAT will then organize the transfer of responsibility to local and state
authorities to sustain the sampling and reporting methods thereafter, including the
conversion to KWA raw water in the future.
We also believe that a forthright response to the Legionella outbreak must similarly engage
trusted, scientific experts drawn from independent institutions. Accordingly, we recommend:
The Michigan Department of Health and Human Services (MHHS) should make a formal
request to the federal Centers for Disease Control and Prevention (CDC) for assistance in
assessing the outbreak of Legionnaires disease in Flint, if they have not already done so.
MHHS, working with CDC, should develop a strategy for improving prevention, rapid
detection, and timely treatment of cases of Legionellosis in Michigan in 2016 and
beyond. While the MDHHS evaluation of the dozens of cases of Legionellosis in 2014
and 2015 has strongly suggested a link to the shift to drinking water from the Flint River
in 2014, further and more intensive evaluation of clinical isolates (i.e., samples from
infected patients) is necessary to understand the route(s) of transmission from
contaminated water to humans. The unique set of outbreak circumstances in the
setting of a change in water source strongly indicates that support from federal public
health authorities would be a welcome way to amplify the publics collective

understanding of risk of contracting Legionella in residences served by the Flint water
system, and in Flint healthcare facilities.
The state should specifically request federal support from the CDC and, as
appropriate, additional federal experts and agencies to advise and assess Flint
healthcare facilities and Flint-based healthcare providers regarding: (a) appropriate
application and timely re-application of biocides to air treatment systems and cooling
towers in all healthcare facilities in Flint, in order to prevent colonization with
Legionella; and (b) proper assessment and timely diagnosis of Legionella among patients
in Flint who present with characteristic signs and symptoms and have a history of
potential exposure to contaminated water. Of note, the risk of resurgent Legionellosis
in Spring 2016 is on the horizon; the first cases of Legionellosis in the 2014 and 2015
outbreaks were diagnosed in June and May, respectively, and Legionella is known to be
much more common in the spring, summer, and fall than in the winter months. Time is
of the essence.
MDHHS should work with its federal partners to assure that investigative efforts related
to Legionella regarding quality and safety of water are conducted in coordination with
the FWSSAT described above. Furthermore, MDHHS should regularly communicate its
findings to the Flint community regarding its efforts to prevent, detect, and treat cases
of Legionella until case levels return to pre-2014 levels.
We expect that these measures will provide members of the Flint community with assurance
that the quality of their tap water is being appropriately monitored and that forthcoming
announcements that Flints tap water is safe to drink are well-founded. Notwithstanding
earnest state agency actions, we believe that the engagement of independent subject matter
experts, whether to assess drinking water quality or public health concerns, is critical to
overcome, over time, the understandable skepticisms that prevail in the Flint community.
We hope that you will receive these recommendations in the same spirit with which they are
offered to advance the recovery and reinvigoration of the Flint community.
Respectfully,
Matthew Davis, M.D.

Chris Kolb
Lawrence Reynolds, M.D.
Eric Rothstein, CPA
Ken Sikkema
APPENDIX III: Interviewee Listing


Interviews and Discussions Listing
No.
Last Name
1
2
Kildee
Ananich
3
4
5
6
Snyder
Muchmore
Baird
Hollins
7
8
9
10
11
Dillon
Workman
Saxton
Byrne
Sampson
12
13
14
15
16
17
18
19
Ambrose
Earley
Kurtz
Brown
Weaver
Walling
Henderson
Freeman
20
21
22
23
24
25
Lundquist
Brown
Croft
Johnson
Wright
Glasgow
26
27
28
Mays
Overton
Shariff
29
30
31
32
33
34
35
Wyant
Sygo
Creagh
Krisztian
Anderson
Shekter Smith
Rosenthal
First Name
Organization
Federal and State Office Holders / Key Officials
Daniel T.
U.S. House of Representatives
James
Michigan State Senate
Michigan Governor's Office
Rick
Dennis
Rich
Harvey
Michigan Department of Treasury
Andy
Treasury Department
Wayne
Treasury Department
Thomas
Treasury Department
Randall
Treasury Department
Jeremy
Treasury Department
Flint Emergency Managers - Office Holders
Jerry
City of Flint
Darnell
City of Flint
Ed
City of Flint
Michael
City of Flint
Karen
City of Flint
Dayne
City of Flint
Natasha
City of Flint
Josh
City of Flint
City of Flint Staff and Consultants
Jody
City of Flint
Inez
City of Flint
Howard
City of Flint
Daugherty
City of Flint
Brent
City of Flint
Mike
City of Flint
Flint Community
Melissa
Flint Citizen
Allan
Flint Citizen
Nayyirah
Flint Citizen
Michigan Department of Environmental Quality
Dan
MDEQ
Jim
MDEQ
Keith
MDEQ
George
MDEQ
Madhu
MDEQ
Liane
MDEQ
Adam
MDEQ

Interviews and Discussions Listing
No.
36
37
Last Name
Busch
Prysby
38
39
40
41
42
43
Lyon
Becker
Wells
Larder
Lasher
Moran
44
45
46
47
48
49
50
51
Hyde
Crooks
Hedman
Kaplan
Del Toral
Porter
Blair
Poy
51
52
53
54
Betanzo
Edwards
Sullivan
McElmurry
54
55
56
57
Hanna-Attisha
Valacak
Doerr
Henry
58
59
Guyette
Fonger
59
60
61
62
63
Wright
O'Brien
Jansen
Wolfson
Koesters
First Name
Organization
Stephen
MDEQ
Mike
MDEQ
Michigan Department of Health and Human Services
Nick
MDHHS
Tim
MDHHS
Eden
MDHHS
Cristin
MDHHS
Geralyn
MDHHS
Susan
MDHHS
US EPA
Tinka
EPA
Jennifer
EPA
Susan
EPA
Bob
EPA
Miguel
EPA
Andrea
EPA
Rita
EPA
Tom
EPA
Technical Experts - WQ and Lead
Elin
Northeast-Midwest Institute
Marc
Virginia Tech
Laura
Kettering University
Shawn
Wayne State University
Public Health Community
Mona
Hurley Medical Center
Mark
Genesee County Health Dept.
Kay
Genesee County Health Dept. - Board of Health
James
Genesee County Health Dept.
Media
Curt
ACLU
Ron
MLive
KWA - DWSD
Jeff
GCDC
John
GCDC
Dave
GCDC
William
GLWA / DWSD
Laurie
GLWA / DWSD
APPENDIX IV: Questions of Lockwood, Andrews, & Newnam


Lockwood, Andrews and Newnam
Flint Water Advisory Task Force Questions
February 22, 2016

1. Please describe your firms experience with drinking water treatment facilities,
specifically related to drinking water quality, treatment of river water supply,
disinfection and disinfection byproduct management, corrosion control, and startup for
full-time operation.
2. Please describe your firms experience with distribution system management, including
corrosion control, disinfection and DBP management, and Legionella management.
3. Please provide the scope of work for your engagements related to preparing the Flint
Water Treatment Plant for full-time operation, as well as any subsequent engagements.
4. Please describe the procurement processes used for contracting these scopes of service.
Please provide copies of relevant proposals and contracts.
5. Please provide a narrative describing LANs involvement with City of Flint and MDEQ
staff throughout your engagement with the City related to full-time operation of the
Flint Water Treatment Plant.
6. Please provide a list of your findings and recommendations to address the various water
quality problems that occurred following startup of full-time operation of the Flint
Water Treatment Plant.
7. Please provide your subjective assessment of the condition and technologies at the Flint
Water Treatment Plant and distribution system prior to full-time operation of the plant.
8. Please identify all team members (including LAN staff and any subconsultants) who
worked on the project to prepare the Flint Water Treatment Plant for full-time
operation. Describe their respective roles on the project and their experience. If any
other staff or consultants were engaged for guidance or review, please include those
individuals as well.
9. Please describe the reporting structure (both LANs project team reporting structure
and its reporting relationship to City of Flint staff and Emergency Manager) for LANs
work on the Flint Water Treatment Plant, specifically for preparations for full-time
operation of the plant.
10. Please provide a copy of any deliverables prepared to support full-time operation of the
Flint Water Treatment Plant, including the plan of treatment that was reviewed with
MDEQ.
11. Please review your discussions with the City of Flint utility staff and MDEQ regarding
Flint River water chemistry and treatment requirements, specifically relating to:
a. Anticipated treatment challenges related to use of Flint River
b. Prospective disinfection requirements and options for management of DBPs
c. Corrosion control
12. Please describe the decision-making processes related to treatment requirements,
specifically with regard to corrosion control treatment.
13. What was the nature of the discussions regarding Lead and Copper Rule compliance
requirements?
14. Did LAN identify requirements for Lead and Copper Rule compliance in advance of
discussions with MDEQ?
15. Did LAN express any concerns or cautions with respect to MDEQs interpretation of Lead
and Copper Rule requirements for water treatment?
16. What were the outcomes of discussions with MDEQ regarding treatment requirements,
specifically regarding compliance with Lead and Copper Rule requirements?
17. Please outline your interactions with other consultants and suppliers working on the
Flint Water Treatment Plant, both during preparation for and after startup of full-time
operation, including Rowe Professional Consultants, Veolia and any others.
18. Please describe LANs involvement with the City of Flints Technical Advisory Committee.
Please provide copies of any presentations or handouts offered in the context of the
Technical Advisory Committee discussions.
19. Please offer any key points or information not already provided that you think would be
of value in addressing the causes of the Flint water crisis and avoiding similar situations
in the future. Please provide any recommendations to address prospective Flint water
system needs.
20. Please offer any key points or information not already provided that you think would be
of value in addressing the causes of the Flint water crisis and avoiding similar situations
in the future. Please provide any recommendations to address prospective Flint water
system needs.
APPENDIX V: Detailed Timeline


Integrated Event Timeline
March 21, 2016
Note: This timeline was compiled by the Flint Water Advisory Task Force to support its investigation of the Flint water crisis. It includes selected events that occurred before and during the crisis. The timeline ends February 29, 2016.
Date
Event
Flint's water system is organized and built under private ownership as the Flint
Water Works Company, pumping raw water from the Flint River to customers
City of Flint purchases water utility ($262,500) and converts it to a Municipally
1903
Owned Corporation
1883
1911 City of Flint adds water filtration to Flint's water system

1947 - 1955
1967
1991
2000
Sources
Brochure provided to FWATF by City of Flint
"The Water Supply of Flint, Michigan" (brochure)
City of Flint invests in capital improvements to the water utility ($12.5M) including
improved water storage, treatment and pumping. "Polyphosphate is added in small
amounts to lessen the corrosion of water pipe when in contact with the cold water,"
p. 11
City of Flint executes long-term water supply contract with Detroit Water and
Contract referenced in "Detroit Water and Sewerage Department - dwsd.org/downloads_n/about_dwsd/history/complete_history.p
Sewerage Department (DWSD) and begins receiving water from DWSD. Flint Water
The First 300 Years," posted to DWSD website
df
Treatment Plant (WTP) subsequently is converted to a backup supply source
EPA issues Lead and Copper Rule (LCR) to control lead and copper in drinking water LCR history and current rule posted to EPA's website
www.epa.gov/dwreginfo/lead-and-copper-rule
Timeline/Analysis/Recommendations (July 15, 2010), prepared by
Flint water supply contract with DWSD expires
Information provided to FWATF
DWSD Wholesale Customer Outreach Team
2001 DWSD and Flint enter into contract negotiations - subsequently suspended
July 2002
Reference Document
Source Water Assessment Report for the City of Flint Water

Supply Flint River Emergency Intake," prepared by U.S.
Technical assessment of Flint River raises concerns about its use for drinking water,
February 2004
Geological Survey, MDEQ and Flint Water Utilities Department. As
noting the source's susceptibility to contamination
reported in Bridge Magazine (Feb. 4, 2016): "Disaster Day by Day:
A detailed Flint crisis timeline"
Genesee County Drain Commission (GCDC) commissions feasibility study on
"Preliminary Report - Long-Term Water Supply for Genesee
alternatives to provide water service to existing and new customers. Report
January 2006
County," prepared by Rowe, Jones & Henry, Gannett Fleming.
indicates Flint River water can be safely treated but does not have adequate
Included in Gov. Snyder's Flint Water timeline (released Jan. 2016)
capacity for permanent use
DWSD (Mercado/Foster) discusses water contract options with Genesee County
Drain Commission (GCDC)
DWSD brings forward pipeline loop in its capital plan to address concerns of City of
September 2007
Flint, Genesee County, and Michigan Department of Environmental Quality (MDEQ)
3/12/16
3/12/16

Under Michigan's Public Act 72 of 1990, Flint is placed under an Emergency Financial MLive (Nov. 10, 2011): "What happened last time? A look back at www.MLive.com/news/flint/index.ssf/2011/11/what_happened_l
Manager (EFM) until 2004. Ed Kurtz is appointed Flint EFM
Flint's 2002 state takeover" (Mostafavi)
ast_time_a_look.html
January 2007
Accessed
3/12/16
bridgemi.com/2016/02/flint-water-disaster-timeline/
3/12/16
Report provided to FWATF by MDEQ.

Gov. Snyder's timeline:
mi.gov/documents/snyder/FlintWaterTimeline_FINAL_511424_7.
pdf
3/20/16

2008
June 3, 2008
June 12, 2008
July 16, 2008
September 3, 2008
GCDC requests negotiation with DWSD for water supply contract; requests short-
term contract due to ongoing evaluation of long-term needs
DWSD issues response to GCDC negotiation request (referenced in July 16, 2008
letter)
Flint advises DWSD that GCDC will represent its interests in negotiations
GCDC and DWSD meet on water supply contracting
Letter from O'Brien/GCDC to Mercado/DWSD
Mercado/DWSD letter
Letter from Williamson & Wright to Detroit Deputy Mayor Adams Information provided to FWATF
Meeting Summary - Project Innovations
2009
February 11, 2009
March 10, 2009
GCDC submits permit application for 85-mgd surface water withdrawal from Lake
Huron
Permit application and supporting data posted to MDEQ website
DWSD offers partnership arrangement: GCDC fund Flint loop north of Oakland
border ($200 million) and obtain 40% reduction on service rates

Information provided to FWATF.
DWSD Wholesale Customer Outreach Team.
www.MLive.com/news/flint/index.ssf/2009/03/halfprice_water_o
MLive (March 11, 2009): "Half Price Water Offer from Detroit Not
ffer_from_det.html
Exactly What it Seems" (Fonger)
Flint Water Crisis Timeline
www.michigan.gov/documents/deq/deq-wb-dwehs-wateruse-
gcdcwwpermitapp_280312_7.pdf
3/12/16
3/19/16
Date
Event
June 2009 DWSD and SOCWA file comments opposing GCDC withdrawal permit application
June 25, 2009 GCDC announces plans to build $600 million water system
June 25, 2009
"Lake Huron Water Supply Study - Karegnondi Water Authority (KWA) Executive
Summary" issued
July 10, 2009 DWSD Interim Director Pamela Turner publishes Letter to Editor in MLive
August 13, 2009 Foster Group provides observations on GCDC cost analysis re: KWA
August 28, 2009 MDEQ issues permit to GCDC for 85-mgd Lake Huron withdrawal for KWA
September 2009 "Lake Huron Water Supply - KWA Preliminary Engineering Report" issued
Reference Document
Sources

Referenced in July 25th letter - DWSD Director Pam Turner
"Lake Huron Water Supply Study - Karegnondi Water Authority
Attachment 3 - MDEQ documentation provided to FWATF Nov. 6,
Executive Summary," prepared by AECOM, Jones & Henry, LAN,
2015
O'Malia, Rowe and Wade Trim
MLive (July 10, 2009): "Another View: Genesee County Water
www.MLive.com/opinion/flint/index.ssf/2009/07/another_viewg
Venture is Risky Business: Think AutoWorld" (Hughes)
enesee_county_wat.html
Foster Group memo: "Observations on Cost Analysis from the Lake
Huron Water Supply Karegnondi Water Authority Preliminary
Engineering Report"
MDEQ Large Quantity Water Withdrawal Permit posted to MDEQ www.michigan.gov/documents/deq/deq-wb-dwehs-wwciu-
website
gcdclqwwpermit_290342_7.pdf
"Lake Huron Water Supply Study - Karegnondi Water Authority
www.scribd.com/doc/52254829/Karegnondi-Water-Authority-
Preliminary Engineering Report," prepared by AECOM, Jones &
Preliminary-Engineering-Report-Sept-2009
Henry, LAN, O'Malia, Rowe and Wade Trim
Accessed
3/20/16
3/12/16
3/12/16
2010
MLive (Feb. 25, 2010): "Another View: Detroit Water and
Sewerage wants to work with leaders in Genesee and Lapeer
counties" (Letter from Pamela Turner/DWSD)
www.MLive.com/opinion/flint/index.ssf/2010/02/another_view_
detroit_water_and.html
3/12/16
April 13, 2010 Genesee County approves KWA Articles of Incorporation
MLive (April 13, 2010): "Genesee County starts regional water

www.MLive.com/news/flint/index.ssf/2010/04/genesee_county_
authority, potential partners plan votes in coming weeks" (Fonger) starts_regional.html
3/12/16
May 14, 2010 MLive reports on GCDC contract with political consultant Sam Riddle
MLive (May 14, 2010): "Drain commissioner paid Sam Riddle

$2,000 a month to work on Genesee county water pipeline"
(Longley)
3/12/16
February 22, 2010 DWSD posts letter to potential KWA partners (Flint, Genesee, Lapeer)
DWSD and GCDC meet to negotiate water supply contract. Notes re: contract
June 17, 2010 termination: "Does not mean DWSD will not continue to provide water but rates will Meeting summary - Project Innovations
reflect stranded cost charge to protect the system"
"2013 Consumer Confidence Report" posted to GCDC website.
MLive (July 10, 2010): "Genesee County drain commissioner's new
July 10, 2010 GCDC issues Consumer Confidence Report supporting KWA pipeline
water quality report focuses on benefits of building new water
pipeline" (Fonger)
www.MLive.com/news/flint/index.ssf/2010/05/drain_commission
er_paid_sam_ri.html
www.gcdcwws.com/images/contentImages/file/2014%20Water%
20Color-WE.pdf
drain_commissio_10.html
3/12/16
Report:
www.scribd.com/doc/64381765/Analysis-of-the-Flint-River-as-a-
Permanent-Water-Supply-for-the-City-of-Flint-July-2011
Appendices:
www.scribd.com/doc/64382181/Analysis-of-the-Flint-River-as-a-
Permanent-Water-Supply-for-the-City-of-Flint-July-2011-
Appendices-1-to-8
3/12/16
www.michigan.gov/documents/treasury/Flint-
GovernorsDetermination-11-8-11_417435_7.pdf
1/31/16
www.MLive.com/news/flint/index.ssf/2011/08/flint_water_sewer
_rates_increa.html
3/12/16
2011
Report is completed for City of Flint on feasibility of using Flint WTP and Flint River
as primary water supply. Notes Flint River water will require more treatment than "Analysis of the Flint River as a Permanent Water Supply for the
July 1, 2011
Lake Huron water; recommends capital improvements and projects capital and
City of Flint," prepared by Rowe and LAN
operating costs (including phosphate addition)
August 29, 2011
September 16, 2011

September 30, 2011
November 11, 2011
November 29, 2011
Michigan Department of Treasury conducts preliminary review of City of Flint

finances and recommends appointment of a Financial Review Team. Noting the
Letter posted to State of Michigan website
city's accumulated deficits of $25.7 million, it concludes "probable financial distress"
exists in the city
City of Flint increases water and sewer rates by 35 percent, following a water and
MLive (Aug. 16, 2011): "Flint water, sewer rates increasing 35
sewer rate increase of 25 and 22 percent, respectively, that took effect in January
percent" (Longley)
2011
Gov. Snyder appoints 8-member Financial Review Team, which convenes in October-
November and recommends appointment of Emergency Manager in Flint
Gov. Snyder notifies Flint Mayor Dayne Walling via letter of intent to appoint
Emergency Manager
Detroit Free Press (February 2016): "How Flint's Water Crisis
Gov. Snyder places City of Flint in receivership under PA 4
Unfolded" (Dixon)
www.freep.com/pages/interactives/flint-water-crisis-timeline/
1/31/16
1/31/16
3/12/16
Date
Event
Michael Brown replaces Ed Kurtz as City of Flint EFM. Brown lays off high-ranking
December 1, 2011 City Hall appointees and eliminates pay for mayor and city council (which he later
partially restored)
Reference Document
Sources
Detroit Free Press (November 30, 2011): "Governor names Flint

native city's emergency financial manager"
www.MLive.com/news/flint/index.ssf/2013/06/hes_back_a_timel
MLive (June 30, 2013): "He's back: A timeline of Michael Brown's ine_of_michael.html
moves as Flint's emergency manager" (Adams)
Accessed
3/12/16
2012
Gov. Snyder delivers statewide public safety message from Flint City Hall to
March 7, 2012 announce plan including reopening Flint lockup and boosting state police patrols in
Flint
Judge grants temporary restraining order against any action by EM Brown pending
March 15, 2012 lawsuit filed by city employee Sam Mum (head of AFSCME Local 1600) alleging state
violated Open Meetings Act in appointing him
Ingham County Circuit Court Judge Rosemarie Aquilina rules in favor of Muma,
March 20, 2012
removing Brown from office and restoring power to the mayor and city council
March 26, 2012 Michigan Court of Appeals reinstates Brown as Flint EM
April 24, 2012 City of Flints Fiscal Year 2013 budget passed by an executive order
Flint Department of Public Works (DPW) Director Howard Croft sends letter to
District Engineer Mike Prysby, MDEQ Office of Drinking Water and Municipal
Assistance (ODWMA), stating KWA "has the potential to be a major factor in our
May 9, 2012
regions economic development... The City of Flint is pleased to be a partner in the
process and we pledge to offer our assets to support the development. We
appreciate your technical support as we develop our components of the project.
Flint City Council President Scott Kincaid files lawsuit against City seeking to repeal
May 24, 2012
recent (Sep. 2011 and May 2012) increases in water and sewer rates
May 30, 2012
June 26, 2012

July 2, 2012
August 8, 2012
September 10, 2012

September 20, 2012
October 31, 2012
November 2013
November 6, 2012
November 6, 2012
December 27, 2012
MLive (March 7, 2012):"Gov. Snyder unveils public safety proposal

in Flint calling for more state police, forensic techs in high-crime
cities" (Longley)
MLive (March 15, 2012): "Restraining order against Flint
emergency manager leaves city without clear chain of command"
(Longley)
MLive (June 30, 2013): "He's back: A timeline of Michael Brown's
MLive (March 26, 2012): "Flint emergency manager reinstated as
battle over Public Act 4 continues" (Longley)
"City of Flint Financial and Operating Plan - Fiscal Year 2013,"
posted final to City of Flint website Sep. 25, 2012
www.MLive.com/news/flint/index.ssf/2012/03/gov_snyder_unvei
ls_public_safe.html
3/12/16
www.MLive.com/news/flint/index.ssf/2012/03/emergency_mana
ger_restraining.html
3/12/16
www.MLive.com/news/flint/index.ssf/2013/06/hes_back_a_timel
ine_of_michael.html
www.MLive.com/news/flint/index.ssf/2012/03/flint_emergency_
manager_reinst.html
www.cityofflint.com/wp-
content/uploads/Reports/FinPlanFY13pdf.pdf
3/12/16
3/12/16
3/12/16
As reported in Bridge Magazine (Feb. 4, 2016): "Disaster Day by

Day: A detailed Flint crisis timeline"
3/12/16
MLive (May 24, 2012): "Lawsuit filed against Flint by council

president over water rate increases" (Ridley)
www.MLive.com/news/flint/index.ssf/2012/05/lawsuit_filed_agai
nst_flint_by.html
3/12/16
Emergency Manager Brown further increases water rates by 12.5 percent and sewer Emergency Manager Order No. 31 - Water and Sewer Rate
rates 45 percent, and ratifies Sep. 2011 increases. (Appeals court subsequently
Increases, posted to City of Flint website
3/12/16
www.cityofflint.com/wp-content/uploads/CityPDF/031.pdf
invalidates.) With this increase, Flint water customers had seen a "110 percent
Referenced in MLive (June 19, 2015): "Flint council members want
www.MLive.com/news/flint/index.ssf/2015/06/flint_council_me
increase in their average water and sewer rates since January 2011"
water customers refunded, lawsuit settled" (Fonger)
mbers_say_city.html
Flint EM Brown sends letter to DWSD for permission to begin blending Flint River
Department of Treasury timeline (dated Sep. 28, 2015), included in somcsprod2govm001.usgovcloudapp.net/files/snyder%20emails.p
water with treated water from DWSD. Letter indicates MDEQ is supporting this
3/12/16
Gov. Snyder's e-mails released Jan. 20, 2016 (pp. 93-94/274)
df
option, which would save City $2 million to $3 million annually
State appeals court dismisses Kincaid lawsuit challenging recent Flint water and
MLive (July 2, 2012): "State appeals court dismisses Flint water
www.MLive.com/news/flint/index.ssf/2012/07/appeals_court_dis
3/12/16
sewer rate increases
rate lawsuit" (Longley)
misses_flint.html
Ed Kurtz (who served as Flint EFM from 2002 to 2004) replaces Brown as Flint EFM,
after Brown has to exit because the state's EM law, Public Act 4, is officially
NBC25 News (Aug. 8, 2012): "Ed Kurtz returns to Flint as
nbc25news.com/news/local/ed-kurtz-returns-to-flint-as-
3/12/16
suspended due to referendum to repeal it. Kurtz appoints Brown as Flint City
emergency manager"
emergency-manager?id=785990
Administrator
MLive (Sep. 10, 2012): "Flint City Council members sue emergency www.MLive.com/news/flint/index.ssf/2012/09/flint_city_council_
Flint City Council files suit against Kurtz's appointment as EFM
3/12/16
financial manager Ed Kurtz" (Longley)
members_sue.html
Flint EFM Ed Kurtz sends letter to DWSD requesting written permission to
3/12/16
implement the blending option. Approval is requested by October 1, 2012
df
Analysis by Flint Finance Director suggests annual cost to purchase water from
3/12/16
DWSD will steadily increase to $23M per year by fiscal year 2020
df
Department of Treasury retains Tucker, Young, Jackson and Tull (TYJT) to evaluate Department of Treasury timeline (dated Sep. 28, 2015), included in somcsprod2govm001.usgovcloudapp.net/files/snyder%20emails.p
3/12/16
KWA proposal to the City of Flint
df
Michigan voters overturn state's EM Law (Public Act 4) in referendum. Kurtz remains MLive (Nov. 7, 2012): "Flint gains public safety millage, loses
3/12/16
as Flint's EFM under Public Act 72
emergency manager law" (Longley)
www.MLive.com/news/flint/index.ssf/2012/11/flint_gains_public_safety_mill.html
Flint EFM Kurtz sends letter to State Treasurer Andy Dillon indicating that a proposal
from DWSD is expected, but that the initial assessment shows switching to KWA is in
3/12/16
df
the best interest of the City of Flint
MLive (Dec. 12, 2012): "Michigan House approves new emergency
Michigan legislature approves new EM law
3/12/16
manager legislation" (Eggert)
www.MLive.com/news/index.ssf/2012/12/michigan_house_approves_new_em.html
Date
Event
Reference Document
Sources
Accessed
2013
January 23, 2013
February 6, 2013
March 2013
March 25, 2013
March 26, 2013

March 26, 2013
March 27, 2013
March 28, 2013
March 28, 2013
March 29, 2013
March 29, 2013
April 1, 2013
April 11, 2013
April 15, 2013

April 15, 2013
April 16, 2013
April 16, 2013
April 17, 2013
Prysby/MDEQ e-mails Liane Shekter Smith, head of ODWMA, and other colleagues
re: feasibility of Flint switching to Flint River. I agree that the city should have
concerns of fully utilizing the Flint River (100%) for the following: the need to soften, As reported in Bridge Magazine (Feb. 4, 2016): "Disaster Day by
the potential for more advanced treatment after next round of crypto monitoring, Day: A detailed Flint crisis timeline"
available capacity in Flint River at 100-year low flow, residuals management
(disposal of lime sludge).
TYJT issues final report to Department of Treasury on comparison between KWA
www.scribd.com/doc/131442949/City-of-Flint-Water-Supply-
"City of Flint Water Supply Assessment," prepared by TYJT
and DWSD, raising concerns about KWA cost estimates and system governance
Assessment-Final-Report-February-6-2013
DWSD contacts City of Flint to begin direct negotiations on contract extension.
Multiple options are provided to Flint EFM Kurtz
df
Flint City Council approves resolution to buy water from KWA and contract with
"Amended Resolution to Purchase Capacity from Karegnondi
KWA to build a pipeline from Lake Huron to Genesee County. Council votes 7-1 to
somcsprod2govm001.usgovcloudapp.net/files/snyder%20emails.p
Water Authority" included in Gov. Snyder's e-mails released Jan.
leave DWSD and go to KWA for water supply. Council's vote is not binding; final
df
20, 2016 (pp. 142-3/274)
decision to switch from DWSD to KWA is Treasurer Dillon's
Genesee County Drain Commissioner Jeffrey Wright issues statement praising Flint
media.wix.com/ugd/60e74e_474a2f7e6f0902948ba9327284c796
Press release posted online
City Council for approving resolution to join KWA
01.pdf
Busch/MDEQ e-mails MDEQ Director Wyant with Shekter Smith and other MDEQ
staff copied, warning about Flint River water quality and microbial/DBP risks
Sygo/MDEQ e-mails Busch re: Flint River water source switch. As you might guess
we are in a situation with Emergency Financial Managers so its entirely possible
that they will be making decisions relative to cost."
Treasurer Dillon e-mails Gov. Snyder recommending support for Flint's decision to As reported in Bridge Magazine (Feb. 4, 2016): "Disaster Day by
join KWA
MLive (March 27, 2013): "Ed Kurtz expected to remain Flint's
State of Michigan's new EM law, Public Act 436, takes effect; Kurtz remains in place
www.MLive.com/news/flint/index.ssf/2013/03/ed_kurtz_expecte
emergency manager through June 30 as new state law takes effect
as Flint EM
d_to_stay_be_f.html
Thursday, March 28" (Adams)
City of Flint enacts resolution signed by EM Kurtz, City Attorney and Finance Director "By the Emergency Manager: Resolution to Purchase Capacity
to purchase capacity from KWA
from Karegnondi Water Authority"
2015
Letter from EM Kurtz to Treasury referenced in letter of approval
Flint EM Kurtz requests state approval of Flint purchasing capacity from KWA
from Treasurer Dillon, included in Gov. Snyder's e-mails released
df
Jan. 20, 2016 (p. 140/274)
DWSD issues statement that Flint's water supply plan will not save money
Unfolded" (Dixon)
State Treasurer Andy Dillon authorizes Flint EM Kurtz, pursuant to Section 12(3) of
Letter of approval from Treasurer Dillon included in Gov. Snyder's somcsprod2govm001.usgovcloudapp.net/files/snyder%20emails.p
PA 436 of 2012, to enter into a contract with KWA if a final offer from DWSD is
e-mails released Jan. 20, 2016 (p. 140/274)
df
either not received or rejected in good faith based upon specific objections
DWSD (McCormick) letter to Flint EM Kurtz and KWA.
reason.com/assets/db/14537555551018.pdf
DWSD provides a best and final offer to the City of Flint, representing 20% savings
ThinkProgress (Jan. 25, 2016): "Leaked Documents Undermine
thinkprogress.org/health/2016/01/25/3742625/documents-
compared to KWA proposal
Official Story Of Flint Water Crisis" (Israel)
michigan-contradict-flint-narrative-snyder/
Analyses by Flint EM Kurtz, MDEQ and Treasurys Office of Fiscal Responsibility
independently conclude that the KWA option is cheaper for the City of Flint
df
GCDC Commissioner Wright and Flint EM Kurtz issue joint statement re: why KWA is
www.gcdcwws.com/images/contentImages/file/Press%20Release
Press release posted to GCDC website
preferable to DWSD's final offer
.Official.Final%20Decision%20on%20KWA.pdf
Flint EM Kurtz signs agreement with KWA and informs State Treasurer Dillon that
the City will join KWA (decision officially announced May 1, 2013)
df
DWSD transmits letter to Flint EM Kurtz terminating service to the

City of Flint effective April 17, 2014
Press Release: DWSD Director Makes Statement on Flint's

Decision, provided by MDEQ.
Detroit Free Press (Oct. 11, 2015): Chemical testing could have
predicted Flint's water crisis (Wisely, Erb).
The Detroit News (Jan. 6, 2016): "Ex-Detroit official reignites Flint
water switch tiff" (Lynch)

2015.
www.freep.com/story/news/local/michigan/2015/10/10/missed-
opportunities-flint-water-crisis/73688428/
www.detroitnews.com/story/news/michigan/flint-water-
crisis/2016/01/26/ex-detroit-official-reignites-flint-water-switch-
tiff/79379770/
3/12/16
3/12/16
3/12/16
3/12/16
3/12/16
3/12/16
3/12/16
3/12/16
3/12/16
3/12/16
3/12/16
3/12/16
3/12/16
3/12/16
3/12/16
3/12/16
Date
Event
May 1, 2013 GCDC announces rejection of DWSD's final offer and partnership with KWA
May 29, 2013 Kurtz sends Gov. Snyder resignation letter indicating July 3, 2013 will be his last day
June 1, 2013 KWA begins construction on pipeline project
City of Flint decides to use the Flint River as a water source, per Gov. Snyder
June 2013
timeline
Flint EM Kurtz signs resolution that allows Flint to hire the engineering firm
June 26, 2013 Lockwood, Andrews, and Newnam (LAN) to prepare Flint WTP for full-time
operation using Flint River as primary drinking water supply source
June 2013
Flint notifies MDEQ of intent to operate Flint Water Treatment Plant full time using
Flint River for drinking water
June 26, 2013 Michael Brown is again appointed by Gov. Snyder as Flint EM
Groundbreaking for KWA begins. City of Flint also requests DEQ approval for full-
June 26, 2013
time use of the Flint WTP with Flint River water as source
June 28, 2013 KWA hosts Pipeline Groundbreaking Ceremony
Financing Contract between City of Flint and KWA is approved, effective August 1,
2013 (document is signed by EM Michael Brown)
City of Flint, Genesee County, MDEQ and LAN representatives meet at Flint WTP to
discuss feasibility of using Flint River as a temporary water supply source while
June 29, 2013
waiting for KWA to come online. Flint DPW and Finance Department recommend
using the Flint River as a temporary water source.
June 28, 2013
June 30, 2013
Flint EM Kurtz submits "City of Flint Financial & Operating Plan, Third Update" (and
EM Kurtz's closing memorandum) to MI Treasury Dept.
Reference Document
Sources
Announcement and attachments from Kevin Sylvester, GCDC

www.gcdcwws.com/images/contentImages/file/Final%20KWA%2
Communications Director, posted to GCDC website
0Decision.05.01.13.pdf
MLive (May 30, 2013): "Flint emergency manager Ed Kurtz submits
www.MLive.com/news/flint/index.ssf/2013/05/flint_4.html
resignation notice to the state" (Adams)
Unfolded" (Dixon)
Gov. Snyder's Flint Water timeline (released Jan. 2016); no other mi.gov/documents/snyder/FlintWaterTimeline_FINAL_511424_7.
documentation located
pdf
Resolution:
Resolution posted online.
mediad.publicbroadcasting.net/p/michigan/files/201512/water_p
lan_resolution.pdf?_ga=1.129405580.1036207224.1446746452
Unfolded" (Dixon).
Referenced in MLive (Oct. 26, 2015): "Ex-emergency manager says
www.MLive.com/news/flint/index.ssf/2015/10/ex-
local leaders made decision to use Flint River water" (Fonger) and
emergency_manager_says_loca.html
in Detroit Free Press (Nov. 22, 2015): "Flint water mystery: How
www.freep.com/story/news/politics/2015/11/21/snyders-top-
was decision made?" (Egan)
aide-talked-flint-water-supply-alternatives/76037130/
Flint WTP Facility Meeting Agenda
2015
MLive (June 30, 2015): "He's back: A timeline of Michael Brown's www.MLive.com/news/flint/index.ssf/2013/06/hes_back_a_timel
ine_of_michael.html
Department of Treasury timeline (dated Sept. 28, 2015), included somcsprod2govm001.usgovcloudapp.net/files/snyder%20emails.p
in Gov. Snyder's e-mails released Jan. 20, 2016 (pp. 93-94/274)
df
Brochure: "KWA Pipeline Groundbreaking Ceremony - Dawn of a Attachment 8 - MDEQ documentation provided to FWATF Nov. 6,
New Era"
2015
df
"City of Flint Water System Questions and Answers," dated
www.cityofflint.com/wp-content/uploads/CoF-Water-System-
January 13, 2015.
QA.pdf
Unfolded" (Dixon)
www.cityofflint.com/wp-
"City of Flint Financial & Operating Plan - Third Update" posted to
content/uploads/Reports/City%20of%20Flint%20Update%203%20
City of Flint website
Financial%20&%20Operating%20Plan%20062813.pdf
Accessed
3/12/16
3/12/16
3/12/16
3/12/16
3/12/16
3/12/16
3/12/16
3/12/16
3/12/16
3/12/16
July 2013
City of Flint begins testing Flint River water treatment at Flint WTP "to see if the
river could adequately supply drinking water during KWA pipeline construction"
MLive (July 23, 2015): "Flint River now an option for drinking water www.MLive.com/news/flint/index.ssf/2013/07/city_readying_wat
following Detroit's termination of contract" (Adams)
er_plant_to_t.html
3/12/16
July 8, 2013
City of Flint retains Lockwood Andrews & Newnam (LAN) engineering firm to get
the Citys WTP up and running while KWA pipeline is built

df
3/12/16
Rowe Professional Services Company completes an engineering proposal for

From October 2014 MDEQ briefing to the Snyder Administration -
August 2013 improvements to the Flint WTP that would allow continuous operation of the WTP as reported in Bridge Magazine (Feb. 4, 2016): "Disaster Day by
utilizing the Flint River in lieu of continuing service from DWSD
Michael Brown resigns as Flint EM, effective October 31, 2013, and Darnell Earley is MLive (Sept. 11, 2013): "New Flint emergency manager Darnell
appointed as replacement
Earley to take over after Michael Brown resigns" (Adams)
City of Flint Water Timeline: City receives engineered estimates
October 3, 2013 City of Flint publishes engineering costs for Flint WTP upgrade
on the ability to upgrade the Flint Water Plant along with costs
estimates
September 2013
3/12/16
www.MLive.com/news/flint/index.ssf/2013/09/michael_brown_r
esigns_as_flint.html
3/12/16
www.flintneighborhoodsunited.org/wp-
content/uploads/2015/03/COf-TTHM-Data.pdf
3/12/16
2014
KWA Board of Directors adopts Resolution 2014-01, authorizing KWA to bond for
February 19, 2014
water line construction on behalf of City of Flint

df
media.wix.com/ugd/60e74e_86bc474fd0d94f019332018dcba332
February 27, 2014 MDEQ approves KWA permit for Lake Huron Pump Station
MDEQ Permit 142004
9a.pdf
March 1, 2014 City of Flint enters consent agreement with MDEQ re: Flint WTP's lime sludge facility
in Gov. Snyder's e-mails released Jan. 20, 2016 (p. 39/274)
df
3/12/16
1/31/16
3/12/16
Date
March 7, 2014
March 26, 2014
April 9, 2014
April 16, 2014
April 17, 2014
April 17, 2014

April 21, 2014
Event
Reference Document
Sources
Flint EM Earley sends letter to Sue McCormick/DWSD explaining that the City of
Attached as Ex. 10 to ACLU Michigan's November 16, 2015 letter www.aclumich.org/article/flint-residents-sue-city-state-over-lead-
Flint has "actively pursued using the Flint River as a temporary water source"
announcing federal lawsuit
drinking-water
instead of accepting DWSD's offer to provide water to the City
Busch/MDEQ e-mails Shekter Smith and Benzie/MDEQ re: uncertainty on startup
requirements for Flint WTP. ... I would like to make sure everyone is on the same
page on... what Flint will be required to do in order to start using their plant full
time... starting up for continuous operation will carry significant changes in
regulatory requirements so there is a very gray area as to what we consider for
startup.
MDEQ issues Flint WTP construction permits for full time operation enhancements
MDEQ Construction Permits W141025 and W141026
W141025 and W141026
2015
Flint laboratory and water quality supervisor Michael Glasgow e-mails Adam
Rosenthal/MDEQ requesting information. ""I am expecting changes to our Water
Quality Monitoring parameters, and possibly our DBP on lead & copper monitoring As reported in Bridge Magazine (Feb. 4, 2016): "Disaster Day by
plan Any information would be appreciated, because it looks as if we will be
starting the plant up tomorrow and are being pushed to start distributing water as
soon as possible"
Glasgow/Flint e-mails Rosenthal, Prysby and Busch/MDEQ. If water is distributed
from this plant in the next couple of weeks, it will be against my direction. I need
www.freep.com/story/news/local/michigan/flint-water-
Detroit Free Press (February 13, 2016): "E-mails: Flint water plant
time to adequately train additional staff and to update our monitoring plans before I
crisis/2016/02/12/e-mails-flint-water-plant-rushed-into-
was rushed into operation" (Egan, Spangler, Shamus)
will feel we are ready. I will reiterate this to management above me, but they seem
operation/80300220/
to have their own agenda."
Water service from DWSD officially ends. City of Flint also conducts two separate
public forums regarding the use of Flint River water, upgrades to Citys water system
df
and overall cost of switch to KWA
media.wix.com/ugd/60e74e_7126cbc7d5cb453f94d0549a370298
MDEQ approves KWA permit for Intermediate Pump Station
MDEQ Permit 142023
d9.pdf
Accessed
3/12/16
3/12/16
3/12/16
3/12/16
3/12/16
3/12/16
Busch/MDEQ e-mails Brad Wurfel/MDEQ re: proposed talking points for the water
switch ceremony to be held in two days. Suggests: While the Department is
satisfied with the Citys ability to treat water from the Flint River, the Department As reported in Bridge Magazine (Feb. 4, 2016): "Disaster Day by
April 23, 2014
looks forward to the long term solution of continued operation of the City of Flint Day: A detailed Flint crisis timeline"
Water Treatment Plant using water from the KWA as a more consistent and higher
quality source water.
3/12/16
Daugherty Johnson, Flint Utilities Administrator, e-mails Flint colleague Howard

April 24, 2014 Croft and Prysby and Busch/MDEQ requesting concurrence that there is no
regulatory requirement for Flint to sign up a back-up agreement with DWSD

3/12/16
City of Flint officially switches its water source to the Flint River, using Flint WTP for
treatment, and hosts changeover ceremony," public event marking the transition
April 25, 2014
to use of Flint River water. MDEQ information shows that transition complete by
May 2015
MDEQ e-mail dated April 28, 2014 describing Flint WTP startup
ceremony on April 25.
MLive (April 25, 2014): "Closing the valve on history: Flint cuts
water flow from Detroit after nearly 50 years" (Adams).
City of Flint press release included in Snyder e-mails released Jan.
20, 2016 (p. 15)
Attachment 10 - MDEQ documentation provided to FWATF Nov.

6, 2015.
www.MLive.com/news/flint/index.ssf/2014/04/closing_the_valve
_on_history_f.html
df
3/12/16
MLive (May 13, 2014): "Kincaid, Flint residents take water rate
lawsuit to federal court" (Fonger)
www.MLive.com/news/flint/index.ssf/2014/05/kincaid_flint_resid
ents_take_w.html
3/12/16

3/12/16
Flint EM Earley notifies Detroit EM that Flint has switched water supply sources to
the Flint River. GCDC remains as a non-contract customer of DWSD
City Council President Scott Kincaid and two other Flint residents file suit re: City of
May 4, 2014
Flint water rates in federal court
Jennifer Crooks/EPA e-mails colleagues Mindy Eisenberg, Thomas Poy and Tinka
Hyde/EPA re: concerns about Flint drinking water expressed by resident Lathan
Jefferson. "Flint River quality is not great, but there is a surface water treatment
May 15, 2014
plan producing water that is currently meeting SDWA standards... his doctor says
the rash is from the new drinking water... He has no interest in speaking with Mike
Prysby; he doesnt trust anyone in MI government."
April 29, 2014
Information provided to Flint Water Advisory Task Force
Date
Event
Resident complaints intensify re: water quality; Flint WTP operators boost use of
lime to address hardness concerns
Adam Rosenthal/MDEQ e-mails Mike Glasgow/Flint confirming no orthophosphate
June 17, 2014
monitoring is necessary at Flint WTP, since no orthophosphate is being added
June 2014
July 1, 2014 Flint begins first 6-month monitoring period for lead and copper in drinking water
Reference Document
Sources
MLive (June 12, 2014): "City adding more lime to Flint River water
as resident complaints pour in" (Fonger)
MLive (Feb. 17, 2016): "Flint water crisis unfolds in key officials'
emails through the years"
www.MLive.com/news/flint/index.ssf/2014/06/treated_flint_river
_water_meet.html
www.MLive.com/news/flint/index.ssf/2016/02/see_flint_water_c
risis_unfold.html#4
pdf
media.wix.com/ugd/60e74e_cc139234530f4fca8bbfb8768ef25d4
a.pdf
media.wix.com/ugd/60e74e_d1b6e185aadc4cb4adbaf737e9421a
96.pdf
Gov. Snyder's Flint Water timeline (released Jan. 2016)

Detroit Free Press (Oct. 11, 2015): "Chemical testing could have
prevented Flint's water crisis"
July 16, 2014 MDEQ approves KWA permit for pipeline
MDEQ Permit 142044
July 29, 2014 MDEQ approves KWA permit for 12-mile transmission main
MDEQ Permit 142049
City of Flint issues boil water advisory due to E. coli bacteria violation (Localized
August 15, 2014 System Boil Water Advisory); City increases flushing of water mains and boosts
chlorine disinfectant use. Advisory lifted Aug. 20, 2014
Second boil water advisory is issued due to coliform bacteria detected in drinking
September 5, 2014 water (expanded on Sept. 7, 2015); City boosts chlorine use again. Advisory lifted
Sep. 9, 2014
September 10, 2014
October 2014
October 1, 2014
October 13, 2014
October 13, 2014
October 14, 2014
October 17, 2014
October 21, 2014
November 1, 2014
November 1, 2014
November 7, 2014
E-mail correspondence and public notifications from MDEQ

6, 2015
MDEQ e-mail dated September 25, 2014; expansion referenced in

MLive (Sep. 7, 2014): "Flint expands boil water advisory area after
more positive tests for total coliform bacteria" (Fonger)
Unfolded" (Dixon)
MDEQ Memo: "Compliance Communication - TTHM Operational
Evaluation Requested"
MLive (Jan. 16, 2016): "Public never told, but investigators
suspected Flint River tie to Legionnaires' in 2014" (Fonger)
Attachments 12 & 13 - MDEQ documentation provided to FWATF

Nov. 6, 2015.
www.MLive.com/news/flint/index.ssf/2014/09/flint_expands_boil
_water.html
6, 2015
www.MLive.com/news/flint/index.ssf/2016/01/documents_show
_agencies_knew_o.html
MDEQ requests preemptive Operational Evaluation for Disinfection Byproducts -

total trihalomethanes (TTHMs)
Genesee County Health Department initially expresses concern to Flint Water re:
increased incidence of Legionellosis and possible connection to water supply
Snyder requests and receives a briefing paper from MDEQ re: Flint water issues. The
paper blames Sep. 2014 boil water advisories on variety of factors, mostly aging cast Governor's Office Briefing Paper - City of Flint Drinking Water
6, 2015
iron pipes. No mention of lead issues
GM announces it is switching from City of Flint water system to Flint Township (Lake
Huron) water for its Flint Engine Operations facility until KWA connection is
MLive (Oct. 13, 2014): "General Motors shutting off Flint River
www.MLive.com/news/flint/index.ssf/2014/10/general_motors_
complete, citing corrosion concerns. Prysby/MDEQ notes Flint water chloride levels water at engine plant over corrosion worries" (Fonger)
wont_use_flint.html
are "easily within" public health guidelines. Annual revenue loss of $400,000
Prysby/MDEQ e-mails Busch, Shekter Smith and others at MDEQ re: inquiry from
E-mail from Mike Prysby/MDEQ dated October 13, 2014 discussing Attachment 14 - MDEQ documentation provided to FWATF Nov.
Ron Fonger/MLive concerning GM's switch to Lake Huron water. Notes Flint water
interview with Fonger
6, 2015
has elevated chlorides but "although not optimal," it is "satisfactory."
Valerie Brader, State Deputy Legal Counsel and Sr. Policy Advisor, sends e-mail to
Governors Chief of Staff Dennis Muchmore and other top aides arguing for a return
to DWSD because of water quality problems. Michael Gadola, then Gov. Snyders
Detroit Free Press (Feb. 26, 2016): "Top Snyder aides urged going www.freep.com/story/news/local/michigan/flint-water-
Legal Counsel, responds agreeing with Brader. Brader and Rich Baird, senior aide to back to Detroit water" (Dolan, Egan)
crisis/2016/02/26/flint-water-crisis-snyder-detroit/80926138/
Gov. Snyder, discuss the idea with EM Earley, who maintains water quality problems
can be solved and it would be cost-prohibitive to return to DWSD
Genesee Co. Health Department (GCHD) representatives hold conference call with
Glasgow and Wright/Flint DPW re: county's concerns about Legionellosis outbreak
emails through the years" - provides screen capture of e-mail
and possible connection to city's water system. DPW "acknowledges that the
risis_unfold.html#4
describing conference call
distribution system has areas of concern"
Susan Bohm/MDHHS e-mails GCHD officials re: Shekter Smith's concern that Flint Detroit Free Press (February 9, 2016): "Flint e-mails: CDC voiced www.freep.com/story/news/local/michigan/flint-water-
water would be publicly linked to Legionellosis outbreak in Flint. "I told her the Flint concerns over Legionnaires' actions" (Dolan, Anderson, Egan,
crisis/2016/02/09/flint-e-mails-state-city-appear-unable-share-
water was at this point just a hypothesis"
Wisely)
info/80028820/
"Operational Evaluation Report, City of Flint, Trihalomethane
LAN issues Operational Evaluation Report to City of Flint, assessing factors
Formation Concern," Nov. 2014, prepared by LAN, posted to City www.cityofflint.com/wp-content/uploads/Operational-Evaluation-
contributing to TTHM levels in Flint drinking water
of Flint website. Referenced in EPA's Interim Report dated June 24, Report.pdf
2015
Flint DPW increases hydrant flushing to reduce the residence time of water in the
Flint Water System Timeline, posted on City of Flint website
www.cityofflint.com/public-works/city-water-system-timeline/
distribution system
City of Flint staff and engineering team meet with MDEQ to discuss quarterly TTHM
results
Accessed
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3/12/16
3/12/16
3/12/16
3/12/16
3/12/16
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1/31/16
1/31/16
7
Date
Event
Reference Document
MLive (Jan. 8, 2015): "Flint report says getting water from Detroit
is possible but would cost $4 million just to reconnect" (Fonger)
City of Flint begins hydraulic modeling to "help identify locations of bad valves"
MDEQ notifies Flint of initial quarterly violation of SDWA Disinfection Byproducts
MDEQ Letter: Violation Notice - MCL for TTHM Operational
(TTHM) requirements
Evaluation - TTHM, 4th Quarter 2014 Monitoring Period
Flints GM engine plant switches off its water supply from Flint's water system,
drawing water instead from neighboring Flint Township
predicted Flint's water crisis" (Wisely, Erb)
First 6-month round of lead and copper monitoring (per MDEQ's interpretation of MDEQ Letter: City of Flint - Lead and Copper Monitoring of
LCR) ends. Results due from City of Flint to MDEQ on January 10, 2015. 100 samples Drinking Water Taps, dated March 30, 2015; MDEQ e-mail dated
within 90th percentile lead level, 6 ppb; 2 samples above lead action level
Feb 27, 2015
November 26, 2014 LAN issues report on cost of reconnection to DWSD

December 1, 2014
December 16, 2014
December 27, 2014
December 31, 2014
Sources
www.MLive.com/news/flint/index.ssf/2015/01/flint_report_says_
going_back_t.html
www.cityofflint.com/wp-content/uploads/City-of-Flint-Violation-
Notice-MCL-TTHM-12_16_14.pdf
Accessed
3/12/16
3/12/16
3/12/16
3/12/16

6, 2015
2015
January 2015
January 1, 2015
January 2, 2015
January 7, 2015
January 7, 2015
January 9, 2015
January 12, 2015
January 12, 2015
January 13, 2015

January 13, 2015
January 21, 2015
January 21, 2015

January 23, 2015
January 27, 2015
Officials from Genesee County hospitals, MDHHS, MDEQ, GCHD meet re:
Legionellosis outbreak in Flint. MDHHS Director Nick Lyon directs GCHD to conduct Information provided by Flint Water Advisory Task Force
and complete its evaluation of causes of the increased cases
City of Flint begins second 6-month monitoring period for lead and copper in
drinking water
pdf
City of Flint issues press release and mails notice to water customers stating the City
water system exceeds maximum contaminant level (MCL) for total trihalomethanes
df
(TTHMs), which are disinfection byproducts
Michigan Department of Technology, Management and Budget announces
Detroit Free Press (January 29, 2016): "Amid denials, state workers
installation of water coolers in Flint's State Office Building. "The coolers will be
crisis/2016/01/28/amid-denials-state-workers-flint-got-clean-
in Flint got clean water" (Egan)
provided as long as the public water does not meet treatment requirements."
water/79470650/
Richard Benzie/MDEQ e-mails colleagues re: discussion of Flint water issues with
State Representative Sheldon Neely (D-Flint) and others. "...there appears to be a As reported in Bridge Magazine (Feb. 4, 2016): "Disaster Day by
significant (I think they used the word complete) loss of public confidence in the
drinking water quality in Flint"
University of Michigan-Flint alerted city officials that it found elevated lead levels in
Detroit Free Press (Feb. 2016): "How Flint's Water Crisis Unfolded"
two locations on campus, prompting the school to shut off some drinking fountains
(Dixon)
and add water filters to others
DWSD offers to reconnect to Flint and waive $4 million connection fee
pdf
MDEQ staff (Prysby, Shekter Smith, Benzie, numerous others) communicate via e-
mail re: decision to provide water coolers at Flint's State Office building. Some
discussion re: how this decision will affect Flint residents' perceptions of drinking
water safety, and how the decision will "make it more difficult... for ODWMA staff"
Gov. Snyder announces that Jerry Ambrose, who previously served as Flint's finance MLive (Jan. 13, 2015): "Jerry Ambrose named Flint's fourth
www.MLive.com/news/flint/index.ssf/2015/01/jerry_ambrose_ta
and administration director, will replace Earley as Flint EM
emergency manager as Darnell Earley heads to Detroit" (Adams) pped_as_next_e.html
Flint DPW posts water system FAQs re: bacteria and TTHM issues in Flint water, and "City of Flint Water System Questions and Answers," dated
www.cityofflint.com/wp-content/uploads/CoF-Water-System-
decision to switch to Flint River as temporary water supply
January 13, 2015
QA.pdf
City of Flint holds public meeting re: disinfection byproducts and bacteria; residents
City of Flint - Public Forum Agenda
attend, bringing containers of water from their taps. LeeAnne Walters shows
6, 2015.
MLive (Jan. 21, 2015): "Officials say Flint water is getting better,
samples of discolored water taken from her taps on Jan. 15 and Jan. 21, 2015, to EM
www.MLive.com/news/flint/index.ssf/2015/01/state_water_offici
but many residents unsatisfied" (Fonger)
Ambrose
als_tell_fli.html
Shekter Smith/MDEQ e-mails colleagues re: Flint water supply . "...when Flint
decided to leave Detroit and operate using the River, our role wasnt to tell them
our opinion; only what steps would be necessary to make the switch
Walling says decision to use Flint River water was made by former EM Earley [who MLive (Jan. 23, 2015): "Flint water problems: Switch aimed to save www.MLive.com/news/flint/index.ssf/2015/01/flints_dilemma_h
later disputes this statement]
$5 million -- but at what cost" (Fonger)
ow_much_to_spe.html
GCHD environmental health supervisor James Henry e-mails colleagues re: inability
to obtain information from local and state officials needed to investigate connection Detroit Free Press (Feb. 9, 2016): "Flint e-mails: CDC voiced
of Flint water system to Legionellosis outbreak. "Initially the water plant was
concerns over Legionnaires' actions" (Dolan, Anderson, Egan,
cooperative, but since the beginning of November they have not responded to
Wisely)
info/80028820/
multiple written and verbal requests"
3/12/16
3/12/16
3/12/16
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3/12/16
3/12/16
3/12/16
3/12/16
3/12/16
3/12/16
3/12/16
3/12/16
Date
Event
Reference Document
Shannon Johnson, MDHHS epidemiologist, emails GCHD re: Legionellosis outbreak

Detroit Free Press (Feb. 9, 2016): "Flint e-mails: CDC voiced
and investigating possible connection to the Flint water system. "A current map of
January 27, 2015
the municipal water system needs to be obtained and cases residences mapped in
Wisely)
relation to the water system
January 29, 2015 Flint EM Ambrose declines DWSD offer to reconnect Flint to Detroit water supply

MLive (Jan. 29, 2015): "Flint emergency manager says there are
two big reasons not to reconnect Detroit water" (Fonger)
Sygo and Shekter Smith/MDEQ e-mail re: Flint water quality problems. Shekter
January 29, 2015 Smith identifies the problem as corrosion across the distribution system rather than
a "premise plumbing" issue
Brad Wurfel/MDEQ e-mails Dave Murray, Governor Snyders deputy press secretary,
re: Legionella, saying said he didnt want MDEQ Director Wyant to say publicly that
Detroit News (Feb. 26, 2016): "Legionnaires fear led staffer to
January 30, 2015 the water in Flint is safe until we get the results of some county health department
warn against calling water safe" (Oosting)
traceback work on 42 cases of Legionnaires disease in Genesee County since last
May
February 1, 2015
February 2, 2015
February 3, 2015
February 4, 2015
February 6, 2015
February 6, 2015
February 10, 2015
February 10, 2015

February 16, 2015
February 18, 2015
February 25, 2015
February 26, 2015
February 26, 2015
Sources
info/80028820/
pdf
www.MLive.com/news/flint/index.ssf/2015/01/flint_extends.html
3/12/16
3/12/16
3/12/16
crisis/2016/02/26/flint-legionnaires-safe-water-wyant-
snyder/80966744/
3/19/16
Briefing memo is prepared for Gov. Snyder on Flint water situation, including info on
residents' complaints about water quality, Mayor Walling's call for assistance, and
MDEQ "backgrounder" downplaying health risks. Wurfel: "It's not like an imminent
df
threat to public health"
City of Flint DPW issues letter to customers offering testing for discoloration, taste
www.cityofflint.com/wp-content/uploads/2015_02_02-Water-
Letter posted to City of Flint website
and odor
Test-Letter.pdf
Gov. Snyder awards Flint $2 million to find leaks in city water lines and replace a
MLive (Feb. 3, 2015): Governor Awards Flint $2 million for
www.MLive.com/news/flint/index.ssf/2015/02/governor_awards
wastewater incinerator, part of state's $8 million Distressed Cities program
Troubled Water System: Mayor Says More is Needed (Fonger)
_flint_2_millio.html
Flint resident LeeAnne Walters shows Flint City Council a video documenting rashes Detroit Free Press (Feb. 2016): "How Flint's Water Crisis Unfolded"
on her son's skin, attributed to drinking water
(Dixon)
Liz Murphy, assistant to Flint EM, and Prysby/MDEQ exchange e-mails re: other
Michigan systems that treat river water, and a source water assessment for Flint
River
Flint ABC affiliate (ABC12) posts report on independent testing showing water
www.abc12.com/flintwaterworries/headlines/ABC12-Investigates-
ABC12 (Feb. 6, 2015): "What's in your water?" (Elliott)
quality is within EPA limits for TTHMs
Whats-in-your-water-291074071.html
www.cityofflint.com/2015/02/10/flint-hires-international-urban-
City of Flint retains Veolia sole-source to provide additional review and
Press release posted to City of Flint website
water-experts-of-veolia-north-america-to-assess-citys-water-
recommendations on water system
issues/
GCDC epidemiologist Shurooq Hasan e-mails outside expert about 47 Legionellosis Detroit Free Press (Feb. 9, 2016): "Flint e-mails: CDC voiced
cases diagnosed in Flint in 2014, almost four times the number in 2013. "We have concerns over Legionnaires' actions" (Dolan, Anderson, Egan,
expanded our investigation to include the city water supply"
Wisely)
info/80028820/
City of Flint posts second Flint Water FAQ document, stating that Flint water is safe "City of Flint Water System Update with Questions and Answers," www.cityofflint.com/wp-content/uploads/Water-Sysytem-FAQ-
to drink
dated February 16, 2015
Update-2-16-151.pdf
Referenced in EPA-MDEQ e-mail correspondence dated February Attachment 18 - MDEQ documentation provided to FWATF Nov.
EPA collects additional samples at LeeAnne Walters's home
26, 2015
6, 2015
Mike Glasgow/Flint DPW tests water in LeeAnne Walters's home and finds high lead Detroit Free Press (Feb. 2016): "How Flint's Water Crisis Unfolded"
levels (104 ppb). She contacts Chicago offices of EPA to discuss
(Dixon)
EPA/MDEQ e-mails included in chronological compilation of e-
Initial e-mail correspondence between EPA (Crooks, Del Toral, Poy) and MDEQ
mails from FOIA requests, created by Roy/Edwards and posted to flintwaterstudy.org/wp-content/uploads/2015/10/MDEQ-USEPA-
(Busch, Prysby) re: elevated lead in sample collected February 18, 2015 at LeeAnne Flint Water Study website.
Final.pdf
Walters's home. Initial inquiry made re: corrosion control treatment (OCCT) at Flint E-mail correspondence between Mrs. Walters and City of Flint
WTP. Crooks: "WOW!!! Did he find LEAD! 104 parts per bilion"
dated Feb. 19-26, 2015; Consumer Notice of Results; Official
6, 2015
Laboratory Report.
Busch/MDEQ e-mails colleagues Shekter Smith and Benzie in response to Crooks
email. As indicated by Mike and Adam the city is meeting 90th percentile. Not sure
why region 5 [EPA] sees this one sample as such a big deal
Accessed
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Date
Event
Reference Document
Sources
flintwaterstudy.org/wp-content/uploads/2015/10/MDEQ-USEPA-
In continued e-mail correspondence, Del Toral/EPA voices concern re: possibility
Chronological compilation of MDEQ e-mails from FOIA requests, Final.pdf
February 27, 2015 that City of Flint's lead sampling protocol (pre-flushing) is biasing lead results toward
created by Roy/Edwards and posted to Flint Water Study website Attachment 19 - MDEQ documentation provided to FWATF Nov.
the low side. Asks again about OCCT at Flint WTP
6, 2015
Busch/MDEQ responds to Del Toral/EPA saying that the City of Flint "Has an
Chronological compilation of MDEQ e-mails from FOIA requests, Final.pdf
February 27, 2015 Optimized Corrosion Control Program," LeeAnne Walters's house is "not part of the
created by Roy/Edwards and posted to Flint Water Study website Attachment 20 - MDEQ documentation provided to FWATF Nov.
City's established sample site pool" and the residence has PVC plumbing
6, 2015
Accessed
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3/12/16
March 3, 2015
In response to complaints re: drinking water quality and related health effects, Flint
EM Ambrose claims costs will increase $12 million with return to DWSD service. He MLive (June 5, 2015): "Lawsuit seeks end to Flint River drinking
provides memo to Deputy State Treasurer Wayne Workman stating reconnection to water, return to Detroit" (Fonger)
DWSD will cost the City $10.1M/year and water could be as high as $1M/month
www.MLive.com/news/flint/index.ssf/2015/06/lawsuit_seeks_en
d_to_flint_riv.html
3/12/16
March 4, 2015
City of Flint/Veolia Technical Advisory Committee holds its first meeting; 17

members from City, County, State, USEPA, hospitals & universities
List of members posted to City of Flint timeline
www.cityofflint.com/public-works/water-advisory-committees/
3/12/16
MDEQ Letter: Violation Notice - MCL for TTHM Operational

Evaluation - TTHM, 1st Quarter 2015 Monitoring Period
emails through the years" - provides screen capture of partial e-
mail

6, 2015
risis_unfold.html#4
3/12/16
March 5, 2015 MDEQ issues second Disinfection Byproducts quarterly violation notice
March 5, 2015
Officials in Governor's Office and MDEQ begin discussing providing water filters to
Flint citizens
March 5, 2015
Citizens Advisory Committee (CAC), hosted by City of Flint, holds its first meeting;
includes 58 members representing various interests
List of members posted to City of Flint timeline
www.cityofflint.com/public-works/water-advisory-committees/
3/12/16
Harvey Hollins/Governor's Office meets with Flint EM and DEQ officials to discuss
possible solutions to Flint water issues
referring to meeting
risis_unfold.html#4
3/12/16
Crooks/EPA e-mails Busch, Prysby and Benzie/MDEQ saying she has been
March 10, 2015 inundated with citizen e-mails referred to her from the White House about Flint
water quality problems

3/12/16
James Henry/GCHD e-mails Howard Croft/Flint DPW, Prysby/MDEQ, Mayor Walling

and others citing the city's and state's lack of cooperation and failure to respond to
his requests for information -- and a Jan. 2015 FOIA -- to support county's
March 10, 2015
investigation of potential causes of Legionellosis outbreak in Flint. "This is rather
glaring information and it needs to be looked into now, prior to the warmer summer
months when Legionella is at its peak and we are potentially faced with a crisis."
3/12/16
Benzie/MDEQ e-mails colleagues Shekter Smith, Busch and Prysby re: thoughts for a As reported in Bridge Magazine (Feb. 4, 2016): "Disaster Day by
plan of action on Legionellosis response
3/12/16
Busch/MDEQ e-mails colleagues Shekter Smith, Prysby and Benzie re: Legionella.
March 12, 2015 there is no evidence or confirmation of Legionella coming directly from the Water
Treatment Plant or in the community water supply distribution system at this time.
3/12/16
March 9, 2015
March 11, 2015
Veolia issues Water Quality Report to City of Flint/EM Ambrose, an evaluation

"Flint, Michigan Water Quality Report," prepared by Veolia, posted Report: www.cityofflint.com/wp-content/uploads/Veolia-REPORT-
providing advice primarily on TTHM control and other operational issues in the
to City of Flint website.
Flint-Water-Quality-20150312.pdf
March 12, 2015 City's water system. Report states that Flint's water meets state and federal
Report and accompanying Veolia presentation included in Gov.
E-mails:
standards for TTHM control, but does not address lead. Also recommends corrosion Snyder's e-mails released Jan. 20, 2016 (pp. 151-186/274).
control at Flint WTP to address iron leaching from pipes - estimated cost $50,000
Referenced in EPA's Interim Report dated June 24, 2015.
df
Wurfel/MDEQ e-mails Harvey Hollins/Governors office and Wyant/MDEQ noting APNewsBreak (Feb. 4, 2016): "Officials warned of water,
bigstory.ap.org/500a2ef5b57d423d876ef25709af1973
uptick in Legionellosis cases, placing responsibility for follow-up on GCHD, and
Legionnaires' link" (Eggert, White)
March 13, 2015
discounting Henry/GCHDs concerns about a possible relationship between uptick in Detroit Free Press (Feb. 4, 2016): "E-mails: Snyder aide was told of crisis/2016/02/04/apnewsbreak-officials-warned-of-water-
Legionellosis and change in water source
Legionnaires' in March" (Egan) - includes link to e-mails
legionnaires-link/79828466/#read
Busch/MDEQ e-mails Henry/GCHD re: Legionellosis investigation. Implies DEQ has
no responsibilities re: Legionella since it isn't regulated by SDWA; says it isn't coming
March 13, 2015 from the WTP but could be associated with main breaks, leaks or repairs to
distribution system; reminds Henry that epidemiological investigation is GCHD's job
and directs him to MDCH (MDHHS) if they need support
3/12/16
3/12/16
3/12/16
10
Date
Event
Busch/MDEQ e-mails Croft/Flint with instructions to conduct monitoring for

Legionella at the WTP tap and in the distribution system
Water in LeeAnne Walters's home is re-tested for lead following thorough flushing;
March 18, 2015 results are extremely high (397 ppb). Crooks/EPA e-mails Busch, Prysby and
Benzie/MDEQ re: those test results
EPA Region 5 calls MDEQ to express concerns about high lead levels found in
March 19, 2015
LeeAnne Walters's home, noting that they suspect lead is coming from service line
March 17, 2015
March 19, 2015 City of Flint responds to 61 questions posed by CAC in March 5 meeting
Henry/GCHD e-mails Busch/MDEQ re: investigation of Legionellosis outbreak in
March 19, 2015 Flint, again requesting MDEQ collaboration and providing documentation of
previous requests
Flint City Council votes 7-1 to end Flint River service and return to Detroit water
service; the vote is non-binding since Flint is under EM control. Flint EM Ambrose:
"It is incomprehensible to me that... Flint City Council would want to send more
March 23, 2015
than $12 million a year to the system serving Southeast Michigan, even if Flint rate
payers could afford it. (Lake Huron) water from Detroit is no safer than water from
Flint."
EPA learns that Genesee County Health Department is investigating uptick in
March 26, 2015 Legionellosis in the county, including Flint; an EPA official questions whether it is
related to switch to Flint River water
March 27, 2015
LeeAnne Walters's son is tested for blood lead levels; results are above CDC's 5
ug/dl "threshold of concern"
Reference Document
3/12/16

3/12/16
Detroit Free Press, "How Flint's Water Crisis Unfolded" (Dixon)
3/12/16
"Water Advisory Committee Questions & Answers," posted to City www.cityofflint.com/wp-content/uploads/2015_03_19-Water-

of Flint website
Advisory-Comittee-Questions-Answers.pdf
3/12/16

3/12/16
MLive (March 24, 2015): "Emergency manager calls City Council's www.MLive.com/news/flint/index.ssf/2015/03/flint_emergency_
Flint River vote 'incomprehensible'" (Fonger)
manager_calls.html
3/12/16
(Dixon)
3/12/16
Flint Water Study website (Sep. 30, 2015): "COMMENTARY: MDEQ flintwaterstudy.org/2015/09/commentary-mdeq-mistakes-
Mistakes and Deception Created the Flint Water Crisis" (Roy)
deception-flint-water-crisis/
3/12/16
MDEQ notifies Flint of results of first 6-month lead and copper monitoring period
(July-December 2014) showing 6 ppb result
Crooks/EPA e-mails Busch, Prysby and Shekter Smith/MDEQ re: EPA conference call
on Legionella in Flint. Cites Del Toral's statement that the city's aggressive pre-
As reported in Bridge Magazine (March 1, 2016): "Flint crisis
March 31, 2015
flushing before lead testing may be contributing to favorable conditions for
timeline: Part 2"
Legionella in disribution system
MDEQ sends Flint LT2 Surface Water Treatment Rule Letter re: monitoring
requirements for Cryptosporidium, E. Coli and turbidity
Flint proposes installation of Granular Activated Carbon filter media to reduce
April 6, 2015
disinfection byproducts
MDHHS hosts conference call regarding Legionella, but the subject matter and
April 7, 2015 participants are not clear. It was suggested that there was a communication plan in
preparation, but no indication that public communication happened as a result
MDEQ Letter: LT2 ESWTR Rule - 2nd Round of Monitoring

Requirements
E-mail from LAN to Busch/MDEQ, cc Croft, dated April 6, 2015
As reported in Bridge Magazine (March 1, 2016): "Flint crisis
timeline: Part 2"
Del Toral/EPA e-mails Cook/MDEQ again to ask re: Flint corrosion control treatment.
April 23, 2015 Cook/MDEQ, in follow-up message to Busch & Prysby/MDEQ: "Other than sampling EPA-MDEQ e-mail correspondence dated April 23-24, 2015
for Pb/Cu, I don't think Flint is doing anything regarding corrosion control"
pdf
3/12/16
bridgemi.com/2016/03/flint-crisis-timeline-part-2/
3/12/16

6, 2015
6, 2015
3/12/16

6, 2015
Chronological compilation of MDEQ e-mails from FOIA requests, flintwaterstudy.org/wp-content/uploads/2015/10/MDEQ-USEPA-

created by Roy/Edwards and posted to Flint Water Study website Final.pdf
April 24, 2015 MDEQ staff indicates to EPA no corrosion control treatment in place in Flint system Gov. Snyder's Flint Water timeline (released Jan. 2016)
Detroit Free Press (Feb. 2016): "How Flint's Water Crisis Unfolded" pdf
(Dixon)
Del Toral/EPA e-mails Cook/MDEQ to express concern re: Flint's lack of corrosion
April 25, 2015 control treatment, pre-flushing and high lead levels. Says Flint does not appear to E-mail from Del Toral/EPA to Cook/MDEQ dated April 25, 2015
6, 2015
meet requirements for OCCT without treatment
Del Toral/EPA e-mails Poy/EPA and other colleagues stating that Cook/MDEQ has
Detroit Free Press (Feb. 2, 2016): "EPA too slow to respond to Flint
April 27, 2015 confirmed the Flint WTP has no corrosion control treatment (CCT), which is very
crisis/2016/02/02/epa-too-slow-respond-flint-crisis-critics-
crisis, critics say" (Spangler)
concerning given the likelihood of lead service lines in the city
say/79652928/
Accessed
March 30, 2015
April 3, 2015
Sources

3/12/16
3/20/16
11
Date
Event
Reference Document
Sources
Del Toral/EPA visits LeeAnne Walters's house, inspects plumbing and finds it is lead- Flint Water Study website (Sep. 30, 2015): "COMMENTARY: MDEQ flintwaterstudy.org/2015/09/commentary-mdeq-mistakes-
April 27, 2015
free; leaves sample bottles and provides Marc Edwards/Virginia Tech's contact info Mistakes and Deception Created the Flint Water Crisis" (Roy)
April 27, 2015
April 27, 2015
April 28, 2015
April 29, 2015
April 29, 2015
Cook, Busch and Prysby/MDEQ exchange e-mails re: Del Toral/EPA's question on
Detroit Free Press (Feb. 14, 2016): "State MDEQ didn't take Flint
corrosion control treatment. Busch: "If he continues to persist, we may need Liane
www.freep.com/story/news/local/michigan/2016/02/13/state-
water concerns seriously" (Shamus)
or Director Wyant to make a call to EPA to help address his over-reaches. Cook: "I
deq-flint-water-concerns/80332954/
Also as reported in Bridge Magazine (Feb. 4, 2016): "Disaster Day
agree, the constant second guessing of how we interpret and implement our rules is
by Day: A detailed Flint crisis timeline"
getting tiresome."
Laurel Garrison/CDC e-mails GCHD officials re: concern over Legionellosis outbreak
in Flint. Indicates that city and state officials allegedly were not supplying needed
information for the countys investigation. "We are very concerned about this
Legionnaires disease outbreak Its very large, one of the largest we know of in the
Wisely)
info/80028820/
past decade, and community-wide, and in our opinion and experience it needs a
comprehensive investigation.
Michigan Office of the Auditor General announces planned performance audit of
Office of Auditor General letter to MDEQ Director Wyant, dated
audgen.michigan.gov/wip/wip761032015.html
MDEQ-Office of Drinking Water and Municipal Assistance
April 28, 2015. Notice of audit posted to OAG website
To resolve an $8 million accumulated deficit in Flint's General Fund, the State
Treasurer and Flint EM, with the concurrence of Flint City Council, sign an
emergency loan agreement between the City and Michigan's Local Financial
Emergency Loan Agreement, signed by EM Ambrose and Treasurer
Document provided to FWATF
Assistance Loan Board for nearly $8 million. The loan agreement includes a
Khouri, dated April 29, 2015
provision that the city of Flint cannot, without prior state approval, return to DWSD
or lower water rates.
Press release: "Gov. Rick Snyder: City of Flint ready to move
Gov. Snyder announces control of City of Flint's finances has been returned to
www.michigan.gov/snyder/0,4668,7-277-57577_57657-353433--
forward as financial emergency resolved" posted to State of MI
Mayor and City Council under supervision of Receivership Transition Advisory Board
,00.html
website
LeeAnne Walterss water samples are sent to Virginia Tech for analysis. Average lead
Flint Water Study website (Aug. 24, 2015): "Hazardous Waste-
May 2015 level is 2,429 ppb lead, the high was 13,200 ppb, and even after 25 minutes
levels of Lead found in a Flint households water" (Roy)
flushing the water never dropped below 200 ppb
Cook/MDEQ responds to Del Toral/EPA re: inquiries about Flint corrosion control,
indicating MDEQ is delaying decision pending completion of second 6-month
E-mail from Cook/MDEQ to Del Toral/EPA dated May 1, 2015,
May 1, 2015 monitoring period in June 2015. Says that since Flint will be switching water source included in chronological compilation of MDEQ e-mails from FOIA
in another year, "requiring a [corrosion control] study at the current time will be of requests (Roy/Edwards) posted to Flint Water Study website
little to no value"
May 6, 2015 City replaces service line at 212 Browning with EPA onsite
May 7, 2015
Crooks/EPA e-mails MDEQ re: EPA visit to LeeAnne Walters's home to deliver
sampling bottles for lead/copper analyses and observe plumbing systems
May 14, 2015 MDEQ approves GCDC permit for surface water impoundment to feed KWA WTP
Second meeting of City of Flint/Veolia Technical Advisory Committee. Meeting
May 20, 2015 notes: ""Some attention has shifted to lead and copper concerns" - no further
mention of lead issue
EPA/MDEQ e-mail correspondence continues re: results of additional sampling at
May 26, 2015
Walters's home and at 2 additional homes connected to same water service line
May 28, 2015 New samples show improved water quality at LeeAnne Walters's residence
EPA e-mail to MDEQ dated May 7, 2015

J. Crooks/EPA e-mail to MDEQ dated May 7, 2015
MDEQ Permit 151036
Meeting summary posted to City of Flint website
Coalition for Clean Water in Flint and others file lawsuit in Genesee County Circuit
Court seeking order for Flint to return to DWSD service
Jim Collins/MDHHS e-mails GCHD officials saying he spoke with officials at federal
June 8, 2015 Centers for Disease Control and Prevention that morning about the Legionellosis
issue. He then chastises county officials for talking to CDC without state approval
June 5, 2015
MLive (June 5, 2015): "Lawsuit seeks end to Flint River drinking

water, return to Detroit" (Ridley)
Detroit Free Press (February 9, 2016): "Flint e-mails: CDC voiced
Wisely)
3/12/16
3/12/16
3/12/16
3/17/16
3/12/16
flintwaterstudy.org/2015/08/hazardous-waste-levels-of-lead-
found-in-a-flint-households-water/
3/13/16
Final.pdf
3/13/16

Nov. 6, 2015
Nov. 6, 2015
media.wix.com/ugd/60e74e_830d3b5098294e78825c8f720f155e
ca.pdf
www.cityofflint.com/wp-content/uploads/2015-05-20-TAC-
Meeting-Summary.pdf
EPA e-mail correspondence dated May 26-27, May 28 and June 2, Attachment 28 & 29 - MDEQ documentation provided to FWATF
2015; laboratory reports attached
Nov. 6, 2015
MDHHS produces a report regarding Legionellosis cases in Genesee County in 2014-

"Summary of Legionellosis Outbreak Genesee County, June
May 29, 2015 15; the conclusion is that the outbreak is over. 42% of the cases had healthcare
2014March 2015," posted to state website
(hospital) contact; 47% had contact with the Flint water supply
Accessed
www.michigan.gov/documents/mdhhs/Genesee_Co_Legionnaires
_Disease_Investigation_Ex_Summary_FINAL_510722_7.pdf
www.MLive.com/news/flint/index.ssf/2015/06/lawsuit_seeks_en
d_to_flint_riv.html
info/80028820/
1/31/16
1/31/16
3/12/16
3/17/16
3/12/16
3/12/16
12
Date
Event
June 9, 2015 MDEQ issues third Disinfection Byproducts quarterly violation notice
Michigan Semi-Annual Conference Call is held with EPA, DNR and MDEQ. EPA
June 10, 2015 recommends that MDEQ offer technical assistance to Flint on managing water
quality issues, including lead
Michigan Court of Appeals reverses Genesee County Circuit Court dismissal of
June 12, 2015 Kincaid rate lawsuit, claiming City didn't follow the proper process for raising rates
and improperly spent the funds collected
Press conference held at UAW Region 1D post with Councilman Kincaid and
June 15, 2015
attorney Val Washington urging City to negotiate on water and sewer rates
U.S. District Judge Stephen J. Murphy III denies Coalition for Clean Water in Flint's
June 23, 2015
motion for the preliminary injunction without prejudice
Del Toral/EPA provides his "Interim Report: High Lead Levels in Flint, Michigan" to
June 24, 2015 his supervisor, Poy/EPA. Report expresses numerous concerns re: lead levels,
sampling methodology, and lack of corrosion control treatment at Flint WTP
Reference Document
Sources
MDEQ Letter: Violation Notice - MCL for TTHMs, 2nd Quarter 2015 Attachment 30 - MDEQ documentation provided to FWATF Nov.
Monitoring Period
6, 2015
J. Crooks/EPA e-mail dated July 1, 2015, with notes from June 10 flintwaterstudy.org/wp-content/uploads/2015/10/MDEQ-USEPA-
conference call; notes posted final July 28, 2015. E-mail and notes Final.pdf
are included in chronological compilation of MDEQ e-mails from Attachment 31 - MDEQ documentation provided to FWATF Nov.
FOIA requests (Roy/Edwards) posted to Flint Water Study website 6, 2015
MLive (June 12, 2015): "Appeals Court breathes new life into Flint www.MLive.com/news/flint/index.ssf/2015/06/appeals_court_sid
water rebate lawsuit" (Fonger)
es_with_flint.html
MLive (June 15, 2015): "Flint councilman urges city to negotiate
end to water rate lawsuit" (Fonger)
MLive (June 23, 2015): "Judge won't force Flint to return to buying
Detroit water" (Fonger)
"Memorandum: High Lead Levels in Flint, Michigan - Interim
Report," prepared by M. Del Toral and transmitted to T. Poy.
Per Curt Guyette/ACLU (interview with FWATF Dec. 10, 2015), Del
Toral provided report to Walters and she provided it to Guyette.
Interim report is available on Flint Water Study website. Final
report issued Nov. 2015 is also posted to ACLU-MI website
www.MLive.com/news/flint/index.ssf/2015/06/flint_councilman_
urges_city_to.html
www.MLive.com/news/flint/index.ssf/2015/06/judge_says_flint_
doesnt_have_t_1.html
flintwaterstudy.org/wp-content/uploads/2015/11/Miguels-
Memo.pdf
Accessed
3/13/16
3/13/16
3/13/16
3/13/16
3/17/16
June 25, 2016
Rosenthal/MDEQ e-mails Glasgow and Wright/Flint DPW reminding them that 61

more lead and copper samples need to be collected and sent to the lab by June 30, Detroit Free Press (Dec. 24, 2015): "State's handling of Flint water www.freep.com/story/news/politics/2015/12/23/states-handling-
2015, and that they are will be [sic] below the AL [action level] for lead. As of now samples delayed action" (Egan)
flint-water-samples-delayed-action/77367872/
with 39 results, Flints 90th percentile is over the AL for lead.
June 30, 2015
EPA e-mails MDEQ as preface to conference call scheduled for July 21, 2015, re:
elevated lead and corrosion control; mentions Del Toral report
E-mail from T. Hyde/EPA to L. Shekter Smith/MDEQ dated June 30,

2015, included in chronological compilation of MDEQ e-mails from
Final.pdf
FOIA requests (Roy/Edwards) posted to Flint Water Study website
3/13/16
June 30, 2015
Second 6-month round of lead and copper monitoring ends. Results due from Flint Included in chronological compilation of MDEQ e-mails from FOIA flintwaterstudy.org/wp-content/uploads/2015/10/MDEQ-USEPA-
to MDEQ July 10, 2015
requests (Roy/Edwards) posted to Flint Water Study website
Final.pdf
3/13/16
July 1, 2015
July 2, 2015
July 2, 2015
July 7, 2015
July 9, 2015
July 9, 2015
July 10, 2015
Gov. Snyder asks MDEQ and MDHHS about Flint; both report nothing unusual or
widespread occurring, Flint complying with LCR, elevated blood levels are seasonal (Dixon)
EPA Region 5 Water Division Director Tinka Hyde tells MDEQ that Region 5 is
"concerned about the lead situation" but acknowledges second round of monitoring Detroit Free Press (Feb. 2016): "How Flint's Water Crisis Unfolded" pdf
is under way
(Dixon)
EPA Region 5 Administrator Susan Hedman writes Mayor Walling to say that EPA
"Highlights of Marc Edwards FOIA," posted to Flint Water Study
flintwaterstudy.org/wp-content/uploads/2015/10/Virginia-Tech-
will work with MDEQ on issues related to lead in water. "it would be premature to
website
FOIA-EPA.pdf
draw any conclusions" based on draft EPA memo regarding lead
Included in chronological compilation of MDEQ e-mails from FOIA
ACLU reporter Curt Guyette contacts MDEQ regarding Del Toral's draft Interim
requests, created by Roy/Edwards and posted to Flint Water Study
Report
Final.pdf
website
Chronological compilation of MDEQ e-mails from FOIA requests
MDEQ Public Information Officer Karen Tommasulo emails Wurfel/MDEQ as
Final.pdf
(Roy/Edwards) posted to Flint Water Study website
Michigan Public Radio begins picking up on the ACLU reports concerning Flint lead-
www.freep.com/story/opinion/columnists/nancy-
Detroit Free Press (Oct. 22, 2015): "MDEQ e-mails show stunning
in-water issue. "Apparently, it is going to be a thing now.
kaffer/2015/10/21/indifference-characterized-state-approach-
indifference to Flint peril" (Kaffer)
flint-water/74289430/
The Nation (July 16, 2015): "In Flint, Michigan, Overpriced Water is www.thenation.com/article/in-flint-michigan-overpriced-water-is-
ACLU-Michigan reporter Curt Guyette breaks story of concerns about lead in Flints Causing People's Skin to Erupt in Rashes and Hair to Fall Out"
causing-peoples-skin-to-erupt-and-hair-to-fall-out/
drinking water by detailing the June 24 EPA-Del Toral memo, reporting the high lead (Guyette)
levels in LeeAnne Walterss water, and exposing the lack of corrosion control in Flint E-mail from B. Wurfel/MDEQ dated July 9, 2015 is included in
6, 2015.
drinking water treatment
chronological compilation of MDEQ e-mails from FOIA requests
Final.pdf
Susan Hedman/EPA Region 5 (based in Chicago) writes to Flint Mayor Walling to say As reported in Bridge Magazine (Feb. 4, 2016): "Disaster Day by
that EPA will work with MDEQ on issues related to lead in water
3/20/16
3/12/16
1/31/16
3/13/16
3/20/16
3/13/16
3/13/16
3/20/16
13
Date
July 13, 2015
July 14, 2015
July 21, 2015
July 22, 2015
July 23, 2015
July 24, 2015
July 27, 2015

July 27, 2015
July 28, 2015
July 28, 2015

August 4, 2015
August 4, 2015
August 7, 2015
August 10, 2015
August 17, 2015
Event
Reference Document
Sources
Michigan Radio quotes Wurfel's reassurances in story on EPA memo. "Let me start
here anyone who is concerned about lead in the drinking water in Flint can relax Michigan Radio (July 13, 2015): Leaked internal memo shows
michiganradio.org/post/leaked-internal-memo-shows-federal-
It does not look like there is any broad problem with the water supply freeing up
federal regulators concerns about lead in Flints water" (Smith)
regulator-s-concerns-about-lead-flint-s-water#stream/0
lead as it goes to homes."
MDEQ issues construction permit to Flint for Granular Activated Carbon filter media
MDEQ Construction Permit W151055
W151055
6, 2015
EPA and MDEQ hold conference call re: LCR implementation and Flint; EPA informs "Notes on Call with MDEQ on July 21, 2015 - MDEQ
MDEQ of its interpretation of LCR. EPA wants corrosion control implemented in
Implementation of LCR Rule and Flint Issues," included in
Flint, but MDEQ believes this is premature, per e-mail from Shekter Smith/MDEQ to chronological compilation of MDEQ e-mails from FOIA requests, Final.pdf
Hyde/EPA later the same day requesting EPA concurrence on MDEQ approach
created by Roy/Edwards and posted to Flint Water Study website
Gov. Snyder's Chief of Staff Dennis Muchmore e-mails MDHHS director Lyon re:
community concerns about lead in the water. "These folks are scared and worried
about the health impacts and they are basically getting blown off by us (as a state
pdf
we're just not sympathizing with their plight)"
Linda Dykema, director of MDHHS Division of Environmental Health, provides
detailed response to the Muchmore inquiry via email to MDHHS managers. "DEQ
has not seen a change in the citys compliance with the lead rule since switching to
the Flint River source Regarding the EPA drinking water official quoted in the press
articles, the report that he issued was a result of his own research and was not
reviewed or approved by EPA management. He has essentially acted outside his
authority"
In response to Muchmore's July 22 e-mail, Wurfel/MDEQ writes, The bottom line is
that the residents of Flint do not need to worry about lead in their water supply, and
Detroit News (Jan. 7, 2016): "Flint crisis response delayed for
www.detroitnews.com/story/news/politics/2016/01/07/flint-
DEQ's recent sampling does not indicate an eminent [sic] health threat"
months" (Lynch)
emails/78410314/
MDEQ prepares e-mail and draft letter re: Flint 90th percentile lead determination MDEQ e-mail correspondence dated July 20-21, 2015; MDEQ letter Attachment 36 - MDEQ documentation provided to FWATF Nov.
at 11 ppb and City of Flint requirement to add corrosion control treatment
to Flint re: Lead and Copper Monitoring dated July 27, 2015
6, 2015
City provides MDEQ its original LCR report documenting lead levels measured in
FOIA'd information on Flint Water Study website, including original flintwaterstudy.org/2015/09/commentary-MDEQ-mistakes-
sampling from 1/1/15 to 6/30/15. LCR report is later "scrubbed" after Flint meets
and "scrubbed" LCR reports
with MDEQ and is released on August 20, with two high lead results excluded
Flint Water Study website: "Chronology of MDHHS E-mails
Cristin Larder/MDHHS e-mails other MDHHS staff indicating blood lead levels were
flintwaterstudy.org/wp-content/uploads/2016/01/MDHHS-FOIA-II-
pertaining to blood lead levels of kids in Michigan, primarily in
unusually elevated in summer 2014
FINAL-For-Web.pdf
Flint - Part II" (Roy/Edwards)
Nancy Peeler/MDDHS sends e-mail confirming analysis shows lead levels spiked in
E-mail correspondence - MDHHS and MDEQ, dated July 22-28,
July-September 2014, but "that pattern was not terribly different from what we saw
6, 2015.
2015
in the previous three years"
flintwaterstudy.org
MDEQ representatives meet with City of Flint representatives, community activists
MDEQ e-mail dated August 10, 2014 documenting meeting notes
and pastors, and LeeAnne Walters at Gov. Snyders office
LeeAnne Walters and Melissa Mays meet with MDEQ officials Shekter Smith, Busch
and Wurfel to discuss lead in water problems. Walters and Mays report Shekter
Flint Water Study website (Sep. 30, 2015): "COMMENTARY: MDEQ
Smith said Mr. Del Toral has been handled and Flint residents would not be
hearing from him again
Genesee County Circuit Court Judge Hayman issues emergency injunction on earlier
Flint water rate increase and orders City to roll back water and sewer rates by 35
MLive (Aug. 7, 2015): "Judge orders Flint to cut water rates 35
percent, repay its water and sewer fund $15.7 million transferred in 2007 to settle a
percent in sweeping injunction" (Fonger)
sewer overflow claim, and immediately stop water disconnections and liens for past-
due bills
Poy/EPA e-mails Shekter Smith and Busch/MDEQ inquiring re: action on corrosion Chronological compilation of MDEQ e-mails from FOIA requests
control in Flint
MDEQ notifies Flint of lead/copper monitoring results from Jan-June 2015
Letter to Wright/Flint from Rosenthal/MDEQ included in
monitoring period, and requires City to install corrosion control for LCR compliance.
chronological compilation of MDEQ e-mails from FOIA requests
Indicates Flint has 6 months to fully optimize corrosion control, but recommends
starting phosphate treatment as soon as possible
Accessed
3/13/16
3/13/16
1/31/16
3/13/16
3/13/16
3/13/16
3/12/16
3/12/16

6, 2015
flintwaterstudy.org/2015/09/commentary-mdeq-mistakes-
3/13/16
www.MLive.com/news/flint/index.ssf/2015/08/flint_ordered_to_
cut_water_rat.html
3/13/16
Final.pdf
3/13/16
Final.pdf
3/13/16
14
Date
Event
Reference Document
Genesee County Circuit Court places preliminary injunction on prior Flint water rate MLive (Aug. 17, 2015): "Judge signs order for lower Flint water
August 17, 2015
increase
rates, $15.7 million payback" (Fonger)
August 20, 2015
August 23, 2015
August 25, 2015
August 27, 2015
August 27, 2015
August 28, 2015
"Scrubbed" LCR report for City of Flint is provided to ACLU-MI in reponse to FOIA
request
E-mail from M. Edwards to MDEQ/Flint dated August 23, 2015 is

included in chronological compilation of MDEQ e-mails from FOIA
requests (Roy/Edwards) posted to Flint Water Study website
Shekter Smith/MDEQ e-mails Ms. Walters updating her on findings related to
E-mail from Shekter Smith to Ms. Walters is included in
questions at the community meeting and summarizing lead sampling / results at 212 chronological compilation of MDEQ e-mails from FOIA requests
Browning
Edwards/VT reports findings of elevated lead levels in its Flint water study; EPA
Region 5 reports to MDEQ that VT study is finding elevated lead levels. 52% of first Flint Water Study website (Aug. 27, 2015): "Analysis of water
48 samples analyzed were at or above 5 ppb "which suggests a serious lead in water samples from 48 Flint homes to date for lead are worrisome" (Roy)
problem"
Mike Brown, Gov. Snyder's senior federal policy representative, e-mails
Wurfel/MDEQ to inquire about discrepancy in lead levels measured in water in
LeeAnne Walters's home. Wurfel replies: "This person is the one who had EPA lead
specialist come to her home and do tests, then released an unvetted draft of his
report (that EPA apologized to us profusely for) to the resident, who shared it with (Roy/Edwards) posted to Flint Water Study website
ACLU, who promptly used it to continue raising hell with the locals... (I)ts been
rough sledding with a steady parade of community groups keeping everyone
hopped-up and misinformed"
Poy/EPA e-mails Shekter Smith/MDEQ re: VT lead testing results in Flint: "...they are
finding lead at levels above five parts per billion and some above 15 parts per
billion"
EPA and MDEQ hold conference call: second 6-month monitioring test results for
August 31, 2015 January-July 2015 indicate 90th percentile at 11 ppb. It is determined that CCT is
needed and implementation steps are delineated
Wurfel/MDEQ e-mails Busch, Shekter Smith, Prysby and Director Wyant/MDEQ,
August 31, 2015 copying Gov. Snyder aides Muchmore, Hollins, Murray and Sara Wurfel. Raises
concerns about Edwards/VT's tests and accompanying media coverage
Genesee County Circuit Court certifies class in class action lawsuit on Sept. 2011
August 31, 2015
water rate increase
Mayor accepts petition calling for return to DWSD service. Administration
August 31, 2015 statements cite TTHM compliance. "Water from the treatment plant is significantly
better now and comparable with Detroit's" - Henderson
August 31, 2015 Edwards/VT reports on corrosive lead levels
City of Flint announces projected loss from disconnect moratorium and new water
September 1, 2015 rates incompliance with Court order; begins sending bills with reduced rates as
mandated by Judge Hayman
VT researchers report elevated lead levels in Flint water, communicating that the
corrosiveness of Flint water is causing lead to leach into residents' water through
September 2, 2015
pipes. "...the current Flint River water leaches 12X more lead to the water than
Detroit water"
www.MLive.com/news/flint/index.ssf/2015/08/judge_certifies_cl
ass_action_l.html
Flint Water Study website (Sep. 30, 2015): "COMMENTARY: MDEQ flintwaterstudy.org/2015/09/commentary-mdeq-mistakes-
Marc Edwards/Virginia Tech notifies City of Flint and MDEQ that VT has begun
collecting samples for a water quality study in Flint
August 28, 2015 Concerned Pastors announce water giveaway in Flint
Sources
Accessed
3/13/16
3/12/16
Final.pdf
3/13/16
Final.pdf
3/13/16
flintwaterstudy.org/2015/08/analysis-of-water-samples-from-48-
flint-homes-to-date-for-lead-are-worrisome/
3/13/16
Final.pdf
3/13/16
Final.pdf
3/13/16
pdf
1/31/16

Final.pdf
3/13/16

3/12/16
MLive (Aug. 31, 2015): "Judge OKs class action lawsuit for Flint
water customers against city" (Fonger)
www.MLive.com/news/flint/index.ssf/2015/08/judge_certifies_cl
ass_action_i.html
3/13/16
MLive (Aug. 31, 2015): "Flint mayor accepts petitions but not call www.MLive.com/news/flint/index.ssf/2015/08/flint_mayor_acce
to end use of Flint River" (Fonger)
pts_petitions.html
3/13/16
MLive (Sep. 2, 2015): "Lead leaches into 'very corrosive' Flint

drinking water, researchers say" (Fonger)
www.MLive.com/news/flint/index.ssf/2015/09/new_testing_sho
ws_flint_water.html
3/13/16
MLive (Sep. 1, 2015): "Unpaid Flint water bills creating $500,000

budget hole, officials say" (Fonger) / "Typical Flint water bill
dropping $18 after ruling on improper rates"
www.MLive.com/news/flint/index.ssf/2015/09/post_436.html
www.MLive.com/news/flint/index.ssf/2015/09/typical_flint_wate
r_bill_will.html
3/13/16
Flint Water Study website (Sep. 2, 2015): "Flint River water is very flintwaterstudy.org/2015/09/flint-rivers-water-is-very-corrosive-
corrosive to lead, and causing lead contamination in homes" (Roy) to-lead-and-causing-lead-contamination-in-homes/
3/13/16
15
Date
Event
Reference Document
Wurfel/MDEQ issues press release disputing Edwards/VT's test results and

conclusions about corrosion and lead leaching. "(W)e want to be very clear that the
September 2, 2015 lead levels being detected in Flint drinking water are not coming from the treatment
plant or the citys transmission lines The issue is how, or whether, and to what
extent the drinking water is interacting with lead plumbing in peoples homes."
Sources
Final.pdf
September 2, 2015
Anonymous company donates 1,500 kitchen water filters to Concerned Pastors for
Gov. Snyder's e-mails (released Jan. 20, 2016)
distribution to Flint residents, as documented in Hollins e-mail to Gov. Snyder

6, 2015
df
September 3, 2015
Prysby/MDEQ e-mails Benzie/MDEQ stating that City administration said there will Chronological compilation of MDEQ e-mails from FOIA requests
be no funding restrictions for installing corrosion control
Final.pdf
September 2, 2015 MDEQ notifies Flint of return to compliance on Disinfection Byproducts (TTHM)
September 3, 2015
September 3, 2015
September 8, 2015
September 8, 2015
September 9, 2015
September 9, 2015
September 10, 2015
September 10, 2015
September 10, 2015
September 11, 2015
September 11, 2015
September 11, 2015
Letter to B. Wright (Flint) from Rosenthal & Prysby (MDEQ)
Croft/Flint DPW e-mails state and local officials announcing that Flint is in
compliance with MI SDWA / report 160+ lead samples since switch, remain within Chronological compilation of MDEQ e-mails from FOIA requests flintwaterstudy.org/wp-content/uploads/2015/10/MDEQ-USEPA-
EPA standards. Note expect optimization plan within 4 months by 1/1/2016 (faster (Roy/Edwards) posted to Flint Water Study website
Final.pdf
than other cities)
MLive (Sep. 3, 2015): "Lower TTHM levels put Flint in compliance www.MLive.com/news/flint/index.ssf/2015/09/lower_tthm_level
MLive reports on compliance with TTHM issues but also notes lead concerns
with Safe Drinking Water Act" (Fonger)
s_moves_flint.html
Edwards/VT publishes full results to date of his Flint water testing. FLINT HAS A
Flint Water Study website: "Lead testing results for water sampled
VERY SERIOUS LEAD IN WATER PROBLEM. Forty percent of the first draw samples
flintwaterstudy.org/information-for-flint-residents/results-for-
by residents" (Edwards, Roy, Rhoads). Includes link to lead data for
are over five parts per billion Several samples exceeded 100 ppb and one sample
citizen-testing-for-lead-300-kits/
all 271 residences sampled at that point
collected after 45 seconds of flushing exceeded 1000 ppb."
Edwards/VT e-mails Mayor Walling re: lead in water issue. "I have no idea what
MDEQs agenda is, but based on their press releases and actions to date, protecting
the public and following Federal laws, does not seem to be a priority."
MDHHS begins to develop educational program regarding reducing the risk of lead
From MDHHS e-mails posted online
somcsprod2govm001.usgovcloudapp.net/files/dhhs.pdf
exposure for children, in response to media coverage of Edwards/VTs test results
Wurfel/MDEQ e-mails Fonger/MLive re: Edwards's test results. Virginia Tech
researchers only just arrived in town and (have) quickly proven the theory they set Chronological compilation of MDEQ e-mails from FOIA requests
out to prove... offering broad, dire public health advice based on some quick testing (Roy/Edwards) posted to Flint Water Study website
could be seen as fanning political flames irresponsibly
Michelle Bruneau/MDHHS e-mails Kory Gretsch/MDHHS: "if we're going to take
action it needs to be soon before the Virginia Tech University folks scandalize us all" Day: A detailed Flint crisis timeline"
Crooks/EPA e-mails Shekter Smith/MDEQ with notes from Aug. 31, 2015 conference
call re: lead in water; includes action plan. "EPA acknowledged that to delay
installation of corrosion control treatment in Flint would likely cause even higher
levels of lead over time as Flints many lead service lines are continuously in contact
with corrosive water"
State Senator Ananich and Representatives Neeley and Phelps send questions re: Chronological compilation of MDEQ e-mails from FOIA requests
Flint lead-in-water issue to Wyant/MDEQ
Dr. Mona Hanna-Attisha contacts Dr. Lawrence Reynolds with concerns re:
childrens blood lead levels in light of Edwards/VT's findings. She convenes Hurley
Medical Center (HMC) Research Team. Dr. Reynolds contacts MDHHS Childhood
Information provided by Dr. Lawrence Reynolds
Lead Poisoning Prevention Program (CLPPP) with data request for Flint EBLLs, and
contacts MDEQ staffer who states MDEQ is awaiting a letter from MDHHS regarding
health issues and action
Robert Scott/MDHHS obtains Edwards/VT's grant proposal to the National Science
Foundation for funding for his Virginia Tech / Flint Water Study and forwards it to As reported in Bridge Magazine (Feb. 4, 2016): "Disaster Day by
MDHHS colleagues Peeler, Lishinski and Priem. "Sounds like there might be more to Day: A detailed Flint crisis timeline"
this than what we learned previously. Yikes!
Crooks/EPA sends e-mail to MDEQ confirming that EPA did not directly transmit the
E-mail from J. Crooks to MDEQ
draft June 24, 2015 Interim Report memo to MDEQ
Accessed
3/13/16
3/12/16
3/13/16
3/13/16
3/13/16
3/13/16
3/12/16
3/19/16
Final.pdf
3/13/16
3/12/16
Final.pdf
3/13/16
Final.pdf
3/13/16
Dr. Lawrence Reynolds's timeline
3/12/16

6, 2015
16
Date
September 11, 2015
September 11, 2015
September 15, 2015
September 15, 2015
September 17, 2016
September 20, 2015
September 21, 2015
September 21, 2015
September 22, 2015

September 22, 2015
September 22, 2015
September 23, 2015
September 23, 2015
Event
Reference Document
Sources
Busch/MDEQ, in reply to request from Fonger/MLive (forwarded by Wurfel/MDEQ),

e-mails that City has until end of 2015 to make a recommendation for corrosion
Chronological compilation of MDEQ e-mails from FOIA requests flintwaterstudy.org/wp-content/uploads/2015/10/MDEQ-USEPA-
control treatment and are planning to have it in place by January 2016. Shekter
Final.pdf
Smith replies that the City has not yet applied for a construction permit to install
corrosion control treatment and "the ball's in their court"
Poy/EPA sends MDEQ a draft response to Congressman Kildee's Sep. 9 letter posing
questions about drinking water quality in Flint. Says EPA is evaluating Flint's
Final.pdf
compliance with LCR
MLive reports on Edwards/VT's statement that results of Flint's lead tests cannot be
trusted - that the City's results amount to "smoke and mirrors" due to flawed testing
procedures. "Flint is the only city in American that I'm aware of that does not have a MLive (Sep. 15, 2015): "Virginia Tech professor says Flint's tests for www.MLive.com/news/flint/index.ssf/2015/09/virginia_tech_rese
corrosion-control plan in place to stop this kind of problem." Wurfel's response,
lead in water can't be trusted" (Fonger)
archer_says.html
quoted in the article: "The problem isn't new. It's just news (now, and) a knee-jerk
reaction would be an irresponsible response."
Dr. Reynolds discusses MDHHS graph for 0-16 yoa children with Flint mailing
addresses and ELLs with two GCHD Board of Health (GCBOH) members (chair Kay
Doer and member Dr. Laura Carravallah) and management staff Mark Valacak,
Director; Dr. Gary Johnson, Medical Director; and John Henry, Environmental
Hygiene in an informal meeting. GCBOH chair reads GCHD mission aloud. GCHD
Directors response: staff and resources to access MCIR data registry for lead levels
are not available; also says it is Flint DPWs responsibility to issue a health advisory,
not GCHD's
Wyant/MDEQ responds to state lawmakers'questions (September 10, 2015) stating Detroit Free Press (Feb. 2016): "How Flint's Water Crisis Unfolded"
that MDEQ "does not receive or review draft memos" from EPA
(Dixon)
Edwards/VT alleges in e-mail to EPA officials that Flints lead sampling techniques
are seriously flawed. "They do not have an approved lead sampling pool. Only 13 of
the lowest lead sampled homes from 2014 were resampled in 2015. The homes
Final.pdf
sampling high in 2014 were not asked to be resampled. At best, their program is
sending out sampling bottles at random across the city"
Meeting with Congressional representatives, legislators, EPA and MDEQ to discuss
MDEQ and EPA Briefing on Flint Water - meeting agenda
issues with water quality in Flint
6, 2015
Greater Flint Health Coalition (GFHC) views presentation by Dr. Hanna-Attisha and
passes resolution requesting health advisory for City of Flint. At noon, members of
GFHC meet with then-mayor Walling, administrator Henderson and DPW director
Crump requesting action on the resolutions, HMC research and VA Tech research.
Administrator's response: Flint cannot change water sources because of cost, and
the water leaving the plant meets MDEQ standards
Meeting/conference call is held with MDHHS, GCHD, and MDEQ to discuss lead
E-mail summarizing call discussion, dated September 24, 2015
education/outreach
6, 2015
Genesee County Medical Society (GCMS) passes resolution requesting health
advisory for City of Flint
Dr. Hanna-Attisha contacts Robert Scott/MDHHS to request access to the state's
childhood blood lead level testing data
Mayor Walling indicates he will issue "an advisory and promote ways to minimize MLive (Sep. 24, 2015): "Elevated lead found in more Flint kids after www.MLive.com/news/flint/index.ssf/2015/09/study_shows_twic
residents' exposure to lead" ... He and others in Flint Admin advise Dr. Hanna-
water switch, study finds" (Fonger)
e_as_many_flin.html
Attisha & Dr. Reynolds "that a return to purchasing water from Detroit would
Detroit News (Sep. 24, 2015): "Doctors warn Flint of high lead
www.detroitnews.com/story/news/local/michigan/2015/09/24/fli
bankrupt the city"
levels in tap water" (AP)
nt-plans-advisory-curbing-exposure-lead/72725736/
Nancy Peeler/MDHHS, director of state's Childhood Lead Poisoning Prevention
Program (CLPPP), corresponds with Scott/MDHHS to consider re-running the
analysis conducted in July, and asking for formal epidemiologic help. Later that day,
MDHHS official Mikelle Robinson reports that the Governors Office briefing
maintains that Flint water does not represent an imminent public health problem
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17
Date
September 24, 2015
September 24, 2015
September 24, 2015
September 24, 2015
September 25, 2015
September 25, 2015
September 25, 2015
September 25, 2015
September 25, 2015
September 26, 2015
September 28, 2015
Event
Reference Document
Sources
In the absence of a response by Flint City Administration or Genesee County Health

Department, a press conference is called by HMC and GFHC members to advise the
"Pediatric Lead Exposure in Flint, MI: Concerns from the Medical
community of a health emergency. In press conference, Dr. Mona Hanna-Attisha
flintwaterstudy.org/wp-content/uploads/2015/09/Pediatric-Lead-
Community," presentation posted to Flint Water Study website
presents HMC's findings of elevated blood levels in Flint children, followed by
Exposure-Flint-Water-092415.pdf
US News & World Report (Sep. 25, 2015): "Did This Michigan Town
remarks by the GCHD Director Mark Valacak. The city administrator attends.
www.usnews.com/news/articles/2015/09/25/flint-michigan-
Poison Its Children?" (AP)
Wurfel/MDEQ calls Hurley findings "unfortunate" and says water controversy is
children-show-high-levels-of-lead-in-blood
Additional information provided by Dr. Lawrence Reynolds
becoming "near-hysteria"; "Flint's drinking water is safe in that it's meeting federal
and state standards"
Robert Scott/MDHHS e-mails colleague Nancy Peeler saying he has attempted to
recreate Hurleys numbers and sees difference between the two years... but not
as much difference as (Hurley) did. "Im sure this one is not for the public"
Debbie Baltazar/EPA, chief of Region 5 Water Divisions State and Tribal Programs
Branch, e-mails colleagues re: use of Drinking Water State Revolving Fund funding
Vox (Mar. 15, 2016): EPA email: "I'm not so sure Flint is the
for water filters in Flint. "Perhaps she [Hedman] knows all this, but I'm not so sure
www.vox.com/2016/3/15/11239438/flint-epa
community we want to go out on a limb for" (Nelson)
Flint is the community we want to go out on a limb for. At least without a better
understanding of where all that money went"
Edwards/VT e-mails Scott/MDHHS re: difficulty in obtaining state blood-lead
records. Can you tell me why it is so difficult to get this data, and why your agency
is raising so many obstacles to sharing it with everyone who asks?I have been
asking to see your data since MDEQ first sent it to reporters back in August, and I
count 10 email that I sent responding to all your questions. As of yet, you have given
me nothing in response
Scott/MDHHS drafts response to Edwards/VT but does not send to him; sends to
Peeler/MDHHS for review who recommends changes. Scott: I agree that his
statements are inappropriate; there are plenty of things Id LIKE to say in response, Day: A detailed Flint crisis timeline"
but wont
Lead Advisory press release; MDEQ e-mails; City of Flint - DPW
GCHD and City of Flint issue lead advisory for residents to be aware of lead levels in
Public Information Plan
6, 2015.
drinking water; City of Flint holds press conference at City Hall regarding drinking
MLive (Sep. 25, 2015): "Flint makes lead advisory official, suggests www.MLive.com/news/flint/index.ssf/2015/09/flint_makes_lead_
water
water filters and flushing" (Fonger)
advisory_offi.html
G. Lasher/MDHHS e-mails Governor's Office and MDEQ with update on Flint
drinking water issue minimizing findings from Dr. Hanna-Attisha's "data"; attaches Included in Gov. Snyder's e-mails released Jan. 20, 2016 (p. 74, e- somcsprod2govm001.usgovcloudapp.net/files/snyder%20emails.p
MDHHS talking points to support claim that elevated blood lead levels in Flint in
mail; pp. 79-82, MDHHS study results and talking points)
df
2014 are consistent with seasonal changes
Scott/MDHHS responds to email from colleagues about Kristi Tanner/Detroit Free
Press's interest in lead issue. Tanner has looked at DHS blood lead data between
2013-2014 and concludes the increase is statistically significant. Scott: While the
trend for Michigan as a whole has shown a steady decrease in lead poisoning year
by year, smaller areas such as the city of Flint have their bumps from year to year
while still trending downward overall." Peeler: My secret hope is that we can work
in the fact that this pattern is similar to the recent past.
Chief of Staff Dennis Muchmore e-mails Gov. Snyder an update on Flint water
issues. "I can't figure out why the state is responsible except that Dillon did make
the ultimate decision so we're not able to avoid the subject. The real responsibility Included in Gov. Snyder's e-mails released Jan. 20, 2016 (p.
rests with the County, city and KWA, but since the issue is the health of citizens and 71/274)
df
their children we're taking a proactive approach putting MDHHS out there as an
educator"
Chief of Staff Dennis Muchmore e-mails Gov. Snyder an update on Flint water
issues. "Now we have the anti everything group turning to the lead content We
Included in Gov. Snyder's e-mails released Jan. 20, 2016 (p.
can't tolerate increased lead levels in any event, but it's really the city's water
73/274)
df
system that needs to deal with it"
MDEQ and MDHHS directors brief Gov. Snyder on potential scope and magnitude of
Briefing documents included in Gov. Snyder's e-mails released Jan. somcsprod2govm001.usgovcloudapp.net/files/snyder%20emails.p
the issue. MDHHS continues to review blood lead data. Briefing documents support
20, 2016 (pp. 87-91)
df
claim that blood lead levels are consistent with seasonal changes
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18
Date
September 28, 2015
September 28, 2015
September 28, 2015
September 28, 2015

September 29, 2015
September 29, 2015
September 29, 2015
September 29, 2015
September 29, 2015
September 29, 2015
September 29, 2015

September 29, 2015
September 30, 2015
Event
Reference Document
Sen. Ananich sends letter to Gov. Snyder requesting assistance in Flint - transition to Included in Gov. Snyder's e-mails released Jan. 20, 2016 (p.
safe water supply, corrosion control treatment, filters, infrastructure
85/274)
MDHHS Director Nick Lyon e-mails staff in his department for help refuting VT/HMC
blood lead level data. I need an analysis of the Virginia Tech/Hurley data and their
conclusions. I would like to make a strong statement with a demonstration of proof
that the lead blood levels seen are not out of the ordinary and are attributable to
seasonal fluctuations. Geralyn (Lasher) is working on this for me but she needs
someone in public health who can work directly with her on immediate
concerns/questions.
Valacek/GCHD e-mails Rashmi and Travis/MDHHS requesting confirmation that
blood lead levels have not shown significant increase since switch to Flint River
water supply -- asks again the following day
Gov. Snyder is copied on a briefing re: Flint lead issue that states the water system is
in compliance. Briefing document under-states lead sampling results, downplays
problems and emphasizes the high cost of replacing lead service lines
Wurfel/MDEQ states in National Public Radio interview that Del Toral's draft report NPR (Sep. 29, 2015): "High Lead Levels In Michigan Kids After City
was the work of a "rogue employee"
Switches Water Source" (Hulett)
Detroit Free Press publishes their own analysis of state's blood lead level data,
Detroit Free Press (Sep. 29, 2015): "State data confirms higher
saying the state's data actually support the HMC findings
blood-lead levels in Flint kids" (Tanner, Kaffer)
Executive Director to the Governor Allison Scott e-mails Snyder aides Muchmore,
Agen, Clement, Wyant/MDEQ and Lyon/MDHHS re: meeting to discuss emergency
management approach for Flint situation
Lasher/MDHHS circulates to colleagues an advisory from Genesee County that
demands fresh analysis of state blood level data and threatens to seek third-party
analysis of the state data MDHHS has consistently used to suggest no elevated
From MDHHS e-mails posted online
blood lead levels due to the Flint water. "I understand that we are still reviewing
the data but the county has basically issued a ransom date that they want this
information by tomorrow"
Lasher/MDHHS e-mails Peeler, Eden Wells (state CMO), Scott/MDHHS requesting
blood lead data for children under age 6, to compare with other evaluations.
Response from Linda Dykema to Corinne Miller, Sara LyonCallo and Eden Wells
discourages "data war"
Dr. Hanna-Attisha e-mails Wells/MDHHS with updated findings on blood lead levels
correlated to water supply switch; Wells asks when Hanna-Attisha is going public
with the results. Hanna-Attisha: "...when we noticed our findings and the glaring
correlation to elevated water lead levels in the same locations and learned that
corrosion control as never added to the water treatment, we ethically could not stay From MDHHS e-mails posted online
silent. In addition, your annual elevated blood level percentage supports our
findings annual decrease (as seen nationally) and then an increase post-water
switch. We also knew that releasing our data would only incite a data war; however,
the more we dig, the more alarming the results."
Gov. Snyder receives a detailed timeline for Flint water issues prepared by Treasury
102/274)
Genesee County issues its own public health advisory for people using water
MLive (Sep. 29, 2015): "Genesee County joins city in issuing health
supplied by Flint system
advisory on lead in Flint water" (Fonger)
Mayor Walling forwards Wyant/MDEQ an e-mail from Fr. Phil Schmitter that states:
You delayed your action on this issue for an inordinate amount of time. People
were told over and over that it was all fine I no longer trust the city on this issue.
And that we have now a lead problem for babies and children is unconscionable.
Walling: "I dont know what more I could have done given the guidance coming
from EPA and DEQ and subsequently city staff but this major health issue did come
up anyway and our community is paying a huge price."
October 2015 City of Flint issues Quarterly Water Quality Report
Posted to City of Flint website
Sources
Accessed
df
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3/13/16
3/13/16
www.npr.org/2015/09/29/444497051/high-lead-levels-in-
michigan-kids-after-city-switches-water-source
kaffer/2015/09/26/state-data-flint-lead/72820798/
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df
also_issues_pub.html
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www.cityofflint.com/wp-content/uploads/Quarterly-Water-
Quality-Report_Oct-15.pdf
3/13/16
19
Date
Event
October 2015 Michigan Office of the Auditor General begins formal review of MDEQ ODWMA
October 1, 2015
October 1, 2015
October 1, 2015
October 1, 2015
October 1, 2015
October 1, 2015
October 2, 2015
October 2, 2015
State CMO Wells confirms HMC blood lead level data (showing greatly increased
blood lead levels in some Flint neighborhoods). After a comprehensive and detailed "Blood Lead Levels in Flint Talking Points," dated Oct. 5, 2015,
review down to the zip code level, we have found that the state analysis is
from MDHHS e-mails posted online
consistent with that presented by Hurley.
Genesee County Board of Commissioners and GCHD issue Do Not Drink Advisory Public Health Emergency Declaration for People Using the Flint
for Flint water using the Flint River as a source; news conference. GCHD declares
City Water Supply with the Flint River as the Source
Public Health Emergency. Flint Mayor Walling issues statement on advisory saying MLive (Oct. 1, 2015): "Don't drink Flint's water, Genesee County
Flint Water customers should filter their water before drinking it
leaders warn" (Johnson)
Private and public sources donate $105,000 to fund 5,000 water filters for Flint
MLive (Oct. 1, 2015): "More than 5,000 in Flint to get lead water
residences; to be distributed to "highest risk populations first"
filters following donation" (Adams)
MLive reports that Flint Water stores service line records on index cards, making it MLive (Oct. 1, 2015): "Flint data on lead water lines stored on
difficult to identify highest-risk locations for lead pollution
45,000 index cards" (Fonger)
Greater Flint chapter ACLU joins petition urging EPA to order Flint to reconnect to MLive (Oct. 2, 2015): "Petition launched for EPA intervention in
DWSD system
Flint water crisis" (Emery)
Referenced in Gov. Snyder's e-mails released Jan. 20, 2016 (p.
DWSD provides proposal for reconnecting Flint to DWSD system
97/274)
Governor's Office, EPA Region 5, City of Flint, MDEQ and MDHHS hold press
conference announcing Governors Flint 10-point Action Plan to address water
Press release - "Gov. Rick Snyder: Comprehensive action plan will
system, $1 million for water filters, and anti-corrosion treatment. Governor's press help Flint residents address water concerns"; press conference
release also says the water leaving Flint's system is safe to drink but families with
announcement
lead plumbing in their homes could have higher lead levels
Gov. Snyder requests "clear side by side comparison of health benefits and cost of Included in Gov. Snyder's e-mails released Jan. 20, 2016 (p.
GLWA vs. a more optimized Flint system" in e-mail to Muchmore
102/274)
October 2, 2015 GCHD school screening water samples are collected for lead analysis
October 6, 2015
October 7, 2015
October 8, 2015
October 8, 2015
October 8, 2015
Reference Document
E-mails indicate Wyant/MDEQ Director will update Gov. Snyder daily on Flint water
action plan announced Oct. 2
State Budget Director John Roberts outlines $10.4 million in state aid to implement
the action plan of October 2
Gov. Snyder holds press conference: Flint to reconnect to Great Lakes Water
Authority/Detroit Water and Sewerage Department
City of Flint develops its plan to reconnect to Detroit Water and Sewerage
Department
Wyant/MDEQ briefs Gov. Snyder on Flint water issues; affirms elevated test results
for lead in water at Flint schools
October 8, 2015 Detroit paper publishes editorial criticizing causes of/response to Flint water crisis
Sources
audgen.michigan.gov/wip/wip761032015.html
Michigan Radio (Oct. 20, 2015): "Auditor general looking into state
michiganradio.org/post/auditor-general-looking-state-agency-
agency responsible for monitoring Flint water" (Carmody)
responsible-monitoring-flint-water#stream/0
Flint Community Schools Testing Results - Initial Screening

102/274)
102/274)
Press release - "Gov. Rick Snyder: Move back to Detroit water
provides best protection for public health in Flint"
As reported in a timeline produced by the Michigan Auditor
General in December 2015
Briefing materials included in Gov. Snyder's e-mails released Jan.
20, 2016 (p. 116-121)
Detroit Free Press (Oct. 8, 2015): "Flint water crisis: An obscene
failure of government" (Editorial Board)
6, 2015.
www.MLive.com/news/flint/index.ssf/2015/10/genesee_county_l
eaders_warn_do.html#incart_river_mobile
www.MLive.com/news/flint/index.ssf/2015/10/more_than_5000
_in_flint_to_get.html
www.MLive.com/news/flint/index.ssf/2015/10/flint_official_says
_data_on_lo.html
www.MLive.com/news/flint/index.ssf/2015/10/greater_flint_aclu
_holds_meeti.html
df
www.michigan.gov/som/0,4669,7-192-29701-366287--,00.html
6, 2015
df
6, 2015
df
df
6, 2015
df
www.freep.com/story/opinion/editorials/2015/10/08/flint-water-
crisis-obscene-failure-government/73578640/
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Detroit Free Press publishes article with details on corrosivity of Flint River water,
based on VT's study. "The tests showed Flint Water without added phosphates
October 11, 2015
corroded the lead at 19 times the rate of Detroit water. Even when phosphates
were added, it corroded at 16 times the rate of the Detroit water." (DFP 10-11-15)
predicted Flint's water crisis" (Wisely, Erb)
3/13/16
October 13, 2015 MDEQ announces plans for statewide lead education campaign focused on schools
Detroit Free Press (Oct. 13, 2015): "Michigan to launch lead

education effort statewide" (Higgins)
www.freep.com/story/news/local/michigan/2015/10/13/lead-
water-flint-michigan-testing/73871480/
3/13/16
State Legislature authorizes $9.35 million to help City of Flint pay for return to
DWSD water system, water filters, and staff at schools to gauge lead exposure
October 14, 2015
(signed by Gov. Snyder Oct. 15). C.S. Mott Foundation pledges another $4 million
and City of Flint will provide additional $2 million
Detroit Free Press (Oct. 14, 2015): "Michigan House OKs $9.35M to www.freep.com/story/news/local/michigan/2015/10/14/michiga
aid in Flint water crisis" (Gray)
n-house-oks-915m-aid-flint-water-crisis/73932980/
October 16, 2015
DWSD and City of Flint execute water supply contract, and City of Flint is
reconnected to DWSD system
October 16, 2015 First weekly coordination meeting held between City of Flint and state agencies
3/13/16
LAN01-#394270-v1-Executed Flint Water Agreement DWSD.PDF,

MDEQ info: Attachment 53 - MDEQ documentation provided to
Letter to B. Wright (Flint) from Rosenthal & Prysby (MDEQ), e-mail
FWATF Nov. 6, 2015
from MDEQ confirming disinfection testing of transmission main
Information provided by MDEQ to Flint Water Advisory Task Force
20
Date
Event
MDEQ meets with Flint Schools Superintendent and Genesee County Health
Department
EPA announces formation of Flint Safe Drinking Water Task Force to provide
October 16, 2015
technical expertise to MDEQ and City of Flint
Edwards/VT e-mails Wyant/DEQ, state legislators and Flint residents Walters and
October 16, 2015
Mays citing inaccuracies in lead sampling and communication
October 16, 2015
October 16, 2015
October 18, 2015
October 21, 2015

October 21, 2015
October 21, 2015
October 22, 2015

October 23, 2015
October 26, 2015
October 28, 2015
October 30, 2015
October 30, 2015
October 31, 2015
Reference Document
Sources
yosemite.epa.gov/opa/admpress.nsf/0/A92DE629DB86E6668525
7EE000579593
Final.pdf
media.wix.com/ugd/60e74e_dc3d45b23fd5418fbb6ec65d0ad974
MDEQ approves GCDC Water Supply System permit for new 30-mgd WTP
MDEQ Permit W151099
13.pdf
Detroit News (Oct. 19, 2015): "Michigan DEQ vows changes in Flint www.detroitnews.com/story/news/environment/2015/10/18/de
MDEQ Director Dan Wyant issues statement saying his office was mistaken in how it water crisis" (Lynch)
q-mistakes/74198882/
interpreted federal rules governing corrosion control for water systems the size of MLive (Oct. 19, 2015): "DEQ chief says state used wrong federal www.MLive.com/news/flint/index.ssf/2015/10/state_deq_flint_s
Flint; also says ODWMA chief Shekter Smith is being reassigned to help with FOIA water rules in Flint for 17 months" (Fonger)
hould_have_be.html
requests, and is being replaced by interim chief Jim Sygo
MLive (Oct. 19, 2015): "DEQ replaces water official after state
www.MLive.com/news/flint/index.ssf/2015/10/top_state_water_
acknowledges 'mistake' in Flint" (Fonger)
official_repla.html
U.S. Rep. Dan Kildee, D-Flint, and state Senate Minority Leader Jim Ananich, D-Flint,
MLive (Oct. 21, 2015): "Kildee, Ananich call for federal
www.MLive.com/news/flint/index.ssf/2015/10/kildee_ananich_ca
issue separate letters to Gina McCarthy, EPA Administrator, requesting federal
investigation into Flint water crisis" (Fonger)
ll_for_federa.html
review of MDEQ's oversight of water treatment
EPA's Flint Safe Drinking Water Task Force provides MDEQ with technical comments
Posted to EPA website
www.epa.gov/mi/flint-safe-drinking-water-task-force-activities
on Draft School Sampling Protocol
Press release - "Gov. Rick Snyder announces Flint Water Task Force
to review state, federal and municipal actions, offer
michigan.gov/snyder/0,4668,7-277--367761--,00.html
Gov. Snyder announces formation of Flint Water Advisory Task Force to complete an
recommendations"
www.freep.com/story/news/politics/2015/10/21/task-force-
After-Action Review
Detroit Free Press (Oct. 21, 2015): "Task force appointed to
appointed-examine-flint-water-controversy/74342628/
examine Flint water controversy" (Gray)
Detroit Free Press (Oct. 21, 2015): "MDEQ e-mails show stunning www.freep.com/story/opinion/columnists/nancy-
Detroit paper publishes column on MDEQ's "stunning indifference" to Flint water
indifference to Flint peril" (Kaffer)
kaffer/2015/10/21/indifference-characterized-state-approach-
crisis
FOIA'd information is also provided on Flint Water Study website flint-water/74289430/
EPA's Flint Safe Drinking Water Task Force provides MDEQ technical comments on Included on Safe Drinking Water Task Force list of activities,
Flint Corrosion Control Plan
posted to EPA website
Former Flint EM Earley issues statement to MLive claiming decision to switch to Flint MLive (Oct. 26, 2015): "Ex-emergency manager says local leaders www.MLive.com/news/flint/index.ssf/2015/10/ex-
River as supply source was "a local decision made by local civic leaders"
made decision to use Flint River water" (Fonger)
emergency_manager_says_loca.html
MDEQ issues construction permit for additional corrosion control treatment
MDEQ Construction Permit W151104
W151104
6, 2015
MDEQ notifies Flint regarding corrosion control treatment operation
Letter from Prysby/MDEQ to Glasgow/Flint
6, 2015
EPA's Flint Safe Drinking Water Task Force provides MDEQ technical comments on Included on Safe Drinking Water Task Force list of activities,
Flint Corrosion Control Permit and cover letter
MLive (Oct. 31, 2015): "Letters to be sent to Flint parents with
www.MLive.com/news/flint/index.ssf/2015/10/letters_to_be_sen
Flint sends letters to parents providing recommendations of GCHD and MDHHS
information on lead testing" (Emery)
t_to_flint_pa.html
EPA press release - "EPA Establishes Safe Drinking Water Task

Force to Provide Technical Expertise to MDEQ and City of Flint"
MI National Action Network (NAN) calls for special court for offenders who
November 2, 2015 consumed water contaminated by lead poisoning in Flint. Governor's Office notes
work of Flint Water Advisory Task Force
MLive (Nov. 2, 2015): "Al Sharpton group wants new Flint court for www.MLive.com/news/flint/index.ssf/2015/11/al_sharpton_grou
possible lead poison victims" (Fonger)
p_wants_specia.html
EPA to conduct "full review of actions taken to address drinking water quality issues
in Flint," with results by end of week of Nov. 2nd (MLive). EPA also will audit
November 3, 2015
MDEQ's drinking water program, which "will take several months" (EPA press
release)
EPA Region 5 press release: "EPA Region 5 to Audit State of

Michigan's Drinking Water Program"
MLive (Nov. 3, 2015): "U.S. EPA will conduct 'full review' of Flint
water crisis" (Fonger)
EPA releases memo indicating differing possible interpretations of the LCR with
November 3, 2015 respect to how OCCT procedures apply to this situation (new water source/new
water treatment)
Karen Weaver defeats incumbent Dayne Walling in Flint mayoral election; takes
November 3, 2015
office November 9, 2015
"Lead and Copper Rule Requirements for Optimal Corrosion

Control Treatment for Large Drinking Water Systems," posted to
EPA website
MLive (Nov. 3, 2015): "Karen Weaver unseats Dayne Walling to
win Flint mayor" (Fonger)
Accessed
Information provided by MDEQ to Flint Water Advisory Task Force
yosemite.epa.gov/opa/admpress.nsf/a5792a626c8dac098525735
900400c2d/9e26559c4478e1cb85257ef900617183!OpenDocume
nt
www.MLive.com/news/flint/index.ssf/2015/11/us_epa_tells_kild
ee_it_will_ca.html
www.epa.gov/sites/production/files/2015-
11/documents/occt_req_memo_signed_pg_2015-11-03-
155158_508.pdf
www.MLive.com/news/flint/index.ssf/2015/11/karen_weaver_m
akes_history_ele.html
3/13/16
3/13/16
3/13/16
3/13/16
3/13/16
3/13/16
3/1/16
3/13/16
3/13/16
3/13/16
3/13/16
3/13/16
3/13/16
3/13/16
3/13/16
21
Date
Event
Reference Document
Sources
"Final Report: High Lead at Three Residences in Flint, Michigan";

EPA issues "Final Report: High Lead at Three Residences in Flint, Michigan"; includes
www.aclumich.org/sites/default/files/Redacted%20EPA%20mem
November 4, 2015
transmittal from T. Hyde/EPA to J. Sygo/MDEQ, posted to ACLU-MI
information June 24 Interim Report, with personal ID/health info redacted
o.110415.pdf
website
November 4, 2015 DEQ authorizes a permit for installation of corrosion control at Flint WTP
risis_unfold.html#4
referring to permit authorization
MDEQ releases water testing data from nearly 400 homes and businesses as well as
Included in Gov. Snyder's e-mails released Jan. 20, 2016 (pp. 200- somcsprod2govm001.usgovcloudapp.net/files/snyder%20emails.p
November 9, 2015 schools; press release says tests indicate lead problem is related to individual
206/274)
df
buildings or faucets, not system-wide
yosemite.epa.gov/opa/admpress.nsf/a5792a626c8dac098525735
EPA Region 5 press release: "EPA Region 5 to Audit State of
EPA announces intent to audit State of Michigan's drinking water program; will
900400c2d/9e26559c4478e1cb85257ef900617183!OpenDocume
Michigan's Drinking Water Program"
November 10, 2015 examine MDEQ's implementation of SDWA and related rules on lead and copper,
nt
MLive (Nov. 10, 2015): "EPA to audit Michigan drinking water
total coliform, nitrates and ground water
www.MLive.com/news/flint/index.ssf/2015/11/epa_says_it_will_
program following Flint lead crisis" (Fonger)
audit_michiga.html#incart_story_package
EPA's Flint Safe Drinking Water Task Force meets in Flint with Rep. Kildee and City of Included on Safe Drinking Water Task Force list of activities,
November 10, 2015
Flint officials to discuss technical issues with optimization of corrosion control
MLive publishes article indicating City of Flint certified that most water samples
came from homes at high risk for lead, but other records indicate most did not -
MLive (Nov. 12, 2015): "Documents show Flint filed false reports www.MLive.com/news/flint/index.ssf/2015/11/documents_show
November 12, 2015
potentially leading the city and state to underestimate for months the extent of lead about testing for lead in water" (Fonger)
_city_filed_fals.html#incart_story_package
pollution in tap water
Flint families file federal lawsuit accusing 14 state and local officials of intentional Detroit Free Press (Nov. 13, 2015): "After Flint Water Crisis,
www.freep.com/story/news/local/michigan/2015/11/13/after-
November 13, 2015
negligence
Families File Lawsuit" (Bethencourt)
flint-water-crisis-families-file-lawsuit/75744376/
Genesee Co. Dept. of Health and Michigan MDHHS announce they are providing
MLive (Nov. 13, 2015): "County Health Department, state partner www.MLive.com/news/flint/index.ssf/2015/11/county_health_de
November 13, 2015 resources to educate Flint residents and primary care providers about lead and what
to educate Flint area on lead" (Johnson)
partment_state.html#incart_story_package
people should do to protect themselves
www.MLive.com/lansing-
MI Board of Canvassers rejects petition filed by Angelo Scott Brown of Detroit to
MLive (Nov. 13, 2015): "Board rejects petition seeking to recall
November 13, 2015
news/index.ssf/2015/11/board_rejects_petition_to_reca.html#inc
recall Gov. Snyder, alleging he is responsible for Flint water crisis
Michigan Gov. Rick Snyder" (Oosting)
art_river_index
Class action lawsuit is filed against Gov. Snyder, State of MIchigan and various city
November 13, 2015
Case is filed in U.S. District Court, Eastern District of Michigan
flintwaterclassaction.com
and state employees on behalf of Melissa Mays and other Flint residents
www.aclumich.org/article/flint-residents-sue-city-state-over-lead-
Press release and notice posted to ACLU-MI website.
ACLU Michigan, NRDC and Concerned Pastors for Social Action announce intended
drinking-water
November 16, 2015
MLive (Nov. 16, 2015): "ACLU, national activists intend to sue Gov.
federal lawsuit against City and State officials over the Flint water crisis
www.MLive.com/news/flint/index.ssf/2015/11/nrdc_aclu_file_no
Snyder, Flint over lead in water" (Fonger)
tice_to_sue_s.html#incart_river_index
MLive (Nov. 16, 2015): "Howard Croft, Flint official responsible for www.MLive.com/news/flint/index.ssf/2015/11/howard_croft_flin
November 16, 2015 Howard Croft resigns as Flint DPW director
water oversight, resigns" (Fonger)
t_official_re.html#incart_river_index
Q&A document dated Nov. 16, 2015 included in Gov. Snyder's e- somcsprod2govm001.usgovcloudapp.net/files/snyder%20emails.p
November 17, 2015 MDEQ provides Flint drinking water Q&A to Flint Water Advisory Task Force
mails released Jan. 20, 2016 (pp. 217-235/274)
df
Elected officials and activists testify before USEPA National Drinking Water Advisory MLive (Nov. 18, 2015): "Story of Flint water crisis, 'failure of
www.MLive.com/news/flint/index.ssf/2015/11/story_of_flint_wat
November 18, 2015
Council regarding Flint water crisis
government,' unfolds in Washington" (Fonger)
er_crisis_fa.html#incart_story_package
E-mail from MDHHS to Governor's Office, press release and talking
MDHHS releases data on October 2015 blood lead levels; 24 of 963 adults and
November 19, 2015
points included in Gov. Snyder's e-mails released Jan. 20, 2016 (pp.
children tested had elevated blood lead levels in October
df
207-216/274)
Detroit Free Press (Nov. 22, 2015): "Flint water mystery: How was www.freep.com/story/news/politics/2015/11/21/snyders-top-
Detroit Free Press reports on Governor's office's involvement in decisions to
decision made?" (Egan)
aide-talked-flint-water-supply-alternatives/76037130/
November 22, 2015
approve KWA and to use Flint River water for City of Flint water supply
Detroit Free Press (Nov. 21, 2015): "Answers prompt more
questions in Flint water crisis" (Kaffer)
kaffer/2015/11/21/flint-water-crisis/76060708/
Flint City Council approves $907,650 contract extension for engineering company MLive (Nov. 23, 2015): "Engineer gets $907,000 contract add-on to www.MLive.com/news/flint/index.ssf/2015/11/engineer_gets_90
November 23, 2015
LAN to prepare Flint WTP for treating Lake Huron water from KWA pipeline
prepare Flint for KWA water" (Fonger)
7000_contract.html
EPA's Flint Safe Drinking Water Task Force releases comments on Flint's residential
www.epa.gov/mi/flint-safe-drinking-water-task-force-comments-
November 23, 2015 lead and copper sampling instructions; agrees with Del Toral that pre-flushing
Comments posted to EPA website
flints-residential-drinking-water-lead-copper
should be removed
EPA's Flint Drinking Water Task Force releases Preliminary Assessment, with
"Lead in Drinking Water - Preliminary Assessment," posted to EPA www.epa.gov/mi/flint-safe-drinking-water-task-force-draft-lead-
November 25, 2016 recommendations on sampling protocol, operating procedures, corrosion control
website
drinking-water-preliminary-assessment
and outreach during transition to KWA pipeline
Accessed
3/13/16
3/12/16
3/12/16
3/13/16
3/13/16
3/13/16
3/13/16
3/13/16
3/13/16
3/13/16
3/13/16
3/13/16
3/12/16
3/13/16
3/12/16
3/13/16
3/13/16
3/13/16
3/13/16
22
Date
Event
Hearing held on whether City has violated Genesee County Circuit Court order to
reduce water and sewer rates
Reference Document
MLive (Nov. 25, 2015): "Flint water customers say no change in
bills, despite court order" (Ridley)
Sources
Accessed
www.MLive.com/news/flint/index.ssf/2015/11/flint_residents_te
stify_on_wat.html
3/13/16
www.MLive.com/news/flint/index.ssf/2015/12/flint_in_talks_wit
h_regulators.html#incart_story_package
3/13/16
www.MLive.com/news/flint/index.ssf/2015/12/lead_levels_in_fli
nts_water_st.html
3/13/16
www.freep.com/story/news/local/michigan/2015/12/03/election
s-board-rejects-latest-snyder-recall-petition/76712410/
3/13/16
www.freep.com/story/news/local/michigan/2015/12/03/flint-kids-
lead-levels/76746474/
3/13/16
www.epa.gov/sites/production/files/2016-01/documents/ftf-
4_task_force_comments_on_mdhhs_residential_sampling_protoc
ol_12-4-15.pdf
3/13/16
James Henry/GCHD recapped events over several months in an e-mail to other

December 4, 2015 county health officials and singled out a specific state health department official he concerns over Legionnaires' actions" (Dolan, Anderson, Egan,
said had sabotaged their Legionella investigation
Wisely)
info/80028820/
3/13/16
Tamara Brickey, GCHD public health division director, e-mails other county health
officials that the state is making clear they are not practicing ethical public health Detroit Free Press (Feb. 9, 2016): "Flint e-mails: CDC voiced
December 5, 2015 practice re: Legionella outbreak. Now evidence is clearly pointing to a deliberate concerns over Legionnaires' actions" (Dolan, Anderson, Egan,
cover-up In my opinion, if we dont act soon, we are going to become guilty by
Wisely)
association.
info/80028820/
3/13/16
FWATF sends letter to Gov. Snyder recommending project coordination framework

December 7, 2015 for Flint water crisis mitigation, with single-point management, goals, timeline,
Letter posted online by MLive
responsibility assignments, contingency planngin and communication
media.MLive.com/newsnow_impact/other/FWATF%20letter%20t
o%20Governor%20Snyder.pdf
1/31/16
November 25, 2015
City of Flint in talks with state and federal regulators to determine how long Flint
MLive (Dec. 11, 2015): "Flint in talks with regulators over length of
December 2015 will be required to practice treating water from a new pipeline before selling it to
test run with KWA water" (Fonger)
customers
Dr. Edwards makes presentation at Hurley Medical Center stating that Flint's water
MLive (Dec. 2, 2015): "Flint water still unsafe without lead filters,
December 2, 2015 is still not safe to drink without filtration in some areas; Mayor Weaver presents him
professor says" (Fonger)
with a Certificate of Appreciation
MI Board of Canvassers again rejects petition filed by Angelo Scott Brown of Detroit Detroit Free Press (Dec. 3, 2015): "Push to recall Snyder over Flint
December 3, 2015
to recall Gov. Snyder; Brown says he will try again
water crisis stalls" (Egan)
State reports that blood lead levels in Flint children have dropped, with the rate
falling to 3% of children under 6, based on results from 1,361 children. Dr. Hanna- Detroit Free Press (Dec. 4, 2015): "State says blood-lead levels in
December 4, 2015
Attisha: the most recent data does not capture past exposure, so it provides limited Flint kids have dropped" (Erb)
information on the population's real exposure
December 4, 2015
December 8, 2015
December 8, 2015
December 9, 2015
December 10, 2015
December 11, 2015

December 11, 2015
December 14, 2015
EPA's Flint Drinking Water Task Force releases comments on MDHHS residential
drinking water sampling protocol
Posted to EPA website
Testimony continues in hearing on whether City has violated Genesee County Circuit MLive (Dec. 8. 2015): "Daughter's piggy bank makes appearance in www.MLive.com/news/flint/index.ssf/2015/12/daughters_piggy_
Court order to reduce water and sewer rates
Flint water rate hearing" (Ridley)
bank_makes_app.html
MLive (Dec. 9, 2015): "Flint administrator says city plans to add
www.MLive.com/news/flint/index.ssf/2015/12/flint_administrato
Mayor Weaver holds first Town Hall meeting; Flint City Administrator Henderson
third-party water testing" (Fonger)
r_says_city_1.html#incart_river_index
announces plan to start independent testing for lead in City of Flint water supply
MLive (Dec. 10, 2015): "Flint will pay for independent water tests, www.MLive.com/news/flint/index.ssf/2015/12/flint_will_pay_for
added phosphate treatment" (Fonger)
_independent.html
City of Flint starts adding supplemental phosphates to water purchased from City of MLive (Dec. 9, 2015): "Flint officials say they've boosted corrosion www.MLive.com/news/flint/index.ssf/2015/12/flint_officials_say
Detroit in an effort to rebuild protective coating in transmission lines
control agents in water" (Fonger)
_theyre_boo.html#incart_river_index
MDEQ issues report finding lead in plumbing system at Brownell STEM Academy -
one of three school buildings that tested above federal limits for lead. Includes
MLive (Dec. 10, 2015): "More lead in plumbing found at Flint's
www.MLive.com/news/flint/index.ssf/2015/12/state_report_iden
quotes from Wurfel attributing high lead levels to "old faucets and drinking water Brownell school, state report says" (Fonger)
tifies_more_l.html#incart_river_index
fountains"
MDHHS releases latest results from blood lead testing conducted in Flint since Oct. Included in Gov. Snyder's e-mails released Jan. 20, 2016 (pp. 246-
1. 39 of 1,386 adults and children had elevated blood lead levels since Oct. 1, 2015 247/274)
Former Flint Mayor James Sharp calls for federal investigations into Flint water
Detroit Free Press (Dec. 11, 2015): "Former Flint mayor wants feds www.freep.com/story/news/local/michigan/2015/12/10/former-
controversy
to probe lead in water" (Egan)
flint-mayor-wants-feds-probe-lead-water/77088024/
Flint Mayor Weaver declares state of emergency in Flint -- the first step in pursuing MLive (Dec. 15, 2015): "Read Flint mayor's state of emergency
www.MLive.com/news/flint/index.ssf/2015/12/read_flint_mayor
a federal disaster declaration. Declaration says the damage done to Flint children by declaration on water crisis"
_karen_weavers.html#incart_river_index
lead exposure is irreversible, creating need for increased spending on special
The Guardian (Dec. 15, 2015): "Flint mayor declares 'manmade
www.theguardian.com/us-news/2015/dec/15/michigan-mayor-
education, mental health and juvenile justice
disaster' over lead-tainted water supply"
declares-manmade-disaster-lead-tainted-water-supply
3/13/16
3/13/16
3/13/16
3/13/16
3/12/16
3/13/16
3/13/16
23
Date
December 14, 2015
December 15, 2015
December 16, 2015

December 17, 2015
December 17, 2015
December 17, 2015

December 17, 2015
December 21, 2015
December 22, 2015
December 22, 2015
December 23, 2015
December 29, 2015

December 29, 2015
December 29, 2015
Event
Reference Document
Sources
Accessed
FEMA sends 28,000 liters of water to Food Bank of Eastern Michigan, for
distribution to partner agencies to serve Flint residents
MLive (Dec. 14, 2015): "FEMA sends 28,000 liters of bottled water www.MLive.com/news/flint/index.ssf/2015/12/fema_sends_thou
3/13/16
to Flint amid lead troubles"
sands_of_cases.html
media.MLive.com/newsnow_impact/other/15.12.15%20Flint%20
Gov. Snyder issues response to FWATF's Dec. 7 letter, naming Harvey Hollins,
Letter dated Dec. 15, 2015 posted online by MLive
Task%20Force%20Letter.pdf
director of Office of Urban Initiatives, to lead Flint water crisis response, with Chris MLive (Dec. 17, 2015): "Read letters from governor, task force on
3/13/16
www.MLive.com/news/flint/index.ssf/2015/12/read_letters_from
DeWitt supporting communications
Flint water crisis" (Fonger)
_governor_tas.html#incart_river_index
EPA's Flint Drinking Water Task Force releases recommendations on Flint drinking
www.epa.gov/mi/flint-safe-drinking-water-task-force-
3/13/16
water treatment prior to switching to KWA source
recommendations-regarding-flint-drinking-water-treatment
Press release described in MLive (Dec. 17, 2015): "Governor's task
www.MLive.com/news/flint/index.ssf/2015/12/state_task_force_
FWATF issues press release re: letter to Gov. Snyder and response
force on Flint water crisis releases early recommendations"
3/13/16
on_flint_wate.html#incart_river_index
(Fonger)
National media coverage of Flint water crisis - e.g.: MSNBC's Rachel Maddow Show MSNBC - Rachel Maddow Show (Dec. 19, 2015): "Flint toxic water www.msnbc.com/rachel-maddow-show/watch/toxic-water-
report on Flint water crisis places blame on Governor's Office and "radical, anti-
tragedy points directly to Michigan Gov. Snyder"
tragedy-points-directly-to-snyder-588635715518
3/13/16
democratic policies"; The Guardian (US edition) article describes interview with Dr. The Guardian (Dec. 17, 2015): "Flint's 'toxic soup' polluted water www.theguardian.com/us-news/2015/dec/17/flint-polluted-
Hanna-Attisha
worse for children than thought, doctor says"
water-toxic-lead-children-at-risk
Genesee County Board of Commissioners Chairman Jamie Curtis sends letter to
MLive (Dec. 18, 2015): "Genesee County chairman says he can
Mayor Weaver saying he is authorized to forward Flint's request for disaster
3/13/16
send Flint disaster request to governor" (Fonger)
board_chair_say.html#incart_story_package
declaration to the Governor's Office
City of Flints Emergency Operations Center (EOC) is activated to begin to coordinate
www.cityofflint.com/2015/12/17/emergency-operations-center-
Announced on City of Flint website
3/13/16
relief efforts
activated/
"Elevated Blood Lead Levels in Children Associated With the Flint
American Journal of Public Health publishes results of further study of blood lead
Drinking Water Crisis: A Spatial Analysis of Risk and Public Health ajph.aphapublications.org/doi/abs/10.2105/AJPH.2015.303003
levels by Dr. Hanna-Attisha et al. New research further details the rise in elevated Response," available via AJPH website.
www.MLive.com/news/flint/index.ssf/2015/12/health_journal_pu
3/13/16
blood levels that was documented in the initial study released Sep. 24
Described in MLive (Dec. 21, 2015): "Newly published study gives blishes_blood.html#incart_story_package
more evidence of elevated lead in Flint kids" (Fonger)
Genesee County Circuit Court Judge Hayman rules city can continue shutting off
water to customers who haven't paid their water bill since September 2015 - not
MLive (Dec. 22, 2015): "Questions over emergency manager law www.MLive.com/news/flint/index.ssf/2015/12/questions_arise_r
3/13/16
others. Also says City must apply 35% rate rollback to service charges as well as
arise in Flint water rates lawsuit" (Emery)
egarding_publ.html#incart_story_package
water commodity rates
Continued national media coverage of Flint water crisis - e.g., Rachel Maddow show
CBS News (Dec. 22, 2015): "New study links tainted water, high
www.cbsnews.com/news/tainted-water-high-lead-levels-kids-flint-
reports on Flint water crisis; CBS News reports on Dr. Hanna-Attisha's refined study
3/13/16
lead levels in kids in Flint, Mich."
michigan/
of blood lead levels
Auditor General issues responses to questions from Sen. Ananich re: Flint water
crisis. Notes no "major infractions" committed by MDEQ but also notes mistakes - Included in Gov. Snyder's e-mails released Jan. 20, 2016 (pp. 250-
3/13/16
corrosion control treatment should have been initiated with switch to Flint River as 264/274)
primary water supply, Tier 1 sample sites not verified, etc.
FWATF issues letter to Gov. Snyder and press release re: initial findings from its
www.scribd.com/doc/294248389/Flint-Water-Advisory-Task-
work; puts primary blame for Flint water crisis on MDEQ but indicates more to come Link to letter posted in Free Press article (see below)
3/13/16
Force-letter-to-Snyder
in final report
Gov. Snyder issues apology for Flint water crisis via press release
Press release posted on michigan.gov
www.michigan.gov/snyder/0,4668,7-277-57577_57657-372335--,00.html
3/13/16
www.freep.com/story/news/local/michigan/2015/12/29/deq-
Detroit Free Press (Dec. 29, 2015): "Snyder apologizes, Wyant
director-wyant-resigns-over-flint-water-crisis/78027052/
resigns in Flint water crisis" (Egan).
www.MLive.com/lansing-
MDEQ Director Wyant and Director of Communication Brad Wurfel submit their
MLive (Dec 29-30, 2015): "Director Dan Wyant resigns after task news/index.ssf/2015/12/deq_director_dan_wyant_resigns.html#i
3/13/16
resignations
force blasts MDEQ over Flint water crisis" (Lawler); "MDEQ
ncart_river_index
spokesman also resigns over Flint water crisis, says city 'didn't feel www.MLive.com/lansing-
like we cared'" (Lawler)
news/index.ssf/2015/12/deq_spokesman_also_resigns_ove.html#
incart_river_index
24
Date
Event
December 29, 2015 Continued national media coverage of Flint water crisis
Mayor Weaver meets with Genesee County Board of Commissioners Chairman

December 30, 2015 Curtis and others involved in emergency planning to discuss the City's Incident
Action Plan
Gov. Snyder reassigns Michigan DNR Director Keith Creagh as interim MDEQ
December 30, 2015
Director, effective January 4, 2016
Reference Document
Sources
Accessed
MSNBC Rachel Maddow (Dec. 29, 2015): "Michigan governor

apologizes for Flint water" (Kildee interview).
The Guardian (Dec. 30, 2015): "Governor Rick Snyder 'very sorry'
about Flint water lead levels debacle" (Felton).
Reuters/Huffington Post (Dec. 29, 2015): "Michigan Gov. Rick
Snyder Apologizes For Flint's Water Crisis" (Klayman).
AP/Wall Street Journal (Dec. 29, 2015): "Michigans Top
Environmental Regulator Resigns Over Flint Water Crisis"
www.msnbc.com/rachel-maddow-show/watch/michigan-
governor-apologizes-for-flint-water-593269827585
www.theguardian.com/us-news/2015/dec/30/michigan-governer-
rick-snyder-very-sorry-about-water-supply-debacle
www.huffingtonpost.com/entry/rick-snyder-flint-water-lead-
poisoning_56830314e4b014efe0d9814f
www.wsj.com/articles/michigans-top-environmental-regulator-
resigns-over-flint-water-crisis-1451432226
3/13/16
Press release posted to City of Flint website
www.cityofflint.com/2015/12/30/mayor-meets-with-county-chair-
over-incident-action-plan/
3/19/16
Press release posted on State of Michigan website
,00.html
3/13/16
2016
Newsweek puts Flint water crisis atop list of "nastiest cases of toxic discharge" in
January 1, 2016
2015
Newsweek (Jan. 1, 2016): "The Year in Pollution" (Schlanger)
January 4, 2016 Genesee County Commission declares state of emergency
Gov. Snyder's Flint Water timeline (released January 2016)
January 5, 2016
Gov. Snyder declares state of emergency for Genesee County, activating the State
Emergency Operations Center
Press release and proclamation on State of Michigan website
www.newsweek.com/year-pollution-here-are-nastiest-cases-toxic-
discharge-2015-410766
pdf
www.michigan.gov/deq/0,4561,7-135-3313_3675_73946-372653--
,00.html
www.michigan.gov/documents/snyder/2016-01-
05_Flint_Water_Governors_Declaration_Final_509966_7.pdf?201
60105162343
Gina Balaya, spokeswoman for the U.S. Attorney's Office in Detroit, said Tuesday her
Detroit Free Press (Jan. 15, 2016): "Snyder declares emergency as www.freep.com/story/news/local/michigan/2016/01/05/us-
January 5, 2016 office is working with the U.S. Environmental Protection Agency on an investigation
feds probe Flint water" (Egan)
attorneys-office-investigating-lead-flint-water/78303960/
of the Flint water situation
State of Michigan launches Joint Information Center (JIC) to coordinate public
Press release - "State of Michigan Joint Information Center Now www.michigan.gov/deq/0,4561,7-135-3313_3675_73946-372766--
January 6, 2016 information from the State Emergency Operations Center, set up to help with health
Operational"
,00.html
and safety issues caused by lead in the city of Flints drinking water
NBC News (Jan. 6, 2015): "Drinking water crisis in Flint, Michigan www.nbcnews.com/nightly-news/video/drinking-water-crisis-in-
prompts federal investigation"
flint--michigan--prompts-federal-investigation-597142595942
January 6, 2016 Continued national media coverage: NBC News, MSNBC
MSNBC Rachel Maddow (Jan. 6, 2015): "Flint toxic water draws
www.msnbc.com/rachel-maddow/watch/flint-toxic-water-draws-
federal scrutiny"; "State dismissed Flint bad water test concerns"; www.msnbc.com/rachel-maddow/watch/state-dismissed-flint-
Guyette interview
bad-water-test-concerns-597320259868
Michigan's chief medical executive, Dr. Eden Wells, says Flint residents should either Detroit Free Press (Feb. 2016): "How Flint's Water Crisis Unfolded"
January 7, 2016
use lead filters or drink bottled water until further notice
(Dixon)
Genesee County Sheriff Robert Pickell deploys work detail and staff to deliver water MLive (Jan. 7, 2016): "Genesee County Sheriff uses work detail to www.MLive.com/news/flint/index.ssf/2016/01/work_detail_used
January 7, 2016
and filters to homes
distribute filters in Flint" (Acosta)
_by_genesee_co.html
Continued national media coverage criticizing state's failure to provide bottled
MSNBC Rachel Maddow (Jan. 7, 2016): "Water donations run dry www.msnbc.com/rachel-maddow/watch/flint-water-donations-
January 7, 2016
water and water filters
in Flint, no action from Governor Snyder"
run-dry--no-state-plan-598134339963
Gov. Snyder and Mayor Weaver announce formation of an inter-agency group to
MLive (Jan. 7, 2016): "Flint Mayor, Gov. Rick Snyder to provide city www.MLive.com/lansing-
January 7, 2016 work with State Emergency Operations Center on taking action to improve the
with 'suite of services' following water crisis" (Lawler)
news/index.ssf/2016/01/flint_mayor_gov_rick_snyder_to.html
situation
January 8, 2016 Gov. Snyder and Mayor Weaver meet to discuss collaboration
pdf
MSP Emergency Management Division announces water resource sites established
January 9, 2016
in Flint with bottled water, filters and testing kits
pdf
Gov. Snyder signs Executive Order to create Flint Water Interagency Coordinating
January 11, 2016
Committee to work on long-term solutions to the Flint water situation
pdf
Gov. Snyder requests FEMA's assistance in coordinating an inter-agency plan and
January 12, 2016
activates Michigan National Guard to help with water resources distribution
pdf
3/13/16
1/31/16
3/13/16
3/13/16
3/13/16
3/13/16
3/13/16
3/13/16
3/13/16
3/13/16
1/31/16
1/31/16
1/31/16
1/31/16
25
Date
January 13, 2016
January 14, 2016

January 15, 2016
January 16, 2016
January 16, 2016
January 19, 2016
Event
Gov. Snyder and MDHHS announce a spike in Legionellosis in Flint between June
2014 and Mar 2015, which may be linked to switch to Flint River. Spike included 87
cases, with 10 deaths, in 18 months. This is the first public notification, 10 months
after MDEQ notified Hollins the outbreak coincided with switch to Flint River water
Gov. Snyder requests Presidential declaration of major disaster and emergency and
requests federal aid
Michigan Attorney General Bill Schuette announces he has opened an investigation
of Flint water crisis
President Obama approves declaration of emergency and request for federal aid,
and declines request for declaration of major disaster
MLive reports that Genesee County Health Dept. officials expressed concern re:
increase in Legionellosis in Oct. 2014 in meeting with Flint Water
Gov. Snyder delivers State of the State address; apologizes for Flint water crisis,
announces release of his own e-mails regarding Flint water, and commits another
$28 million in short-term for more filters, bottled water, school nurses, intervention
specialists, testing and monitoring
January 19, 2016 Flint Mayor Weaver meets with President Obama in Washington, DC
Reference Document
Sources
Accessed
MLive (Jan. 13, 2016): "87 cases, 10 fatal, of Legionella bacteria

found in Flint area; connection to water crisis unclear" (Al Hajal);
also reported nationally on CNN, ABC, Washington Post
www.MLive.com/news/detroit/index.ssf/2016/01/legionaires_dis
ease_spike_disc.html
3/13/16
pdf
1/31/16
(Dixon)
pdf
MLive (Jan. 16, 2016): "Public never told, but investigators
www.MLive.com/news/flint/index.ssf/2016/01/documents_show
suspected Flint River tie to Legionnaires' in 2014" (Fonger)
_agencies_knew_o.html
3/13/16
1/31/16
3/13/16
New York Times (Jan. 20, 2016): "Gov. Rick Snyder of Michigan
Apologizes in Flint Water Crisis" (Bosman, Smith)
www.nytimes.com/2016/01/20/us/obama-set-to-meet-with-
mayor-of-flint-about-water-crisis.html?_r=0
3/13/16
Detroit Free Press (Jan. 19, 2016): "Obama meets Flint mayor,
responds to lead crisis" (Spangler)
crisis/2016/01/19/flint-mayor-meet-white-house-
officials/79001256/
3/13/16
df
3/12/16
www.usnews.com/news/us/articles/2016-01-20/michigan-
governor-on-flint-water-i-let-you-down
3/13/16
Class action lawsuit is filed against City of Flint and various city and state employees
Case filed in Genesee County Circuit Court
on behalf of Melissa Mays and other Flint residents
Gov. Snyder voluntarily posts his e-mails regarding Flint water to his website
January 20, 2016
(Governor's office is exempt from Michigan FOIA)
Posted to Gov. Snyder's webpage at www.michigan.gov/snyder
US News & World Report (Jan. 20, 2016): "Michigan Gov. Rick
Snyder is asking President Barack Obama to reconsider his denial
Gov. Snyder asks President Obama to reconsider denial of federal disaster
January 20, 2016
of a federal disaster declaration to address the drinking water
declaration
crisis in Flint, saying its severity poses an 'imminent and long-term
threat' to residents" (Eggert/AP)
State budget office asks legislature for $28 million to aid in Flint water crisis; House MLive (Jan. 20, 2016): "Michigan House approves $28M in
January 20, 2016
approves; heads next week to Senate
immediate assistance for Flint" (Lawler)
EPA's Flint Safe Drinking Water Task Force provides recommendation that all
January 20, 2016
Documented posted to EPA website
samples for lead analysis be collected using wide-mouth sample bottles
CBS News (Jan. 20, 2016): "Michigan gov.: We don't want people
January 20, 2016 CBS Evening News interviews Gov. Snyder
to assume Flint water is safe"
Detroit News (Jan. 21, 2016): "Obama gives $80 million to
President Obama announces $80 million in financial aid for water infrastructure
Michigan for Flint" (Burke)
January 21, 2016 projects in Michigan, including Flint. Money is being provided for state's revolving
MLive (Jan. 23, 2016): "$80 million announced in connection with
loan fund, not as an appropriation
Flint water is revolving loan fund"
NBC News (Jan. 21, 2016): "EPA Administrator quits over Flint
January 21, 2016 EPA Region 5 Director Susan Hedman resigns, effective Feb. 1, 2016
water crisis" (Seville/Helsel)
EPA issues SDWA Emergency Order saying authorities in Michigan failed to properly
respond to Flint water crisis and prescribing various actions for the City and MDEQ.
PA will begin testing the citys water; order a range of data collection, plans and
January 21, 2016 reports from the City and MDEQ; and form an Independent Advisory Panel of
Order posted to EPA website
drinking water / treatment experts and community members to recommend next
steps. EPA Administrator Gina McCarthy also asks EPA inspector general to conduct
independent review of Region 5's oversight of public water systems
MDEQ Director Creagh responds to EPA by saying they will comply, but questioning
Detroit News (Jan. 22, 2016): "Michigan questions legality of EPA
January 22, 2016 McCarthy/EPA's legal authority to direct MDEQ in Flint response, and stating MDEQ
directive on Flint" (Oosting) (includes letter response)
has complied with all EPA's recent demands
January 19, 2016
January 22, 2016
MDHHS releases data showing 70% of people who contracted Legionellosis in the
Flint outbreak were exposed to Flint water 2 weeks before their symptoms began
Detroit Free Press (Jan. 22, 2016): "Legionnaires expert blames

spike in cases on Flint water" (Tanner, Anderson)
www.MLive.com/news/index.ssf/2016/01/michigan_house_appr
oves_28m_in.html
https://www.epa.gov/mi/flint-safe-drinking-water-task-force-
recommendations-regarding-wide-mouth-sampling-bottles
www.cbsnews.com/news/michigan-gov-at-least-100-kids-affected-
by-lead-in-flint-water/
www.detroitnews.com/story/news/politics/2016/01/21/stabeno
w-obama-gives-million-flint/79134306/
www.MLive.com/news/kalamazoo/index.ssf/2016/01/80_million_
announced_in_connec.html
www.nbcnews.com/storyline/flint-water-crisis/epa-administrator-
quits-amid-flint-water-crisis-n501561
3/13/16
3/18/15
3/13/16
3/13/16
3/13/16
01/documents/1_21_sdwa_1431_emergency_admin_order_0121
16.pdf
3/13/16
www.detroitnews.com/story/news/politics/2016/01/22/michigan-
questions-legality-epa-directive-flint/79202618/
3/13/16
crisis/2016/01/22/legionnaires-expert-blames-spike-cases-flint-
water/79203614/
3/13/16
26
Date
Event
FWATF sends letter to Gov. Snyder calling for him to engage experts versed in LCR
January 22, 2016 requirements, including Del Toral/EPA, and a work group including Edwards/VT;
various other recommendations re: lead sampling and control
Two MDEQ staffers are suspended without pay pending an investigation. The
January 22, 2016 employees are not named in the press release but soon are identified as Stephen
Busch and Liane Shekter Smith
Gov. Snyder returns additional executive powers to Flint's mayor. Mayor Weaver
January 22, 2016 will now have the authority to appoint the city administrator and all department
heads. Todays action is the next step in transitioning to full, local control in Flint
January 22, 2016
Detroit Free Press reports that hacker group Anonymous has launched a Flint
operation and is calling for Gov. Snyder to be charged with manslaughter
Michigan AG Schuette names Todd Flood (defense attorney and former Wayne
County assistant prosecutor) and former Detroit FBI bureau chief Andy Arena to
January 25, 2016 lead investigation into potential misconduct in office concerning Flint water crisis.
State Rep. LaTanya Garrett (D-Detroit) files petition with U.S. AG Loretta Lynch to
remove Schuettes office from Flint water investigation citing conflicts of interest
ACLU Michigan, NRDC and Concerned Pastors for Social Action file federal lawsuit
January 27, 2016 against city and state officials seeking to force owners and operators of Flint's water
system to comply with SDWA
Pastor Edwin Anderson, Aline Anderson and Beatrice Boler file federal lawsuit
January 31, 2016 against city and state officials seeking compensatory and punitive damages over
Flint water crisis
February 1, 2016
Michigan Attorney General Schuette says his office "likely" can't defend the seven
MDEQ workers being sued over Flint water crisis; asked federal judge to decide
FBI joins federal investigation of Flint water crisis, which also involves U.S.
February 2, 2016 Attorney's office, US Postal Inspection Service and EPA Criminal Investigation
Division
February 2, 2016
$100 million lawsuit is filed against McLaren Flint Hospital and State of Michigan
over Flint Legionellosis cases, on behalf of four who contracted the disease
Reference Document
1/31/16
Press release posted to Gov. Snyder's webpage
www.michigan.gov/snyder/0,4668,7-277-57577-374565--,00.html
3/13/16
,00.html
3/13/16
Detroit Free Press (Jan. 22, 2016): "State on high cyber alert after
crisis/2016/01/22/activist-hacker-group-anonymous-starts-flint-
Anonymous threat" (Egan)
campaign/79157780/
3/13/16
The State (Jan. 26, 2016): "Ex-prosecutor to spearhead

investigation into Flint water crisis" (Eggert, Householder)
www.thestate.com/news/nation-
world/national/article56583968.html
3/13/16
crisis/2016/01/31/deq-workers-need-find-own-lawyer-flint-
lawsuit/79608504/
3/13/16
Filed in U.S. District Court, Eastern District of Michigan

Detroit Free Press (Feb. 1, 2016): "State might not defend MDEQ
workers in Flint water suit" (Baldas)
NBC News (Feb. 2, 2016): "FBI Investigating Flint's Poisoned Water www.nbcnews.com/storyline/flint-water-crisis/fbi-investigating-
Crisis" (Connor)
flint-s-poisoned-water-crisis-n509686
Detroit Free Press (Feb. 2, 2016): "Fieger files $100-million suit
over Flint Legionnaires' disease cases" (Wisely, Dixon)
U.S. Small Business Admnistration approves Gov. Snyder's request to aid businesses
MLive (Feb. 5, 2016): "Businesses affected by Flint water crisis can
February 5, 2016 in Flint and Genesee County affected by Flint water crisis. SBA will provide access to
seek disaster loans from SBA" (Emery)
federal Economic Injury Disaster Loans for small businesses
EPA's Flint Safe Drinking Water Task Force provides recommendations on MDEQ's
February 5, 2016
Documented posted to EPA website
Draft Sentinel Site Selection
Detroit Free Press (Feb. 7, 2016): "Hillary Clinton: What happened
February 7, 2016 Democratic presidential candidate Hillary Clinton visits Flint
in Flint is immoral" (Gray, Stafford)
Luke Waid and Michelle Rodriguez file federal lawsuit over 2-year-old daughter's
February 8, 2016
lead poisoning
Detroit Free Press (Feb. 9, 2016): "Flint issues boil advisory after
water main break" (Bethencourt)
3/13/16
crisis/2016/02/02/fieger-flint-lawsuit-mclaren-water-
crisis/79704852/
3/13/16
crisis/2016/02/03/flint-water-congressional-hearing/79728072/
www.nbcnews.com/storyline/flint-water-crisis/house-panel-chair-
vows-hunt-down-official-behind-flint-water-n510411
3/13/16
crisis/2016/02/03/snyder-water-bills/79753564/
,00.html
www.MLive.com/news/flint/index.ssf/2016/02/businesses_affect
ed_by_flint_w.html
www.epa.gov/flint/flint-safe-drinking-water-task-force-
recommendations-mdeqs-draft-sentinel-site-selection
crisis/2016/02/07/hillary-clinton-flint-campaign-stop/79902530/
crisis/2016/02/09/flint-residents-asked-boil-their-filtered-
water/80086916/
Gov. Snyder proposes state budget for FY 2017 that includes $195 million to address MLive (Feb. 10, 2016): "Gov. Rick Snyder proposes $195M for Flint www.MLive.com/news/index.ssf/2016/02/gov_rick_snyder_prop
February 10, 2016
Flint water crisis
water as protesters call for his removal" (Lawler)
oses_195m.html
February 9, 2016 Flint issues boil water advisory due to broken water main
Accessed
www.gongwer.com/public/fwatf-letter.pdf
House Committee on Oversight and Government Reform holds hearing where

Detroit News (Feb. 5, 2016): "Lawmakers spar on state's blame for
Beauvais/EPA, Creagh/MDEQ, Edwards/VT and Flint resident Walters testify re: Flint
Flint water" (Burke, Lynch)
February 3, 2016 water crisis; former Flint EM Earley declines to appear. Edwards: "I am personally
NBC News (Feb. 3, 2016): "House Panel Accuses Officials of
shamed that the profession I belong to, the drinking water industry in this country,
Covering Up Flint Water Crisis" (Schuppe)
has allowed this to occur."
Snyder proposes $30 million in state funds to offset a portion of Flint residents'
Detroit News (Feb. 3, 2016): "Snyder pitches $30 million for Flint
February 3, 2016
water bills. Approved by Michigan Senate Feb. 4, by House Feb. 17
water bill refunds" (Livengood, Carah, Oosting)
February 5, 2016 Gov. Snyder announces that Shekter Smith/MDEQ, head of ODWMA, is fired
Sources
3/13/16
3/13/16
3/13/16
3/18/16
3/13/16
3/18/16
3/18/16
27
Date
February 10, 2016
February 10, 2016
February 10, 2016
February 11, 2016
February 11, 2016
February 12, 2016

February 12, 2016
February 12, 2016
February 12, 2016

February 14, 2016
February 15, 2016

February 15, 2016
February 16, 2016
February 16, 2016
February 16, 2016
February 16, 2016
February 17, 2016
Event
Reference Document
Mayor Weaver, Dr. Hanna-Attisha, Yanna Lambrinidou and others address House
MLive (Feb. 10, 2016): "Flint mayor, superintendent ask for short
Democratic Steering and Policy Committee in D.C. Gov. Snyder was invited but
and long-term water crisis help" (Acosta)
declined due to concurrent state budget proposal
U.S. House of Representatives passes H.R. 4470, which specifies notification
Act posted to congress.gov website
requirements for lead action level exceedances in public water systems
U.S. Small Business Administration opens Flint Business Recovery Center to aid
MLive (Feb. 10, 2016): "Help center opens for small businesses
entrepreneurs and business owners affected by Flint water crisis
impacted by Flint's water crisis" (Adams)
U.S. District Judge John Corbett O'Meara grants request by state attorneys to
withdraw from representing 7 MDEQ employees who are being sued over Flint
Detroit Free Press (Feb. 11, 2016): "AG's office freed from MDEQ
water crisis, due to conflict of interest. State lawyers noted the MDEQ employees workers in Flint water case" (Baldas)
will still get lawyers paid for by the state
Obama administration officials tell Democratic members of Congress they anticipate
providing a Medicaid expansion that will cover lead blood-level monitoring,
Detroit Free Press (Feb. 12, 2016): "Obama administration to offer
behavioral health services and nutritional support for children and pregnant women more benefits in Flint" (Spangler)
in Flint as a result of water crisis
Gov. Snyder calls U.S. House Oversight and Government Reform Committee chair Detroit Free Press (Feb. 27, 2016): "Snyder to testify before
Chaffetz to offer his testimony on Flint water crisis
Congress on Flint crisis" (Spangler, Dolan)
MDEQ announces plan to regularly test water from 400 Flint addresses for lead over
Detroit Free Press (Feb. 12, 2016): "Flint water tests to track
next 8 weeks; public should be able to track the results through a map of the sites
change in lead levels" (Allen)
on www.michigan.gov/flintwater
Department of Environmental Quality:Part 1 (381MB PDF) | Part 2
(206MB PDF) | Part 3 (185MB PDF) | Part 4 (227MB PDF)
Department of Technology, Management and Budget (2.38MB
State of Michigan activates website containing numerous e-mails related to Flint
PDF)
water crisis
Department of Health and Human Services (6.51MB PDF)
Department of Agriculture and Rural Development (33KB PDF)
Department of Treasury (12.5MB PDF)
Lawsuit is filed against LAN, alleging professional negligence in preparing Flint WTP NBC25 News (Feb. 12, 2016): "Engineering firm hired to fix Flint
for full-time operation
water plant now facing multi-million dollar lawsuit" (Moore)
Sources
3/18/16
www.congress.gov/bill/114th-congress/house-bill/4470/text
3/18/16
www.MLive.com/news/flint/index.ssf/2016/02/help_center_open
s_for_small_bu.html
3/19/16
crisis/2016/02/11/ags-office-freed-deq-workers-flint-water-
case/80257552/
3/19/16
crisis/2016/02/12/obama-administration-offer-more-benefits-
flint/80298130/
3/19/16
crisis/2016/02/12/snyder-wants-testify-congress-flint/80290232/
3/19/16
www.freep.com/story/news/local/michigan/2016/02/12/flint-
water-tests-track-lead-levels/80282428/
3/19/16
Links published in Detroit Free Press (Feb. 12, 2016): "State

releases trove of e-mails related to Flint water" (Egan):
crisis/2016/02/12/flint-water-crisis-emails/80278914/
3/19/16
nbc25news.com/news/local/engineering-firm-hired-to-fix-flint-
water-plant-now-facing-multi-million-dollar-lawsuit
Gov. Snyder asks for expanded Medicaid support for about 15,000 Flint residents in Detroit Free Press (Feb. 14, 2016): "Snyder asks for more Medicaid
crisis/2016/02/14/snyder-asks-more-medicaid-support-
the wake of Flint water crisis
support for Flint" (Bethencourt)
flint/80382696/
U.S. Surgeon General Vivek Murthy visits Flint and meets with 150 local doctors,
Detroit Free Press (Feb. 15, 2016): "U.S. surgeon general to Flint's
social workers and students; says "trusted voices" need to impart critical nutrition
crisis/2016/02/15/us-surgeon-general-flint-crisis-dr-vivek-
trusted voices: Speak up" (Allen)
and education to Flint residents
murthy/80431666/
NAACP announces it will invite "disruptive civil disobedience" in Flint if Gov. Snyder Detroit Free Press (Feb. 15, 2016): "NAACP threatens civil
does not produce a plan within 30 days for replacing the city's water pipes
disobedience over Flint pipes" (Allen)
crisis/2016/02/15/naacp-president-flint-outrage/80416032/
www.foodandwaterwatch.org/news/lessons-flint-and-price-water-
Food & Water Watch releases report showing Flint residents were being charged
Report posted to Food & Water Watch website
privatization
more for water than any other customers in the nation's 500 largest community
MLive (Feb. 16, 2016): "Flint water rates highest in country, study
www.MLive.com/news/flint/index.ssf/2016/02/flints_water_rates
water systems
claims" (Ridley)
_highest_in.html
Detroit Free Press publishes Google map of Flint homes that have tested with
dangerously high lead levels. "666 addresses with levels of more than 15 parts per Detroit Free Press (Feb. 16, 2016): "Flint map: See 666 homes
billion of lead found the water. That's out of 9,940 tests taken from September
where lead levels too high" (Allen)
crisis/2016/02/16/flint-lead-water-map/80445272/
through Feb. 13"
2-page report posted online
www.fas.org/sgp/crs/misc/IN10446.pdf
Congressional Research Service issues report stating EPA did not respond to Flint's
MLive (Feb. 18, 2016): "EPA didn't respond to Flint's water crisis as www.MLive.com/news/flint/index.ssf/2016/02/epa_didnt_respon
water crisis as soon as it could have
soon as it could have, report says" (Emery)
d_to_flints_wa.html
Governor's Office announces it has contracted with Rowe Professional Services to
MLive (Feb. 16, 2016): "Effort to replace lead water pipes
update a recent analysis of Flint's water pipes, beginning the work required to
underway in Flint" (Williams)
crisis/2016/02/16/lead-water-pipe-replacement-flint/80478866/
replace lead service lines.
Federal class action lawsuit is filed on behalf of Angela McIntosh and other Flint
PR Newswire (Feb. 17, 2016): "Class action law firm and personal www.prnewswire.com/news-releases/class-action-law-firm-and-
water crisis victims. While other lawsuits have been filed, no case has yet been
injury Super Lawyer filed lawsuit on behalf of thousands of Flint personal-injury-super-lawyer-filed-lawsuit-on-behalf-of-thousands-
granted class action status by any state or federal court
victims"
of-flint-victims-300221443.html
Accessed
www.MLive.com/news/flint/index.ssf/2016/02/flint_mayor_super
intendent_ask.html
3/19/16
3/19/16
3/19/16
3/19/16
3/19/16
3/19/16
3/19/16
3/19/16
3/19/16
28
Date
Event
Reference Document
RT.com (Feb. 18, 2016): "Flint water crisis: Mayor, governor spar
over timeline to replace lead pipes"
Mayor Weaver counters state lead replacement plan with Flint Fast Start Plan,
Detroit Free Press (Feb. 17, 2016): "State signs agreement for Flint
February 18, 2016 working with Lansing employees; Gov. Snyder announces grant of $2M to help with
pipe testing" (Dolan)
pipeline replacement
MLive (Feb. 18, 2016): "Flint gets $2 million from state to start
lead service water replacements" (Fonger)
U.S. DHHS Secretary Sylvia Burwell visits Flint; announces her agency will provide an MLive (Feb. 18, 2016): "Additional $500,000 in federal money to
February 18, 2016
additional $500,000 to help mitigate potential lead damage in Flint children
fight lead damage in Flint children" (Johnson)
Rev. Jesse Jackson's Rainbow PUSH Coalition and Concerned Pastors for Social
MLive (Feb. 19, 2016): "Flint water crisis march with Jesse Jackson
February 19, 2016
Action organize a march from Metropolitan Baptist Tabernacle to Flint WTP
draws thousands" (Acosta)
February 20, 2016
Mark Pollins/EPA sends letter to MDEQ and Flint officials saying they are not doing
Letter posted to EPA website
enough to comply with SDWA emergency order on lead contamination
Board of State Canvassers approves petition to recall Gov. Snyder over Flint water
crisis, submitted by David Bullock
Dr. Marty Kaufman/University of Michigan-Flint says in press conference that it is
still unknown what types of pipes are running to 13,000 properties in Flint. Thus far,
February 22, 2016
4,376 locations with lead pipes have been identified; records do not exist for more
than 10,000 properties
February 22, 2016
MLive (Feb. 22, 2016): "Petition to recall Gov. Rick Snyder over
Flint water crisis clears Michigan panel" (Lawler)
Sources
www.rt.com/usa/332817-flint-water-pipe-replacement-pfcs/
crisis/2016/02/17/state-agreement-flint-pipe-testing/80470524/
www.MLive.com/news/flint/index.ssf/2016/02/governor_says_2-
million_grant.html
www.MLive.com/news/flint/index.ssf/2016/02/us_department_o
f_health_announ.html
www.MLive.com/news/flint/index.ssf/2016/02/flint_water_crisis_
march_with.html
02/documents/epa_letter_to_mdeq_and_city_of_flint_w_attach
ments_2.19.16.pdf
www.MLive.com/news/index.ssf/2016/02/petition_to_recall_gov
_rick_sn.html#incart_river_index_topics
MLive (Feb. 22, 2016): "Work still needed to identify service lines www.MLive.com/news/flint/index.ssf/2016/02/work_still_needed
to 13,000 Flint properties" (Acosta)
_to_identify.html#incart_river_index_topics
MLive (Feb. 22, 2016): "Latest Flint water tests show 1 in 10 sites www.MLive.com/news/flint/index.ssf/2016/02/latest_flint_water
still exceed federal lead limit" (Fonger)
_testing_sho.html#incart_river_index_topics
Gov. Snyder announces his office will release e-mails his staff sent or received dating Detroit News (Feb. 22, 2016): "Snyder: Office will release staff
crisis/2016/02/22/snyder-office-release-staff-emails-flint-
back to 2011 re: Flint water supply switch and subsequent contamination
emails on Flint water" (Livengood)
water/80771952/
MLive (Feb. 22, 2016): "Six takeaways on Flint water crisis from
www.mlive.com/news/flint/index.ssf/2016/02/six_takeaways_on
Congressional delegation led by U.S. Rep. Dan Kildee, D-Flint Township, visits Flint
Congressional delegation" (Acosta)
_flint_water_c.html#incart_river_index_topics
Michigan CMO Wells announces MDHHS has requested Assessment of Chemical
CBS Detroit (Feb. 23, 2016): "Federal Officials To Probe Rashes
detroit.cbslocal.com/2016/02/23/federal-officials-to-probe-rashes-
Exposure from U.S. DHHS to assess skin rashes reported during Flint water crisis
Amid Flint Water Crisis" (AP)
amid-flint-water-crisis/
State lawmakers announce they have created a joint committee to begin formally MLive (Feb. 23, 2016): "Flint water crisis to get fresh probe by
www.MLive.com/news/flint/index.ssf/2016/02/state_lawmakers_
reviewing Flint's ongoing water crisis
state lawmakers" (Ridley)
form_committee.html#incart_story_package
Ruth Mott Foundation dedicates $1 million to go toward short- and long-term needs MLive (Feb. 24, 2016): "Ruth Mott Foundation gives $1M to aid in www.mlive.com/news/flint/index.ssf/2016/02/ruth_mott_founda
of Flint residents exposed to lead
Flint water crisis" (Adams)
tion_gives_1m.html#incart_river_index_topics
MLive (Feb. 26, 2016): "Gov. Snyder signs $30 million water relief www.mlive.com/news/flint/index.ssf/2016/02/snyder_signs_30_
Gov. Snyder signs $30 million bill to provide water bill relief for Flint residents
bill for Flint" (Johnson)
million_water.html
#JUSTICEFORFLINT benefit show is held at The Whiting in Flint, raising more than
MLive (Mar. 1, 2016): "Justice for Flint benefit show raises
www.mlive.com/news/flint/index.ssf/2016/03/justice_for_flint_b
$150,000 to benefit Flint residents
$156,000 for water crisis relief" (Acosta)
enefit_show.html
Accessed
3/19/16
3/19/16
3/19/16
3/19/16
3/19/16
3/19/16
February 22, 2016 MLive reports some test sites still exceed federal limit for lead in water
3/19/16
February 22, 2016
3/19/16
February 22, 2016

February 23, 2016
February 23, 2016
February 24, 2016
February 26, 2016
February 28, 2016
3/19/16
3/19/16
3/19/16
3/19/16
29
APPENDIX VI: Abbreviations and Acronyms

Abbreviation
ACLU
AG
AJPH
AWWA
CAC
CCT
CDC
CLPPP
Cu
DBPs
DEQ
DHHS
DNR
DPW
DWSD
EBLL
EFM
ELL
EM
EPA
FAQs
FOIA
FWATF
FWICC
GCBOH
GCDC
GCHD
GCMS
GFHC
GM
HMC
KWA
LAN
LCR
LSL
MCIR
MCL
MDCH
MDEQ
MDHHS
mgd
NAN

Definition
American Civil Liberties Union
Attorney General
American Journal of Public Health
American Water Works Association
Citizens Advisory Committee
Corrosion control treatment
Centers for Disease Control and Prevention
Childhood Lead Poisoning Prevention Program
Copper
Disinfection byproducts
Department of Environmental Quality
Department of Health and Human Services
Department of Natural Resources
City of Flint Department of Public Works
Detroit Water and Sewerage Department
Elevated blood lead level
Emergency financial manager
Elevated lead level
Emergency manager
U.S. Environmental Protection Agency
Frequently Asked Questions
Freedom of Information Act
Flint Water Interagency Coordinating Committee
GCHD Board of Health
Genesee County Drain Commission
Genesee County Health Department
Genesee County Medical Society
Greater Flint Health Coalition
General Motors
Hurley Medical Center
Karegnondi Water Authority
Lockwood, Andrews, & Newnam, Inc.
Lead Contaminant Rule
Lead service line
Michigan Care Improvement Registry
Maximum Contaminant Level
Michigan Department of Community Health
Michigan Department of Environmental Quality
Michigan Department of Health and Human Services
Million gallons per day
National Action Network

NDWAC
NRDC
OAG
OCCT
ODMWA
O&M
Pb
ppb
SDWA
TAC
TTHMs
TYJT
UAW
g/l
VT
WTP
National Drinking Water Advisory Council

National Resources Defense Council
Office of the Auditor General
Optimal Corrosion Control Treatment
Office of Drinking Water and Municipal Assistance
Operations and maintenance
Lead
Parts per billion
Safe Drinking Water Act
City of Flint/Veolia Technical Advisory Committee
Total trihalomethanes
Tucker, Young, Jackson, Tull Inc.
United Auto Workers Union
Micrograms per liter
Virginia Tech (Virginia Polytechnic Institute and State University
Water Treatment Plant

Final Flint Water Advisory Task Force Report 21march2016

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Final Flint Water Advisory Task Force Report 21march2016

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Flint Water Advisory Task Force

March 21, 2016

Flint Water Advisory Task Force

FLINT WATER ADVISORY TASK FORCEFINAL REPORT

FLINT WATER ADVISORY TASK FORCEFINAL REPORT

A Series of Government Failures

FLINT WATER ADVISORY TASK FORCEFINAL REPORT

FWATF Membership, Charge and Scope of Review

Roles of Government Entities in the Flint Water Crisis

FLINT WATER ADVISORY TASK FORCEFINAL REPORT

FLINT WATER ADVISORY TASK FORCEFINAL REPORT

FLINT WATER ADVISORY TASK FORCEFINAL REPORT

January 201610 have demonstrated that emergency operations can be deployed

FLINT WATER ADVISORY TASK FORCEFINAL REPORT

Findings of the Task Force

FLINT WATER ADVISORY TASK FORCEFINAL REPORT

FLINT WATER ADVISORY TASK FORCEFINAL REPORT

FLINT WATER ADVISORY TASK FORCEFINAL REPORT

FLINT WATER ADVISORY TASK FORCEFINAL REPORT

Recommendations of the Task Force

FLINT WATER ADVISORY TASK FORCEFINAL REPORT

FLINT WATER ADVISORY TASK FORCEFINAL REPORT

FLINT WATER ADVISORY TASK FORCEFINAL REPORT

Issues Presented by the Flint Water Crisis

FLINT WATER ADVISORY TASK FORCEFINAL REPORT

FLINT WATER ADVISORY TASK FORCEFINAL REPORT

FLINT WATER ADVISORY TASK FORCEFINAL REPORT

Summary Timeline of Key Events

FLINT WATER ADVISORY TASK FORCEFINAL REPORT

FLINT WATER ADVISORY TASK FORCEFINAL REPORT

FLINT WATER ADVISORY TASK FORCEFINAL REPORT

FLINT WATER ADVISORY TASK FORCEFINAL REPORT

FLINT WATER ADVISORY TASK FORCEFINAL REPORT

FLINT WATER ADVISORY TASK FORCEFINAL REPORT

42 U.S.C. 300f et seq., 1974

LCR Short-Term Revisions State Implementation Guidance-Final June 2008

FLINT WATER ADVISORY TASK FORCEFINAL REPORT

Public Health Context

FLINT WATER ADVISORY TASK FORCEFINAL REPORT

FLINT WATER ADVISORY TASK FORCEFINAL REPORT

FLINT WATER ADVISORY TASK FORCEFINAL REPORT

Roles of Government Entities in the Flint Water Crisis

Michigan Department of Environmental Quality (MDEQ)

FLINT WATER ADVISORY TASK FORCEFINAL REPORT

FLINT WATER ADVISORY TASK FORCEFINAL REPORT

FLINT WATER ADVISORY TASK FORCEFINAL REPORT

having to have corrosion control treatmenteven under MDEQs flawed

FLINT WATER ADVISORY TASK FORCEFINAL REPORT

Michigan Department of Health and Human Services (MDHHS)

FLINT WATER ADVISORY TASK FORCEFINAL REPORT

FLINT WATER ADVISORY TASK FORCEFINAL REPORT

FLINT WATER ADVISORY TASK FORCEFINAL REPORT

Cases of Legionella Infection

FLINT WATER ADVISORY TASK FORCEFINAL REPORT

FLINT WATER ADVISORY TASK FORCEFINAL REPORT

Michigan Governors Office

FLINT WATER ADVISORY TASK FORCEFINAL REPORT

FLINT WATER ADVISORY TASK FORCEFINAL REPORT

FLINT WATER ADVISORY TASK FORCEFINAL REPORT

FLINT WATER ADVISORY TASK FORCEFINAL REPORT

information. View informed opinionseven if critical of state governmentas an

State-Appointed Emergency Managers

Imposed under PA 72 of 1990.

FLINT WATER ADVISORY TASK FORCEFINAL REPORT