OFFICE OF INSPECTOR GENERAL

U.S. ENVIRONMENTAL PROTECTION AGENCY

CUSTOMER SERVICE ~ INTEGRITY ~ ACCOUNTABILITY

Ensuring clean and safe water

The EPA Needs to Fully
Address the OIG's
2018 Flint Water Crisis
Report Recommendations by
Improving Controls, Training,
and Risk Assessments

Report No. 22-P-0046	May 17, 2022


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Report Contributors: Debra Coffel

Michael D. Davis
Kathryn Hess
Juliana llieva
Heather Layne
Cara Lindsey
Renee McGhee-Lenart
DeTravion White

Abbreviations:

C.F.R.

Code of Federal Regulations

EPA

U.S. Environmental Protection Agency

LCR

Lead and Copper Rule

OECA

Office of Enforcement and Compliance Assurance

OIG

Office of Inspector General

OW

Office of Water

PWSS

Public Water System Supervision

RAV

Report a Violation

SDWA

Safe Drinking Water Act

U.S.C.

United States Code

Cover Image:

Water treatment plant, Flint, Michigan. (EPAOIG image)

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Office of Inspector General

U.S. Environmental Protection Agency

At a Glance

22-P-0046
May 17, 2022

Why We Did This Audit

The U.S. Environmental
Protection Agency's Office of
Inspector General conducted this
audit to determine whether the
EPA implemented agreed-upon
corrective actions in response to
OIG Report No. 18-P-0221.
Management Weaknesses
Delayed Response to Flint Water
Crisis, issued July 19, 2018, as
well as whether those actions
effectively addressed the
identified program deficiencies.

After Flint, Michigan, switched its
drinking water supply in
April 2014, inadequate treatment
of the water exposed residents to
lead. Due to EPA, state, and city
oversight lapses, this
contamination was not identified
or mitigated in a timely manner.
To improve the EPA's oversight
of state drinking water programs
and response to drinking water
emergencies, our 2018 report
issued nine recommendations:
five jointly to the Offices of Water
and Enforcement and
Compliance Assurance, one to
the Office of Water, and three to
EPA Region 5.

This audit supports EPA
mission-related efforts:

•	Ensuring clean and safe water.

•	Compliance with the law.

•	Operating efficiently and
effectively.

This audit addresses a top EPA
management challenge:

•	Integrating and leading
environmental justice, including
communicating risks.

Address inquiries to our public
affairs office at (202) 566-2391 or
OIG WEBCOMMENTS@epa.gov.

List of OIG reports.

The EPA Needs to Fully Address the OIG's 2018 Flint
Water Crisis Report Recommendations by Improving
Controls, Training, and Risk Assessments

What We Found

The EPA certified that it completed corrective
actions to address all nine recommendations
issued in our 2018 report. However, the EPA's
corrective actions for three recommendations—

Recommendations 1, 6, and 8—did not fully
address the identified deficiencies in oversight.

Specifically:

•	The Office of Water did not establish controls to require that states are
monitoring water system compliance with all Lead and Copper Rule
requirements.

•	The Office of Enforcement and Compliance Assurance could not confirm
who received training on Safe Drinking Water Act tools and authorities.

•	The Office of Enforcement and Compliance Assurance did not incorporate
functions into its Report a Violation system to assess risks associated with
citizen tips and to track resolution of these tips.

The Safe Drinking Water Act gives the EPA emergency authority to act when a
contaminant may present an "imminent and substantial endangerment" to
human health and when the appropriate state and local authorities have not
acted to protect the public. Because the EPA did not fully implement corrective
actions addressing the 2018 OIG report, residents whose homes are served by
lead service lines may continue to be exposed to lead in drinking water, EPA
personnel may not be familiar with how to employ Safe Drinking Water Act tools
and authorities, and citizens' tips may not be effectively monitored and used to
alert the EPA of public health concerns.

Recommendations and Planned Agency Corrective Actions

In response to this follow-up audit, the Office of Water began requiring EPA
regions to annually review whether states monitor water system compliance
with the Lead and Copper Rule. We therefore consider the corrective action for
Recommendation 1 of our 2018 report complete. To fully address
Recommendations 6 and 8 of our 2018 report, we make two recommendations
for the assistant administrator for Enforcement and Compliance Assurance to
document Safe Drinking Water Act training attendance and to enhance the
Report a Violation system to assess and track citizen tips. The EPA agreed with
the training recommendation, which is resolved with corrective actions pending.
Based on the Agency's response to our draft report, we revised the
recommendation related to the Report a Violation system; that recommendation
is unresolved with resolution efforts in progress. Where appropriate, we revised
the report based on technical comments provided by the EPA.

Without complete
oversight of the drinking
water program, the public's
health is still at risk from
lead in drinking water.


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UNITED STATES ENVIRONMENTAL PROTECTION AGENCY

WASHINGTON, D.C. 20460

THE INSPECTOR GENERAL

May 17, 2022

MEMORANDUM

SUBJECT: The EPA Needs to Fully Address the OIG's 2018 Flint Water Crisis Report
Recommendations by Improving Controls, Training, and Risk Assessments
Renort No 22-P-0046

FROM:

TO:

Lawrence Starfield, Acting Assistant Administrator
Office of Enforcement and Compliance Assurance

RadhikaFox, Assistant Administrator
Office of Water

This is our report on the subject audit conducted by the Office of Inspector General of the
U.S. Environmental Protection Agency. The project number for this audit was OA-FY21-Q123. This
report contains findings that describe the problems the OIG has identified and corrective actions the OIG
recommends. Final determinations on matters in this report will be made by EPA managers in accordance
with established audit resolution procedures.

The EPA's Office of Enforcement and Compliance Assurance and Office of Water are responsible for the
issues discussed in the report. However, this report issued recommendations to only the Office of
Enforcement and Compliance Assurance. In accordance with EPA Manual 2750, the Office of
Enforcement and Compliance Assurance provided acceptable corrective actions and estimated milestone
dates for Recommendation 1. This recommendation is resolved.

Action Required

Recommendation 2 is unresolved. The resolution process, as described in the EPA's Audit Management
Procedures, begins immediately with the issuance of this report. Furthermore, we request a written
response to the final report within 60 days of this memorandum. Your response will be posted on the
OIG's website, along with our memorandum commenting on your response. Your response should be
provided as an Adobe PDF file that complies with the accessibility requirements of Section 508 of the
Rehabilitation Act of 1973, as amended. The final response should not contain data that you do not want
to be released to the public; if your response contains such data, you should identify the data for redaction
or removal along with corresponding justification.

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


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The EPA Needs to Fully Address the OIG's 2018 Flint
Water Crisis Report Recommendations by
Improving Controls, Training, and Risk Assessments

22-P-0046

Table of C

Chapters

1	Introduction	1

Purpose	1

Background	1

Responsible Offices	4

Scope and Methodology	5

Prior Report	6

2	The OW Did Not Establish Controls to Require that States Monitor Compliance

with the LCR	7

LCR Requirements and 2018 Report Recommendation 1	7

The OW's Corrective Action Did Not Fully Address the 2018 Report Recommendation 1	7

Lack of Capacity Hinders the EPA's Oversight	9

Continued Health Risks and Exposure to Lead in Drinking Water	9

2021 OW Action	9

Agency Response and OIG Assessment	10

3	OECA Could Not Confirm Who Received Training on SDWA Tools and Authorities	11

SDWA Training and 2018 Report Recommendation 6	11

The OIG Could Not Determine Whether OECA's Corrective Actions Fully Addressed

2018 Report Recommendation 6	11

Proper Oversight and Monitoring Prevents and Detects Risks to Public Health

and the Environment	13

Recommendation	13

Agency Response and OIG Assessment	13

4	OECA Did Not Develop System to Assess Risk and Track Resolution of Citizen Tips	14

Citizen Tips About Public Health Concerns and 2018 Report Recommendation 8	14

The EPA Did Not Fully Address 2018 Report Recommendation 8	14

Public Concerns Alert the EPA to Risks	16

Recommendation	16

Agency Response and OIG Assessment	16

Status of Recommendations	17

Appendixes

A OIG Evaluation of the EPA's Actions in Response to OIG Report No. 18-P-0221	18

B Agency Response to Draft Report	23

C Distribution	26


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Chapter 1

Introduction

Purpose

The U.S. Environmental Protection Agency's Office of inspector General initiated this follow-up audit to
EPA OIG Report No. 18-P-0221. Management Weaknesses Delayed Response to Flint Water Crisis, issued
on July 19, 2018, to determine whether the:

•	EPA implemented corrective actions to close the resolved recommendations.

•	Corrective actions taken effectively addressed the identified program deficiencies.

Top Management Challenge Addressed

This audit addresses the following top management challenge for the Agency, as identified in OIG Report
No, 22-N-0004. EPA's Fiscal Year 2022 Top Management Challenges, issued November 12, 2021:

• integrating and leading environmental justice, including communicating risks.

Background

In April 2014, the water system for Flint, Michigan, which serves drinking water to a population of nearly
100,000 residents, switched from purchasing treated water from the Detroit Water and Sewerage
Department to sourcing its water supply from the Flint River. The City of Flint's process for treating
water from the river did not include a method to prevent
corrosion of lead-containing components in the
water-distribution system, which allowed lead to begin
leaching into drinking water. After the source switch, Flint
residents began reporting issues with the quality of their
water.

Safe Drinking Water Act

The Safe Drinking Water Act, or SDWA, as amended,

42 U.S.C. § 300f et seq., gives the EPA administrator the
authority to protect public health by setting and enforcing
drinking water regulations. These regulations are codified at 40 C.F.R. parts 141-143. The EPA, states,
territories, tribes,1 and water systems work together to ensure that water systems comply with these
regulations. Under SDWA, the EPA has issued regulations that address more than 90 contaminants,
including lead, and set legally enforceable standards and treatment techniques that limit contaminant
levels in drinking water. The EPA also provides the public with information about drinking water, collects
drinking water data, and oversees state drinking water programs.

Flint River, Flint, Michigan. (EPA image)

1 Hereafter, we use the term state to refer to state, territory, and tribe when discussing delegated authority.
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SDWA allows the EPA to grant primacy to states that meet certain requirements. Primacy states have
the primary authority to implement and enforce federal SDWA regulations. To be granted primacy, a
state must show it will adopt standards that are at least as stringent as the EPA's standards and ensure
that its water systems meet those standards. The designated agency within each primacy state, also
known as the primacy agency:

•	Ensures water systems test for contaminants.

•	Reviews plans for water system improvements.

•	Conducts on-site inspections and sanitary surveys.

•	Provides training and technical assistance.

•	Takes action against water systems that do not meet the standards.

The EPA retains enforcement oversight authority to ensure that primacy agencies and water systems
comply with SDWA. Section 1414 of SDWA gives the Agency the authority to issue an administrative
order to or commence a civil action against a water system that does not comply with applicable
requirements if, after 30 days of notifying the state, the state does not act. Section 1431 of SDWA gives
the EPA emergency authority to act when a contaminant may present an "imminent and substantial
endangerment" to human health and the appropriate authorities have not acted to protect the public.

In addition to oversight, the EPA assists primacy agencies in implementing SDWA by providing grants
that help primacy agencies develop and implement state-level Public Water System Supervision, or
PWSS, Programs that adequately enforce the requirements of SDWA and ensure their water systems
comply with SDWA regulations.

SDWA Regulations for Lead in Drinking Water

SDWA regulations for lead—which are known as the "Lead and Copper Rule," or LCR, and are found at
40 C.F.R. part 141, subpart I—set treatment techniques for lead in drinking water. The EPA originally
established the LCR in 1991 to protect public health and reduce
exposure to lead in drinking water. Lead enters drinking water mainly
from the corrosion of lead-containing components in the
water-distribution system. The EPA estimates that drinking water can
make up 20 percent or more of a person's total exposure to lead. The
EPA established a goal of no lead in drinking water.

Instead of setting an enforceable maximum contaminant level for lead,
the LCR established an action level and complex sampling requirements
that are intended to protect the public from exposure to lead in
drinking water.2 The LCR requires all large water systems, as well as
small- and medium-size water systems with amounts of lead in their
water that exceed the action level, to regularly monitor for changes in

lead concentration. This requires the water systems to identify targeted sampling sites, such as
single-family homes, that are served by lead service lines. The highest-priority sampling sites are

2 The LCR requires water systems to take action when the level of lead in the drinking water exceeds the action
level of 15 micrograms per liter.

Health Effects of Lead

Lead has acute (short-term) and
chronic (long-term) impacts on
the body. Exposure to lead is
known to present serious health
risks to the brains and nervous
systems of children. Lead
exposure also causes damage to
the brain and kidneys. In
addition, lead exposure can
interfere with the production of
red blood cells, which carry
oxygen to all parts of the body.

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identified as Tier 1 sampling sites. Water systems must have the expertise and resources to accurately
identify sampling locations and to correctly collect and analyze the water samples.

The LCR also requires water systems to optimize corrosion control, which is a treatment method used to
minimize the amount of lead leaching from components within the distribution system into the drinking
water. If the amount of lead in the water exceeds the action level, the water system is required to
optimize and maintain continuous corrosion-control treatment. The LCR does not prescribe specific
corrosion-control treatments. Instead, the LCR provides a range of methods that water systems can use.

In 2021, the EPA revised the LCR to strengthen the rule and further reduce public exposure to lead in
drinking water. According to the revised LCR, implementation of the revisions will better identify when
and where lead contamination occurs or has the potential to occur. The LCR revisions require water
systems to take actions to address lead contamination more effectively and sooner than under the
previous rule, to follow improved sampling procedures, to replace lead service lines, and to identify
distribution system materials.

The OIG Identified Deficiencies That Contributed to the Flint Water Crisis and
Issued Recommendations for Improvement

In 2018, EPA OIG Report No. 18-P-0221. Management Weaknesses Delayed Response to Flint Water
Crisis, reported that the City of Flint did not adhere to LCR requirements to identify and maintain
sampling sites and to install and maintain continuous corrosion-control treatment throughout its
water-distribution system. We also identified deficiencies in the EPA's oversight of state drinking water
programs, as well as in the EPA's response to drinking water contamination emergencies. In addition, we
found that staff and managers in EPA Region 5—which oversees the PWSS Program in Michigan, as well
as in Illinois, Indiana, Minnesota, Ohio, and Wisconsin—did not establish clear roles and responsibilities
for the oversight and monitoring of Michigan's PWSS Program.

Our 2018 report made nine recommendations: five issued jointly to the EPA's Office of Water, or OW,
and the EPA's Office of Enforcement and Compliance Assurance, or OECA; one issued to the OW; and
three issued to EPA Region 5.3 Beginning on December 21, 2018, the Agency issued three separate
certification memorandums to the chief financial officer certifying that it had completed corrective
actions to address all nine recommendations.4 However, as we discuss in Chapters 2, 3, and 4 of this
follow-up report, the Agency's corrective actions did not fully address the following three 2018
recommendations:

• Recommendation 1: The EPA should "[establish controls to annually verify that states are
monitoring compliance with all Lead and Copper Rule requirements, including accurately
identifying tier 1 sampling sites and maintaining continuous corrosion control treatment."

3	For eight recommendations, the Agency proposed acceptable corrective actions before we issued our final
report, and we recorded these recommendations as resolved. Recommendation 1 remained unresolved when the
report was issued, but the Agency subsequently proposed an acceptable corrective action in a November 13, 2018
memorandum. We recorded our agreement with this corrective action in a December 7, 2018 memorandum.

4	The certification memorandum from the OW, dated July 7, 2021, addressed Recommendations 1, 2, and 6-8; the
certification memorandum from OECA, dated December 10, 2020, addressed Recommendations 6 and 9; and the
certification memorandum from Region 5, dated December 21, 2018, addressed Recommendations 3-5.

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•	Recommendation 6: The EPA should "[pjrovide regular training for EPA drinking water staff,
managers and senior leaders on Safe Drinking Water Act tools and authorities; state and agency
roles and responsibilities; and any Safe Drinking Water Act amendments or Lead and Copper
Rule revisions."

•	Recommendation 8: The EPA should "[c]reate a system that tracks citizen complaints and
gathers information on emerging issues. The system should assess the risk associated with the
complaints, including efficient and effective resolution."

We disagree that the Agency completed the corrective actions for these three recommendations, and
the Agency should not have closed these recommendations in its audit tracking system.

Appendix A details the recommendations from the 2018 report, summarizes the EPA's proposed
corrective actions, and provides our analysis of the EPA's actions taken in response to the nine resolved
recommendations.

Michigan Residents Continue to Be Exposed to Excessive Levels of Lead in
Drinking Water

The residents of the City of Flint are not the only Michigan residents who have been exposed to
excessive levels of lead in drinking water. The City of Benton Harbor's water system, which serves nearly
10,000 residents, has had levels of lead in its drinking water that exceeded the action level. As of 2021,
these excessive levels had persisted for three years, since 2018. On September 9, 2021, a petition for
emergency action was submitted to the EPA on behalf of Benton Harbor residents. On September 30,
2021, the State of Michigan began providing free bottled water and distributing water filters to Benton
Harbor residents. These efforts were followed by other actions to protect residents, including:

•	Blood testing for lead.

•	Services to find and remove lead hazards from homes.

•	Water deliveries to students, teachers, and support staff in schools.

•	Water deliveries to residents in multifamily dwellings.

In a joint, multiday inspection in September 2021, the EPA and the State of Michigan identified multiple
violations of drinking water regulations. On November 2, 2021, using its authority under section 1414 of
SDWA, EPA Region 5 issued an administrative order requiring that the City of Benton Harbor address
these violations.

In a separate audit, we are determining the extent to which the EPA followed its 2016 elevation policy
memorandum, Policy on Elevation of Critical Public Health Issues, when responding to evidence of
drinking water lead contamination in the water system for the City of Benton Harbor.

Responsible Offices

OECA works with EPA regional offices and in partnership with state governments and other federal
agencies to enforce the nation's environmental laws.

The OW works with EPA regional offices, other federal agencies, state and local governments, the
regulated community, organized professional and interest groups, landowners and managers, and the

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public at large to implement federal laws, such as SDWA. The OW also provides guidance, performs
oversight, and facilitates communication among those involved in implementing laws and regulations.

Scope and Methodology

We conducted this performance audit from February 2021 to February 2022 in accordance with
generally accepted government auditing standards. Those standards require that we plan and perform
the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings and
conclusions based on our audit objective. We believe that the evidence obtained provides a reasonable
basis for our findings and conclusions based on our audit objective.

We assessed the internal controls necessary to satisfy our audit objective.5 In particular, we assessed
the internal control components—as outlined in the U.S. Government Accountability Office's Green
Book—significant to our audit objective. Any internal control deficiencies we found are discussed in this
report.

To verify whether the Agency completed the agreed-to corrective actions in response to OIG Report
No. 18-P-0221. we obtained an understanding of the deficiencies identified in the 2018 report and
reviewed the report's recommendations; the Agency's proposed corrective actions; information from
the Agency's Enterprise Audit Management System, which is the EPA's audit tracking system; and the
Agency's memorandums certifying the corrective actions as completed.

To determine whether the Agency's corrective actions effectively addressed the deficiencies identified
in our 2018 report, we interviewed staff in OECA; the OW; Region 5; the Office of Congressional and
Intergovernmental Relations; and the Michigan Department of Environment, Great Lakes, and Energy,
formerly known as the Department of Environment Quality. In addition, we reviewed applicable criteria
relating to the nine recommendations issued in the 2018 OIG report. We also:

•	Analyzed the requirements in SDWA and relevant regulations.

•	Determined to what extent the OW revised its annual PWSS Program review protocols for EPA
regions to verify that states are monitoring water system implementation of LCR requirements,
including identifying Tier 1 sampling sites and maintaining continuous corrosion-control
treatment.

•	Analyzed the EPA regions' PWSS Program reviews to determine whether monitoring of LCR
requirements was included.

•	Assessed whether Michigan's PWSS Program review reports were publicly available.

•	Analyzed the Michigan Corrective Action Plan from the 2018 PWSS Program review to determine
to what extent Michigan was completing required activities.

5 An entity designs, implements, and operates internal controls to achieve its objectives related to operations,
reporting, and compliance. The U.S. Government Accountability Office sets internal control standards for federal
entities in GAO-14-704G, Standards for Internal Control in the Federal Government (also known as the "Green
Book"), issued September 10, 2014.

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•	Reviewed and compared recent Michigan work plans to determine whether roles and
responsibilities were clearly defined.

•	Analyzed data on the various Region 5 incentive awards by fiscal year, type, and number of
awards to determine to what extent awards were presented for human health and
environmental issues.

•	Reviewed OECA training materials to determine training topics and to verify that the training
events were conducted. Assessed training participation to determine whether senior leaders
were being trained.

•	Assessed the National Compliance Initiative strategy and determined how it addresses the
identification of risk for noncompliance.

•	Reviewed OECA's standard operating procedure for the Report a Violation, or RAV, system and
the OW's Protocol for Addressing Water Quality Concerns from the Public for the Safe Drinking
Water Hotline system to determine how these tools are used to receive citizen tips, assess risks,
and record resolutions.

•	Analyzed EPA administrators' electronic messages issued in 2016, 2017, 2018, and 2021 to all
EPA staff on the importance of elevating issues to determine whether the process for elevating
issues was clearly defined, whether effective communication existed, and the extent to which
the responses to elevated issues were timely and effective.

Prior Report

Before we issued Report No. 18-P-0221. we issued a management alert about the Flint water crisis,
which was Report No. 17-P-0004. Management Alert: Drinking Water Contamination in Flint, Michigan,
Demonstrates a Need to Clarify EPA Authority to Issue Emergency Orders to Protect the Public, issued
October 20, 2016. In that report, we recommended that OECA update the EPA's 1991 guidance on
section 1431 of SDWA. We also recommended that OECA require all relevant EPA drinking water and
water enforcement program management and staff to attend training on the section 1431 authority.
The Agency certified in August 2018 that all corrective actions were completed. Our follow-up audit did
not assess whether the Agency's completed corrective actions addressed the recommendations of the
2016 report.

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Chapter 2

The OW Did Not Establish Controls to Require
that States Monitor Compliance with the LCR

The corrective action that the OW implemented in response to Recommendation 1 of our 2018 report,
Report No. 18-P-0221, Management Weaknesses Delayed Response to Flint Water Crisis, did not fully
address the recommendation. Specifically, the OW's 2020 revision to its annual PWSS Program review
protocol—which EPA regions use to verify that states are monitoring water systems' compliance with
SDWA requirements—made regional oversight of LCR compliance optional. Unless the EPA can ascertain
that water systems are complying with all LCR
requirements, communities across the United States may
continue to be exposed to lead in drinking water.

In 2021, during the course of our follow-up audit, the OW
further revised its annual PWSS Program review protocol to
make regional oversight of LCR compliance mandatory and
to specifically address Tier 1 sampling sites and continuous
corrosion-control treatment. With these revisions, the OW has fully addressed Recommendation 1 of
our 2018 report, and we now agree that the corrective action is complete.

LCR Requirements and 2018 Report Recommendation 1

The LCR requires primacy agencies to monitor water systems to ensure that they are adhering to all LCR
requirements, including identifying Tier 1 sampling sites and maintaining continuous corrosion-control
treatment. As shown in the green box above, Recommendation 1 of our 2018 report said that the EPA
should establish controls to annually verify that states are monitoring whether water systems are
adhering to these requirements. This recommendation was unresolved when the final report was
published on July 19, 2018.

In a November 13, 2018 memorandum responding to the unresolved recommendation, the OW said that
it would revise its annual PWSS Program review protocol "as needed to verify that states are
implementing [LCR] requirements." In a December 7, 2018 memorandum to the OW, the OIG accepted
the OW's planned corrective action and changed the status of Recommendation 1 to resolved with
corrective actions pending. In response to our follow-up audit, the OW issued a July 7, 2021 certification
memorandum stating that the OW had completed the corrective action for Recommendation 1 by
implementing a revised protocol in 2020. The certification memorandum also said that each region
submits its annual PWSS Program review reports to the OW so that the OW can track the reviews.

The OW's Corrective Action Did Not Fully Address the 2018 Report
Recommendation 1

While the OW took corrective action to monitor state oversight of water systems' implementation of
LCR requirements, the action taken did not fully correct the deficiencies identified in our 2018 report.

OIG Report No. 18-P-0221: Recommendation 1

The EPA should "establish controls to annually
verify that states are monitoring compliance
with all Lead and Copper Rule requirements,
including accurately identifying tier 1 sampling
sites and maintaining continuous corrosion
control treatment."

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Specifically, the 2020 revision to the OW's PWSS Program review protocol did not make regional
oversight of LCR compliance mandatory.

In response to our 2018 report Recommendation 1, the Agency, through its Drinking Water Oversight
Workgroup, revised its annual PWSS Program review protocol that EPA regions use to assess the states'
PWSS Programs. The revised protocol, which was implemented in 2020, included a step addressing LCR
compliance. However, this step made the oversight optional, and it did not specifically include reviews
related to Tier 1 sampling sites or continuous corrosion-control treatment:

This review could [emphasis added] include a discussion of [LCR] implementation to
ensure that states are monitoring compliance with all LCR requirements, including
documenting systems out of compliance with the LCR.

The OW Believed the Corrective Action Addressed the 2018 Report
Recommendation 1

With the 2020 revision to its annual PWSS Program review protocol, the OW believed that it had
completed the corrective action for Recommendation 1 of our 2018 report. In the OW's July 7, 2021
certification memorandum to the EPA's chief financial officer, the OW said that the corrective action for
the recommendation was complete. Accordingly, the OW closed the recommendation in the Agency's
audit tracking system. To complete and close Recommendation 1 of our 2018 report, however, the
Agency needed to require—not suggest—that the EPA regions oversee whether states are monitoring
water system compliance with all LCR requirements. As such, in light of the 2020 revisions to the annual
PWSS Program review protocol, we considered the recommendation to be unimplemented, with
corrective actions pending.

Some Regions Proactiveiy Conducted LCR Oversight

Even though the 2020 revision to the annual PWSS Program review protocol made oversight optional
and did not specifically address the identification of Tier 1 sampling sites and maintenance of continuous
corrosion-control treatment, some EPA regions did proactiveiy monitor state oversight of LCR
requirements. We found that five (50 percent) of the EPA's ten regions specifically addressed Tier 1
sampling sites and four (40 percent) of the ten regions specifically addressed corrosion-control
treatment in their reviews of LCR implementation (Table 1).

Table 1: OIG analysis of regional PWSS Program reviews

Region

Selection of Tier 1 sampling sites

Monitoring for
corrosion-control treatment

1

~

~

2

~



3

~

V

4





5

~

V

6





7

~

~

8





9





10





Percent

50%

40%

Source: OIG analysis of regional PWSS Program review protocols. (EPA OIG table)

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Lack of Capacity Hinders the EPA's Oversight

In its response to our 2018 report, the EPA cited workload issues and a lack of state-level staffing as
impediments to comprehensive oversight. During our follow-up audit fieldwork, in an interview with
Agency water and enforcement managers, we were told that:

•	About 70,000 water systems are required to comply with the LCR.

•	Workloads were too heavy for the states to verify water systems' selection of Tier 1 sampling
sites and continuous corrosion-control treatment.

•	The EPA does not have the capacity to identify the Tier 1 sampling sites.

•	The EPA clearly communicated the continuous corrosion-control treatment requirements to the
states.

•	The EPA issued a memorandum to the states regarding how to identify Tier 1 sampling sites.

•	The EPA oversees state implementation of requirements through annual PWSS Program
reviews.

As discussed in the section above, however, fully implementing Recommendation 1 of our 2018 report
requires the Agency to review whether the states are monitoring water system compliance with the LCR
requirements, including accurately identifying Tier 1 sampling sites and maintaining corrosion-control
treatment. The OW, as part of its oversight role, should work with the EPA regions to ensure adequate
oversight.

Continued Health Risks and Exposure to Lead in Drinking Water

Until the EPA improves its oversight and can ascertain that water systems are complying with all LCR
requirements, communities across the United States may continue to be exposed to lead in drinking
water at levels that require action under the LCR. In our 2018 report, we identified that the
circumstances and response to Flint's drinking water contamination involved implementation and
oversight lapses at the EPA, state, and local levels. Oversight lapses resulted in infrastructure damage
and the prolonged exposure of Flint residents to lead in their drinking water. To prevent similar crises in
other communities, the EPA regions should conduct mandatory oversight of LCR requirements, including
the Tier 1 sampling and continuous corrosion-control treatment requirements.

2021 OW Action

On October 18, 2021, in response to our sharing our draft follow-up audit findings, the OW further
revised its PWSS Program review protocol. This revision clarified that each review must include oversight
of LCR requirements, including how the state is working with water systems to accurately identify Tier 1
sampling sites and maintain continuous corrosion-control treatment. The OW's revised protocol states:

This review must include a discussion of the state's approach to [LCR] implementation
to ensure that states are monitoring compliance with all LCR requirements. ... This
review must include, but is not limited to, the following, how the state is working with

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systems to accurately identifying Tier 1 sampling sites and maintaining continuous
corrosion control, [emphases added]

This 2021 revision to the PWSS Program review protocol is responsive to Recommendation 1 of our
2018 report. With this revision to the protocol, we consider the corrective action for the
recommendation to be completed and the recommendation appropriately listed as closed in the
Agency's audit tracking system.

Agency Response and OIG Assessment

The Agency provided a response to our draft report. Where appropriate, we revised the report based
technical comments provided by the EPA. Appendix B contains the Agency's response to the draft
report.

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Chapter 3

OECA Could Not Confirm Who Received
Training on SDWA Tools and Authorities

OECA could not demonstrate that it fully addressed Recommendation 6 of our 2018 report, Report
No. 18-P-0221, Management Weaknesses Delayed Response to Flint Water Crisis. While OECA provided
training on SDWA tools and authorities, it did not track
who attended the training. We, therefore, could not
determine whether "drinking water staff, managers, and
senior leaders" attended the trainings in accordance with
the recommendation. Public health is not best protected
when the EPA's drinking water program and enforcement
staff, managers, and senior leaders do not appropriately
use or are not trained on the EPA's oversight and
enforcement authorities, such as SDWA's emergency powers under section 1431 and the enforcement
of drinking water regulations under section 1414. If EPA employees are not aware of available SDWA
tools and authorities, the EPA is at risk of not effectively responding to protect public health when an
imminent and substantial endangerment to human health exists. In response to our follow-up audit
findings, OECA tracked attendance for SDWA training held in 2021 and found that only one of the four
invited senior leaders attended.

SDWA Training and 2018 Report Recommendation 6

Educating the EPA's drinking water program and enforcement staff, managers, and senior leaders on
SDWA tools and authorities best equips them to:

•	Verify that primacy agencies are implementing SDWA requirements.

•	Act if the state does not when an imminent threat to public health exists.

In our 2018 report, we determined that Region 5 did not use SDWA tools and authorities at its disposal
to require water system compliance during the Flint water crisis. As such, and as shown in the green box
above, we issued Recommendation 6 to improve the EPA's SDWA training. To address this
recommendation, the EPA proposed providing regular training nationally about SDWA tools and
authorities, such as sections 1414 and 1431, and various drinking water regulations, including the LCR.
The EPA also said that it would make these trainings available to staff, managers, and senior leaders. In
our 2018 report, we accepted the planned corrective actions and recorded the recommendation as
resolved. In a certification memorandum dated December 10, 2020, OECA stated that it had completed
its corrective actions for Recommendation 6.

The OIG Could Not Determine Whether OECA's Corrective Actions
Fully Addressed 2018 Report Recommendation 6

Even though OECA provided SDWA training in response to Recommendation 6 of our 2018 report, the
office could not provide documentation of which employees attended these trainings. Because of the

OIG Report No. 18-P-0221: Recommendation 6

The EPA should "provide regular training for EPA
drinking water staff, managers and senior leaders
on Safe Drinking Water Act tools and authorities;
state and agency roles and responsibilities; and
any Safe Drinking Water Act amendments or Lead
and Copper Rule revisions."

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lack of attendance documentation, we were unable to determine whether the Agency's corrective
actions fully addressed the recommendation.

OECA Provided SDWA Training

Our analysis of SDWA training documents shows that OECA's May 7, 2020 training session provided
information on sections 1414 and 1431 tools and authorities; the OIG's 2016 management alert
regarding the Flint water crisis, Report No. 17-P-0004; and other pertinent topics (Table 2).

Table 2: OECA's May 7, 2020 SDWA training

Topic areas addressed

Background of EPA OIG Report No. 17-P-0004
OECA's updated guidance on SDWA section 1431

EPA administrators' electronic messages issued in 2016 and 2017 to EPA staff on the importance of elevating issues

Emergency administrative powers in the EPA's Delegations Manual, Chapters 9 through 17

Emergency orders in Indian Country

Penalties for failure to comply

SDWA section 1447, "Federal Agencies"

March 2013 memorandum, Language Regarding Judicial Review of Certain Administrative Enforcement Orders
Following the Supreme Court Decision in Sackett v. EPA

Guidance on developing administrative records for unilateral administrative enforcement orders
Emergency orders

OECA's points of contact for consultation

Source: OIG analysis of OECA's 2020 training slides. (EPA OIG table)

Because OECA Did Not Track Attendance, It Could Not Support Claims that
Corrective Actions Were Completed

Although OECA provided SDWA training that was responsive to Recommendation 6 of our 2018 report,
OECA could not provide documentation showing that "drinking water staff, managers and senior
leaders" attended the training. As such, we could not ascertain whether the Agency fully addressed the
recommendation.

In its December 10, 2020 certification memorandum addressing Recommendation 6, OECA stated that it
continues to hold regular SDWA trainings for staff and managers; it did not specifically mention senior
leaders. The certification memorandum did state that OECA conducts "consultations" with the regions
on specific potential emergency drinking water situations. We were told by an OECA manager that these
"consultations" can, but do not always, include senior leaders. In our opinion these "consultations" are
less formal than training and do not meet the part of Recommendation 6 that was intended to train
senior leaders.

During the course of our follow-up audit, OECA held a SDWA training on September 23, 2021, and
provided us with a list of the 139 employees who attended. Four senior leaders were invited, but only
one attended. All other attendees were staff or managers. OECA did not identify any invited attendees
as regional senior leaders.

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Proper Oversight and Monitoring Prevents and Detects Risks to
Public Health and the Environment

Public health is at greater risk if the EPA's staff, managers, and senior leaders are not fully aware of the
EPA's oversight and enforcement authorities. Awareness of SDWA tools and authorities, including SDWA
sections 1414 and 1431, best equips the EPA to readily employ these tools when an imminent and
substantial endangerment to human health exists.

Recommendation

We recommend that the assistant administrator for Enforcement and Compliance Assurance:

1. Document and monitor attendance at Safe Drinking Water Act training events to ensure the
appropriate staff members, managers, and senior leaders attend the training and are aware of
the EPA's oversight and enforcement tools and authorities, including sections 1414 and 1431 of
the Safe Drinking Water Act.

Agency Response and OIG Assessment

The Agency provided a response to our draft report. OECA agreed with Recommendation 1 and
proposed to document and monitor attendance by staff, managers, and senior leaders at SDWA
sections 1414 and 1431 trainings and to present information on the EPA's SDWA sections 1414 and 1431
oversight and enforcement tools and authorities to OECA's directors and regional counsels at their
annual meetings. The planned completion date is December 31, 2022. These corrective actions satisfy
our recommendation; therefore, Recommendation 1 is resolved with corrective actions pending.

Appendix B contains the Agency's response to the draft report.

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Chapter 4

OECA Did Not Develop System to Assess
Risk and Track Resolution of Citizen Tips

OECA did not complete actions to address Recommendation 8 of our 2018 report, Report No. 18-P-0221,
Management Weaknesses Delayed Response to Flint Water Crisis. In response to Recommendation 8,
the OW developed a Safe Drinking Water Hotline protocol that
includes risk assessment and resolution tracking, but the hotline
is not the only mechanism available to report drinking water
concerns. OECA's RAV system receives citizen tips on
environmental concerns regardless of media and can include
drinking water-related tips. However, the RAV system does not
assess the risks or track the resolution of the issues reported,
and OECA did not take action to incorporate these functions into
the system. Unless the EPA comprehensively assesses the risks and tracks resolution of issues reported
via citizen tips, the Agency's ability to proactively oversee public health issues in the regions and states is
impaired.

Citizen Tips About Public Health Concerns and 2018 Report
Recommendation 8

Citizen tips can serve as critical indicators to alert the Agency of water systems that could potentially be
in violation of drinking water regulations. One of the EPA's goals related to drinking water is to better
leverage stakeholder information to ensure timely identification and resolution of problems.
Recommendation 8 of our 2018 report, as shown in the green box above, aimed to improve how the
EPA uses information received through citizen tips. The recommendation was issued jointly to two
offices: the OW and OECA.

To address this recommendation, the EPA proposed to "identify potential enhancements to existing
systems and/or identify new system requirements that can support tracking of citizen complaints." In our
2018 report, we accepted this planned corrective action and recorded the recommendation as resolved
with corrective actions pending. According to its July 7, 2021 certification memorandum, to address this
recommendation, the OW developed a protocol to be used for tips received through the Safe Drinking
Water Hotline. However, in its December 10, 2020 certification memorandum, OECA only addressed
Recommendations 6 and 9; it did not mention any corrective action taken for Recommendation 8.

The EPA Did Not Fully Address 2018 Report Recommendation 8

The functionalities of the two systems that the EPA uses to gather citizen tips—OECA's RAV system and
the OW's Safe Drinking Water Hotline—differ in their capacity to manage citizens' concerns, as shown in
Table 3. Another difference between the systems is that OECA's RAV system is for reporting citizen
complaints regardless of media, whereas the OW's Safe Drinking Water Hotline is specifically for
reporting citizen complaints regarding drinking water. In our 2018 report, we recommended that OECA
and the OW create a system that tracks citizen complaints; we did not identify a specific media. We

OIG Report No. 18-P-0221:
Recommendation 8

The OW and OECA should "create a
system that tracks citizen complaints and
gathers information on emerging issues.
The system should assess the risk
associated with the complaints, including
efficient and effective resolution."

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found that the OW's revised protocol is responsive to Recommendation 8 of our 2018 report. However,
OECA did not take corrective actions to address Recommendation 8.

Table 3: Functionalities of the two systems used to gather citizen tips

Function

OECA's RAV system

The OW's Safe Drinking
Water Hotline

Has standard operation procedure or process steps

y

y

Differentiates between civil and criminal violations

y



Allows images, media, and audio to be attached to complaint

y



Assesses the risks associated with potential violations



y*

Tracks resolution of tips submitted



y**

Communicates resolution to those who provided tips



y

Tracks the locations or areas of potential violations

y



Has an information-filtering system

y



Tracks and stores tips about specific water issues

y

y**

Filters tips arising from same locations or areas

y

y**

Produces reports of potential violations

y



Source: OIG analysis of the functionality of OECA's RAV system and the OW's Safe Drinking Water Hotline.
(EPA OIG table)

* EPA employees assess the concern presented.

** Email folders are used to track and manage issues.

The OW's Hotline Protocol Is Responsive to Recommendation 8

The OW's Safe Drinking Water Hotline allows the public to submit tips and concerns about drinking
water via an online form, which is routed to an electronic mailbox that EPA staff members manage. In
2019, in response to Recommendation 8 of our 2018 report, the OW developed its Protocol for
Addressing Water Quality Concerns from the Public, which requires the OW to track public concerns
raised through the Safe Drinking Water Hotline system tips, to assess risks associated with the tips, and
to determine and record each tip's resolution.

The OW's protocol states that tips are to be sent to the appropriate EPA staff for follow up within "24 to
48 hours" of submission. A headquarters employee determines whether the tip can be addressed with
existing publicly available information or should be delegated to an EPA subject-matter expert, who
should then address the concern and communicate with the person who submitted the tip. An OW
manager told us that OW staff manage and assess the risk associated with each tip before forwarding it
to the appropriate subject-matter expert or region and that the electronic mailbox allows for staff to
track and manage information regarding tips received through the hotline. These OW corrective actions
were responsive to our 2018 report Recommendation 8.

OECA Did Not Take Corrective Action to Address Recommendation 8

OECA did not take action to address Recommendation 8 of our 2018 report and did not submit a
memorandum certifying that any corrective actions were completed for that recommendation. An OECA
manager told us that OECA assumed no further action was required since the OW completed corrective
actions in response to the recommendation. However, the effectiveness of OECA's RAV system is limited
because it does not assess the risk or track the resolution of tips. We thus consider Recommendation 8
of our 2018 report resolved but still open pending completion of corrective actions by OECA.

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OECA implemented the RAV system in January 2006. Upon receipt of a tip through the RAV system, the
EPA either refers it to another entity, such as a state, or retains it for action. For retained tips, the EPA
assesses whether tips submitted via this system are criminal or civil in nature and then routes them to
the appropriate program office or region. The RAV coordinator can track to
whom an issue was referred, and RAV system operators can review and refer
incoming tips, prepare and print reports, open or close cases, and report tips to
Congress. But there is no functionality to assess the risks or track the
resolutions of tips.

In responding to the OIG's draft 2018 report, the assistant administrators for
Enforcement and Compliance Assurance and for Water stated that the "EPA
could use the RAV as the foundation of an improved system that captures
citizen reports and sorts them into ranked categories to facilitate identification of management risks that
require EPA response." OECA did make enhancements to the RAV tool, such as increasing the visibility of
the tool and adding the ability to submit photographs and video files. However, these enhancements did
not add the functionality to assess risks associated with and track resolutions of tips, as recommended in
our 2018 report.

Public Concerns Alert the EPA to Risks

Citizens' concerns can serve as critical indicators of emerging problems. Assessing citizen tips allows the
Agency to identify patterns, irregularities, and trends more efficiently. Through improved assessment of
risks associated with tips and better resolution of tips, the Agency can improve oversight and its efforts to
protect public health. Given the large number of water systems in the country that the EPA regions and
states must oversee, public health is at risk if the EPA does not adequately consider indicators of dangers,
such as citizen tips.

Recommendation

We recommend that the assistant administrator for Enforcement and Compliance Assurance:

2. Incorporate controls into the Report a Violation system to assess the risks associated with tips
retained by the EPA and to track when and how the retained tips are resolved.

Agency Response and OIG Assessment

The Agency provided a response to our draft report (Appendix B). In that response, OECA disagreed with
Recommendation 2. OECA stated that it "does not have the resources to prepare an assessment of the
risk associated with each tip and complaint [OECA receives] through the system and track when
resolution is achieved." OECA stated that the RAV system has been used "to gather citizen tips and
complaints on possible noncompliance issues - large and small - regardless of the media." In its
response, OECA also reported that the RAV system receives 14,000 tips per year, a large number of which
are referred to the states. In response to these comments, we revised Recommendation 2 to give the EPA
flexibility to assess the risks of only those tips that the EPA retains for action. We maintain that assessing
the risks and resolutions of tips reported in the RAV system is critical to the EPA's mission to protect
public health and the environment. Recommendation 2 is unresolved with resolution efforts in progress.

Environmental
Violations

The EPA's RAV system
logo. (EPA image)

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Status of Recommendations

RECOMMENDATIONS











Planned

Rec.

Page







Completion

No.

No.

Subject

Status1

Action Official

Date

13 Document and monitor attendance at Safe Drinking Water Act
training events to ensure the appropriate staff members,
managers, and senior leaders attend the training and are aware
of the EPA's oversight and enforcement tools and authorities,
including sections 1414 and 1431 of the Safe Drinking Water
Act.

Assistant Administrator for

Enforcement and
Compliance Assurance

12/31/22

16 Incorporate controls into the Report a Violation system to assess
the risks associated with tips retained by the EPA and to track
when and how the retained tips are resolved.

Assistant Administrator for

Enforcement and
Compliance Assurance

1 C = Corrective action completed.

R = Recommendation resolved with corrective action pending.
U = Recommendation unresolved with resolution efforts in progress.

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Appendix A

OIG Evaluation of the EPA's Actions
in Response to 01G Report No. 18-P-0221

Recommendation 1:

Text of

recommendation

Establish controls to annually verify that states are monitoring compliance with all Lead and Copper Rule
requirements, including accurately identifying tier 1 sampling sites and maintaining continuous corrosion
control treatment.

Issued to

Assistant Administrator for Enforcement and Compliance Assurance and Assistant Administrator for Water

OIG finding
leading to
recommendation

The City of Flint did not develop or maintain accurate records of lead service line locations to identify Tier 1
sampling sites. Primacy states, such as the State of Michigan, must require water systems to collect and
maintain lead service line information in accordance with the LCR. Without this information, the City of Flint
could not prioritize its sampling efforts to collect water samples where higher levels of lead contamination
were most likely to occur, which is required by the LCR. See Recommendation 2 of our 2018 report for more
information on maintaining continuous corrosion-control treatment.

Agency-proposed
corrective action

In December 2018, the EPA will hold a meeting with the regional branch chiefs to review and update the
protocol used for the fiscal year 2018 annual PWSS Program reviews. As part of this review, the EPA will
amend the PWSS Program review protocol as needed to verify that states are implementing LCR
requirements. The changes made will be implemented in the fiscal year 2019 and future annual program
reviews.

Agency action

According to the OWs certification memorandum dated July 7, 2021, the OW took the lead in addressing
the recommendation. The effort to update the State Drinking Water Annual Program Evaluation protocol to
explicitly include the LCR was first discussed during the June 12, 2018 Drinking Water Oversight
Workgroup call. On December 17, 2018, the Drinking Water Oversight Workgroup finalized the updates to
the protocol. Starting in fiscal year 2020, completion of the annual program reviews was added as a
Bowling Chart Measure that is tracked nationally.

OIG assessment
of Agency action

COMPLETED. The actions taken by the OW prior to its July 7, 2021 certification memorandum did not fully
correct the identified deficiencies because the State Drinking Water Annual Program Evaluation protocol
did not make regional oversight mandatory, nor did the protocol specifically address the identification of
Tier 1 sampling sites and maintenance of continuous corrosion-control treatment. In response to this
follow-up audit, on October 18, 2021, the OW revised its protocol to fully address the recommendation.
Further details are discussed in Chapter 2 of our follow-up report.

Recommendation 2:

Text of

recommendation

Revise the Lead and Copper Rule to improve the effectiveness of monitoring corrosion control treatment
protocols.

Issued to

Assistant Administrator for Water

OIG finding
leading to
recommendation

According to EPA Region 5, the Michigan Department of Environmental Quality concluded that Flint's
change in source water would require Flint to revert to the LCR provision that required the water system to
conduct tests to determine whether corrosion-control treatment was necessary. Region 5 disagreed with
the department's interpretation. The LCR treats water systems, such as Flint's, that change their source
water or treatment as existing systems. Therefore, under the LCR, the city needed to maintain continuous
corrosion-control treatment.

Agency-proposed
corrective action

The Agency is evaluating input received from state, local, and tribal partners, as well as the best available
peer-reviewed science, to ensure the rule reflects the best ways to improve public health protection.

Agency action

According to the OWs certification memorandum dated July 7, 2021, the EPA is evaluating input from state
and local, partners, as well as the best available peer-reviewed science, to ensure the LCR reflects the
best ways to improve public health protection.

OIG assessment
of Agency action

COMPLETED. The OW finalized revisions to the LCR to improve the effectiveness of monitoring and
corrosion-control treatment protocol. However, implementation was delayed because of the change in
administration. The EPA extended the effective date of the revision to December 16, 2021, with a
compliance deadline of September 16, 2024.

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Recommendation 3:

Text of

recommendation

Publicly document clear expectations, roles and responsibilities between the EPA and the state of
Michigan in an official document, such as a memorandum of understanding or a supplemental primacy
document.

Issued to

Region 5 Regional Administrator

OIG finding
leading to
recommendation

The EPA retains the authority and responsibility to oversee states with primacy over their drinking water
programs. The EPA is empowered and required to intervene when states do not fulfill their obligations.
However, EPA Region 5 staff and managers did not establish the clear roles and responsibilities needed to
foster a constructive relationship with Michigan's drinking water program staff.

Agency-proposed
corrective action

Region 5 will document clear expectations, roles, and responsibilities between the region and each of its
states in the annual work plan for the PWSS Program grant. Region 5 will post the annual Michigan PWSS
Program work plan and end-of-year evaluation on the EPA's website so that the information is publicly
available.

Agency action

According to the Region 5 certification memorandum dated December 21, 2018, Region 5 publicly
documented on October 1, 2018, clear expectations, roles, and responsibilities for the EPA and the State
of Michigan in the PWSS Program annual work plan for Michigan's PWSS grant. On October 26, 2017,
Region 5 publicly posted on its website the final report documenting its review of Michigan's drinking water
program.

OIG assessment
of Agency action

COMPLETED. Region 5 publicly posted on its website the fiscal year 2020 work plan between the EPA
and Michigan for the PWSS Program grant, which outlined expectations, roles, and responsibilities. In
June 2021, the Michigan drinking water staff stated that the new work plan offers more clarity on what the
state should be doing under the grant, what the roles of the EPA are, and communication between the
state and Region 5.

Recommendation 4:

Text of

recommendation

Implement a system for regional drinking water staff, managers, and senior leaders that incentivizes staff
elevating and managers addressing important and emerging issues in accordance with the EPA's Policy on
Elevation of Critical Environmental and Public Health Issues.

Issued to

Region 5 Regional Administrator

OIG finding
leading to
recommendation

Communication weaknesses contributed to a delayed federal response in Flint. For effective oversight,
management needs accurate and complete information and clear communication. However,
the interaction between the EPA and the Michigan Department of Environmental Quality did not convey key
information about human health risks from lead contamination in Flint. Communication within the EPA was
also problematic.

Agency-proposed
corrective action

Within Region 5, staff are encouraged to participate and share concerns in a variety of meetings, including
team, section, branch, division, and regional meetings. These regular check-in meetings among managers
and staff allow information to flow from regional leaders down to staff and vice versa. Region 5 agrees to
incentivize staff, managers, and senior leaders to elevate and address issues of concern during these
engagement opportunities, including providing feedback during midyear and end-of-year reviews,
specifically on the customer service critical element present in all staff performance agreements. Region 5
will incentivize staff, management, and senior leadership to elevate and address important and emerging
issues, including the use of awards.

Agency action

According to the Region 5 certification memorandum dated December 21, 2018, Region 5's administrator
has been clear in all staff meetings that she actively encourages employees to meet with her on any issue,
including public or environmental issues. Region 5's Groundwater and Drinking Water Branch established
a public health protection recognition program that consists of a traveling trophy to be presented during a
branch meeting to a staff person who raised a public health or environmental concern. In 2018, Region 5
began implementing an internal peer-to-peer recognition program called "Shooting Star."

OIG assessment
of Agency action

COMPLETED. Region 5 implemented various systems and award programs to incentivize staff to elevate
important and emerging issues in accordance with the EPA's Policy on Elevation of Critical Environmental
and Public Health Issues. The Water Division director in Region 5 holds meetings during which employees
can raise any issue. Based on the examples provided, we determined that Region 5 has created incentives
for staff to elevate public health issues or environmental concerns to management.

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Recommendation 5:

Text of

recommendation

Provide the public with all results from EPA reviews of Michigan's Safe Drinking Water Act program and track
the progress of identified corrective actions.

Issued to

Region 5 Regional Administrator

OIG finding
leading to
recommendation

Region 5 did not use oversight and monitoring authorities and tools to influence the Michigan Department
of Environmental Quality.

Agency-proposed
corrective action

The 2010 and 2016 Michigan Drinking Water Program Review Reports are available on the EPA's
website. In addition, Region 5's fiscal years 2010-2016 End-of-Year Evaluation Reports for the State of
Michigan's PWSS Program are available to the public through the Freedom of Information Act online
website. Reaion 5 and the state are finalizina a corrective action Dlan that has been developed from the
recommendations in the 2016 Program Review Report, which Region 5 released in October 2017. Once
final and approved by Region 5, Region 5 will post the corrective action plan to the Agency's website and
provide progress updates on a quarterly basis. In addition, the Michigan corrective action plan will be
attached to the fiscal year 2018 and subsequent PWSS grant work plans, so that both state and EPA
commitments are clear. Frequent check-ins with the state are planned to ensure progress in implementing
the EPA's recommendations to strengthen Michigan's drinking water program.

Agency action

According to the Region 5 certification memorandum dated December 21, 2018, Region 5 posted on the
EPA's website the 2016 Michigan Drinking Water Program Review Report on October 26, 2017. In
addition, Region 5's fiscal years 2011-2016 End-of-Year Evaluation Reports for the State of Michigan's
PWSS Program are available through Freedom of Information Act online. Region 5 ensures that issues
found in previous data and enforcement program reviews of the state's PWSS implementation are included
in the following year's annual PWSS Program work plan and tracked for progress. Region 5 and the
Michigan Department of Environmental Quality are implementing a corrective action plan that has been
developed from the recommendations in the 2016 Program Review Report, which Region 5 released in
October 2017.

OIG assessment
of Agency action

COMPLETED. Region 5 published results on its website from EPA reviews of Michigan's SDWA program.
The corrective action plan for fiscal year 2018 in which the Agency tracked the progress of identified
corrective actions was also available online. Our comparison of the corrective action plan updates
determined that Region 5 tracked the progress of identified corrective actions, and ongoing activities are
carried forward in the next year's corrective action plan. Michigan has completed 78 percent of the
recommendations in the initial corrective action plan. Furthermore, Region 5 provided the Freedom of
Information Act link where end-of-year evaluations for the State of Michigan from fiscal years 2010 through
2016 are available.

Recommendation 6:

Text of

recommendation

Provide regular training for EPA drinking water staff, managers and senior leaders on Safe Drinking Water
Act tools and authorities; state and Agency roles and responsibilities; and any Safe Drinking Water Act
amendments or Lead and Copper Rule revisions.

Issued to

Assistant Administrator for Enforcement and Compliance Assurance and Assistant Administrator for Water

OIG finding
leading to
recommendation

Region 5 used several tools to oversee the Michigan Department of Environmental Quality's handling of
contamination in Flint. However, when those approaches did not result in swift action to protect public
health, Region 5 did not employ other SDWA authorities at its disposal to require compliance in Flint. Most
authorities were not used because regional managers did not recognize them or deem them appropriate.
Region 5 did not place additional conditions on the Michigan PWSS grant, even when issues were
identified.

Agency-proposed
corrective action

The EPA has provided and will continue to provide regular training nationally to staff and managers about
SDWA tools and authorities, such as sections 1414 and 1431, and various drinking water regulations,
including the LCR. The EPA will also make these trainings available to senior managers. As part of ongoing
Agency efforts to enhance national implementation of the LCR, the EPA has been providing training on the
rule's optimal corrosion-control treatment and optimal water-quality parameter requirements. The
workshops provide a review of LCR requirements and emphasize the tools and authorities drinking water
programs can leverage to implement the requirements more effectively. The training has been delivered
through in-person workshops at each of the EPA regions, as well as through special conference sessions.
Since the inaugural workshop in fiscal year 2016, the training has reached approximately 1,300 drinking
water professionals at the staff and managerial level from federal and state drinking water programs,
technical assistance providers, and water utilities.

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Agency action

According to OECA's certification memorandum dated December 10, 2020, OECA took the lead in
addressing the recommendation. OECA continues to hold regular SDWA training on sections 1414 and
1431 for staff and managers and to conduct consultations with the regions regarding specific potential
emergency drinking water situations. The presentations from the training events are available electronically
to EPA personnel on the internal National Drinking Water Enforcement site.

OIG assessment
of Agency action

DID NOT FULLY ADDRESS RECOMMENDATION. OECA's corrective action did not meet the intent of
Recommendation 6. The Agency provided training on SDWA sections 1414 and 1431 tools and authorities
to staff. However, the Agency was not able to provide documentation of which staff members, managers,
and senior leaders attended the training. During the course of our follow-up audit, a SDWA training was
held on September 23, 2021. OECA provided the OIG with a list of attendees. Further details are
discussed in Chapter 3 of this report.

Recommendation 7:

Text of

recommendation

Implement a system to identify management risks in state drinking water programs, including elements
such as atypical events, emerging public health concerns, environmental justice concerns and public
health analyses.

Issued to

Assistant Administrator for Enforcement and Compliance Assurance and Assistant Administrator for Water

OIG finding
leading to
recommendation

EPA Region 5 did not have effective risk-assessment processes that would have alerted the region to
growing issues in Flint. An effective risk-assessment system provides the basis for responding to threats
that impact human health.

Agency-proposed
corrective action

The EPA has initiated a workgroup with participation from OECA, the OW, and the regions. The workgroup
will explore how best to use drinking water data and measures to identify public water systems that present
or are likely to present significant risks to public health. The workgroup will develop procedures and
strategies to ensure timely and effective intervention where risks to public health are identified.

Agency action

According to the OWs certification memorandum dated July 7, 2021, the OW took the lead in addressing
the recommendation. The corrective action for this recommendation focuses on the EPA's annual reviews
of state drinking water programs. Since 2017, the OW has led a national oversight workgroup that has the
priority to refine the protocol for the EPA's State Drinking Water Annual Program Evaluation and the
contents of the reports. Since fiscal year 2020, one ofthe OWs measures has been the completion of
these reports for each primacy agency. The OW has reviewed all the fiscal year 2019 reports to understand
common challenges and to provide key best management practices. The EPA created and maintains a
workgroup with participation from OECA, the OW, and the regions. One area of focus for the workgroup is
determining how to best use drinking water data to identify public water systems that present significant
risk to public health.

OIG assessment
of Agency action

COMPLETED. OECA developed a National Compliance Initiative to work with the states to address
community water systems with known, ongoing noncompliance issues and to identify and address risks for
noncompliance at community water systems that may have gone unnoticed. In addition, the OW reviewed
PWSS Program annual reviews to verify that states are implementing the LCR. Based upon our review of
the meeting notes, we determined that the Agency identifies and discusses public water systems that
present risks to public health.

Recommendation 8:

Text of

recommendation

Create a system that tracks citizen complaints and gathers information on emerging issues. The system
should assess the risk associated with the complaints, including efficient and effective resolution.

Issued to

Assistant Administrator for Enforcement and Compliance Assurance and Assistant Administrator for Water

OIG finding
leading

to recommendatio
n

Some citizens interviewed expressed frustration at the lack of resolution of their tips by Region 5. Staff and
managers in Region 5 did not have a system for cataloging and responding to citizen tips, nor did they use
citizen tips or the volume of calls as indicators of problems with Flint's water system. As a result, Region 5
could not assess the severity of the situation, and staff were not able to alert management of an emerging
incident.

Agency-proposed
corrective action

Identify potential enhancements to existing systems and/or identify new system requirements that can
support tracking of citizen complaints.

Agency action

According to the OWs certification memorandum dated July 7, 2021, the OW took the lead in addressing
the recommendation and identifying potential enhancements to existing systems and new system
requirements that can support tracking of citizen tips. In 2019, the OW developed a Protocol for Addressing
Water Quality Concerns from the Public to address this OIG recommendation. This protocol was shared
with the OIG in March 2021.

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OIG assessment
of Agency action

DID NOT FULLY ADDRESS RECOMMENDATION. The EPA has two key systems that gather citizen tips.
The OW implemented the SDWA hotline's Protocol for Addressing Water Quality Concerns from the Public
to manage drinking water-related tips, including assessing tip risk and tracking tip resolution. The OW's
corrective actions address Recommendation 8. The RAV system is used by OECA to gather citizen tips on
environmental issues regardless of media. The system does not assess risk or track information on the
resolution of issues raised. Further details are discussed in Chapter 4 of our follow-up report.

Recommendation 9:

Text of

recommendation

Improve oversight by establishing a clear and credible escalation policy for EPA intervention in states. The
policy should provide steps the will take when states do not act.

Issued to

Assistant Administrator for Enforcement and Compliance Assurance and Assistant Administrator for Water

OIG finding
leading to
recommendation

Between May 2014 and the issuance of the EPA's Emergency Administrative Order in January 2016, EPA
Region 5 staff received 87 citizen tips about drinking water conditions in Flint. Thirty of the tips included
concerns about lead. Region 5 officials responded with form letters that recommended citizens resolve
their concerns by contacting the Michigan Department of Environmental Quality or Flint's water system
staff. Region 5 did not have a system for cataloging and responding to citizen tips, nor did it use tips or the
volume of calls as indicators of problems with Flint's water system. Tips can serve as critical indicators of
potential problems. Instead of referring complaints back to state and local officials to resolve, the region
could have taken a more proactive stance.

Agency-proposed
corrective action

OECA will continue to provide training on SDWA authorities, including the use of section 1431 authority
when state and local authorities have not acted to protect public health. The EPA has initiated a workgroup
with participation from OECA, the OW, and the regions. The workgroup will develop procedures and
strategies to ensure timely and effective EPA intervention if a state's response to a risk is insufficient to
protect the public's health.

Agency action

According to OECA's certification memorandum dated December 10, 2020, OECA took the lead in
addressing the recommendation. On August 15, 2017, EPA Administrator Scott Pruitt reaffirmed the EPA's
Policy on Elevation of Critical Environmental and Public Health Issues. He directed EPA staff to elevate
concerns quickly and the regions to inform headquarters of any issues elevated under this policy. On
June 7, 2019, OECA identified "Reducing Non-Compliance with Drinking Water Standards at Community
Water Systems" as a National Compliance Initiative for fiscal years 2020-2023. These initiatives
strategically focus enforcement and compliance assurance resources where they can be most
impactful. As part of the drinking water National Compliance Initiative, the EPA will work with partner
states, tribes, and territories to address community water systems whose known, ongoing noncompliance
with SDWA presents a threat to public health. Additionally, the National Compliance Initiative will seek to
identify and address undiscovered risks involving community water systems that may also pose a threat.
An increased EPA compliance and enforcement presence and integrated cooperation with primacy
agencies will improve compliance with the National Primary Drinking Water Regulations and protect public
health.

OIG assessment
of Agency action

COMPLETED. On January 21, 2016, EPA Administrator Gina McCarthy issued the Policy on Elevation of
Critical Public Health Issues. The policy describes which offices should be contacted if a concern needs to
be elevated, as well as the characteristics of issues that should be elevated. The policy was reaffirmed by
subsequent Administrators Scott Pruitt, Andrew Wheeler, and Michael Regan. Additionally,
then-Administrator Andrew Wheeler introduced the "Report-an-lssue" tool as an additional avenue for
employees to elevate concerns. The Report-an-lssue tool allows an EPA employee to provide Agency
senior management with notice of a perceived or unaddressed significant risk to public health or the
environment. As of April 2021, only two issues had been reported via the Report-an-lssue tool; however,
management believes that the number of issues reported is not an indicator of effectiveness, as the
policy requires staff to go to management first and report an issue via the Report-an-lssue tool as a last
resort.

Source: OIG assessment of the EPA's corrective actions. (EPA OIG table)

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Appendix B

Agency Response to Draft Report

UNITED STATES ENVIRONMENTAL PROTECTION AGENCY



WASHINGTON, D.C. 20460

OFFICE OF
ENFORCEMENT AND
COMPLIANCE ASSURANCE

April 15, 2022

MEMORANDUM

SUBJECT:

FROM:
TO:

Response to Office of Inspector General Draft Report OA-FY21-0123,
The EPA Needs to Fully Address the OIG's 2018 Flint Water Crisis Report
Recommendations by Improving Controls, Training, and Risk Assessments,
dated March 18, 2022

Lawrence E. Starfield, Acting Assistant Administrator
Michael D. Davis, Director

Environmental Investment and Infrastructure Directorate
Office of Audit

LAWRENCE
STARFIELD

Digitally signed by
LAWRENCE STARFIELD
Date: 2022.04.15
14:19:51 -04'00'

Thank you for the opportunity to respond to the recommendations in the subject audit report. The
following is our position on each of the report recommendati ons. The Agency agrees with
Recommendation 1 and has provided a high-level intended corrective action and estimated
completion date. The Office of Enforcement and Compliance Assurance (OECA) does not agree
with Recommendation 2 and has provided our position for your consideration. Additionally,
attached is one technical comment on the draft report.

AGENCY'S POSITION

Recommendation 1 - Agree

Document and monitor attendance at Safe Drinking Water Act training events to ensure the
appropriate staff members, managers, and senior leaders attend the training and are aware of the
EPA's oversight and enforcement tools and authorities, including sections 1414 and 1431 of the
Safe Drinking Water Act.

RESPONSE:

We accept Recommendation 1. OECA has been offering and will continue to offer training to
staff, managers, and senior leaders regarding Safe Drinking Water Act sections 1414 and 1431.
We will document and monitor attendance by staff, managers, and senior leaders at these
trainings. Before the COVID-19 pandemic, EPA did not routinely use the full array of Microsoft

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Teams functions, including the attendance report. However, since the pandemic and moving
forward, particularly given a possible sustained hybrid work environment, OECA will make sure
to generate and download attendance reports. Moreover, to ensure we address the OIG's
concerns about training senior leaders in particular, OECA will present information on EPA's
Safe Drinking Water Act oversight and enforcement tools and authorities to the Regional
Enforcement and Compliance Assurance Directors and Regional Counsels during one of their
meetings each year. These are standing meetings that are generally well attended by senior
leaders (e.g., SES Director level), which will ensure that we capture as large an audience as
possible at this senior level.

Recommendation 2 - Disagree

Incorporate controls into the Report a Violation system to assess the risk associated with each tip
and track when resolution of each tip is achieved.

RESPONSE: OECA agrees that an Agency system to track citizen tips, gather information, and
assess risk on emerging drinking water issues is important. In fact, the Office of Water (OW)
effectively fulfilled this recommendation in response to the 2018 OIG report, "Management
Weaknesses Delayed Response to Flint Water Crisis," when it implemented an SDWA hotline
"Protocol for Addressing Water Quality Concerns from the Public" (Protocol) to manage
drinking water-related tips, including assessment of tip risk and tracking of tip resolution. OECA
owns and operates another system, as noted by the OIG, called Report A Violation (RAV). The
RAV system is an existing tool used by OECA for many years to gather citizen tips and
complaints on possible noncompliance issues - large and small - regardless of media. This
system goes well beyond the scope of OW's SDWA hotline Protocol and beyond the OIG's
effort to "fully address the OIG's 2018 Flint Water Crisis Report Recommendations by
improving controls." Given that there is already a system in place to "assess the risk associated
with each [drinking water-related] tip" and that tracks "when resolution of each tip is achieved"
as it relates to public drinking water, it is not necessary to "incorporate [identical] controls into
the Report A Violation (RAV) system." Creating such a redundancy in a second system (i.e., via
costly system changes to RAV) is unnecessary, and is not a prudent or efficient use of Agency
funds.

Also, given the extremely large number of tips in the RAV system (14,000 tips per year vs. 5,000
per year to the SDWA hotline) and the broad multimedia nature of RAV, OECA does not have
the resources to prepare an assessment of the risk associated with each tip and complaint we
receive through the system and track when resolution is achieved. In addition, most RAV tips
are referred to the appropriate state for review. Requiring the state to report back to EPA on the
risk associated with each tip and its resolution would constitute a significant burden on the states.
Additionally, it is unclear whether EPA has the authority to require that information from the
states for all programs and in any event would trigger the Paperwork Reduction Act.

For all these reasons, OECA does not agree with Recommendation 2 in the 2022 OIG report to
"Incorporate controls into the Report a Violation system to assess the risk associated with each
tip and track when resolution of each tip achieved."

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AGENCY'S RESPONSE TO REPORT RECOMMENDATIONS



Recommendation

High-Level Intended Corrective
Action(s)

Estimated

Completion

Date

1

Document and monitor attendance at
Safe Drinking Water Act training
events to ensure the appropriate staff
members, managers, and senior
leaders attend the training and are
aware of the EPA's oversight and
enforcement tools and authorities,
including sections 1414 and 1431 of
the Safe Drinking Water Act.

a.	Document and monitor
attendance by staff, managers
and senior leaders at Safe
Drinking Water Act 1414 and
1431 trainings.

b.	Present information on EPA's
Safe Drinking Water Act 1414
and 1431 oversight and
enforcement tools and
authorities to the Enforcement
and Compliance Assurance
Directors and Regional Counsels
at one of their meetings each
year.

12/31/22
12/31/22

CONTACT INFORMATION

If you have any questions regarding this response, please have your staff contact OECA's Audit

Follow-Up Coordinator, Gwendolyn Spriggs, at spriggs.gwendolyn@epa.gov or 202-564-2439.

Attachment: Technical Comment

cc: Benita Best-Wong, OW/DAA
David Cozad, OECA/IO
Mark Badalamente, OECA/OAP
Henry Barnett, OECA/OCEFT
John Dombrowski, OECA/OC
Rosemarie Kelley, OECA/OCE
Macara Lousberg, OW/IO
Jennifer McLain, OW/OGWDW
Karen Wirth, OW/OGWDW
Tiffany Crawford, OW AFC
Gwendolyn Spriggs, OECA AFC

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Distribution

The Administrator

Deputy Administrator

Chief of Staff, Office of the Administrator

Deputy Chief of Staff, Office of the Administrator

Agency Follow-Up Official (the CFO)

Assistant Administrator for Enforcement and Compliance Assurance

Principal Deputy Assistant Administrator for Enforcement and Compliance Assurance

Assistant Administrator for Water

Deputy Assistant Administrators for Water

Director, Office of Regional Operations

Regional Administrator for Region 5

Deputy Regional Administrator for Region 5

Agency Follow-Up Coordinator

General Counsel

Associate Administrator for Congressional and Intergovernmental Relations
Associate Administrator for Public Affairs

Director, Office of Continuous Improvement, Office of the Chief Financial Officer
Director, Office of Regional Operations
Public Affairs Officer, Region 5

Audit Follow-Up Coordinator, Office of the Administrator

Audit Follow-Up Coordinator, Office of Enforcement and Compliance Assurance

Audit Follow-Up Coordinator, Office of Water

Audit Follow-Up Coordinator, Region 5

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