BY JULIE MACK, RON FONGER AND JOHN COUNTS

May 3, 2016

A year ago, Gov. Rick Snyder was stoking rumors of a presidential bid as a metrics-driven Republican whose ability to run government like a business transformed a troubled state.

But the leadership style so lauded a year ago -- the emphasis on problem-solving over politics, the laser-like focus on the bottom line, the reliance on emergency financial managers to whip troubled cities into shape -- has proven to be his undoing. Now, he is viewed as the person ultimately responsible for one of the nation’s biggest public-health disasters in memory -- the lead contamination of a water system serving 100,000 people, and a possible link between the water system and an outbreak of Legionnaire’s disease that killed 12 people.

Snyder has apologized repeatedly for the crisis and has vowed to fix Flint. But, to this day, he and his administration push a storyline that diminishes their role.

It has never been fully explained how crucial information didn't reach the governor, or why the Snyder administration allowed the people of Flint to use undrinkable water for so long.

Red flags were being waved furiously for a year before Snyder took action, as Snyder's top aides -- including his chief of staff and his legal counsel -- expressed concern to the governor about Flint water quality reports.

"If they weren't passing along those assessments to the governor, that's a huge problem," said Eric Rothstein, a member of the Snyder-appointed Flint Water Advisory Task Force. "But, if they were passing along those assessments and the governor wasn't taking action, that's a huge problem, too."

Snyder declined requests to be interviewed for this story, but his spokesman Ari Adler submitted written answers to questions from MLive.

"The Governor isn't going to get into playing what-ifs on what staff could have or should have told him," Adler wrote. "His focus is on fixing the problems in Flint and on changing direction on how we are doing things in state government, all the way up to the Executive Office."

Deflecting the blame

A team of MLive reporters conducted an investigation reviewing thousands of emails and other documents and interviewing numerous key players in an attempt to get to the bottom of what exactly happened in Flint.

That investigation shows the water crisis was an unintended consequence of the state's takeover of Flint in 2011, after which a series of four emergency managers were given near-dictatorial powers so they could cut the city's budget and bring the books in line.

Among the cost-saving measures: Change the city's water supply and do it on the cheap.

Snyder was aware by fall 2014 that using the Flint River for the city's water was causing serious water-quality issues. But, for the next 12 months, he and his administration saw fixing Flint's finances as the higher priority.

In explaining the decision to continue using the Flint River for drinking water until October 2015, the governor said he was relying on DEQ's false assurances that the water was safe. That was despite growing evidence to the contrary in the months leading up to Snyder's acknowledgement of widespread lead contamination.

The MLive investigation also found many of Snyder's claims downplaying his administration's role in the crisis are contradicted by the facts.

-- “This was never about money,” Snyder tweeted on March 6.

From Day One, the decision to switch Flint’s water supply was to cut costs. Once it was clear the new drinking water had serious problems, state officials wouldn’t switch back to buying water from Detroit because of finances.

-- “You have a handful of quote-unquote experts who were career service people that made terrible decisions,” Snyder said during a Jan. 22 interview with MSNBC.

Snyder has repeatedly blamed the crisis on Michigan Department of Environmental Quality civil servants, two of whom now face criminal charges for their alleged role in the crisis. But Snyder’s defense belies the fact that his inner circle was deeply involved in the decision to switch Flint’s water source and were well aware of problems with water quality long before it became a national scandal.

-- “This was a failure of government at all levels,” Snyder said in the March 6 tweet.

While mistakes were made by local and federal employees, the Flint water crisis occurred because of decisions by the Snyder administration. It was his governing priorities, his emergency managers and his state employees who made the decisions that resulted in the poisoning of Flint.

-- “There are many communities with potentially dangerous lead problems. And if the DEQ and EPA do not change -- and if the dumb and dangerous federal lead and copper rule is not changed -- then this tragedy will befall other American cities,” Snyder said in his March 17 testimony before Congress.

Snyder and members of his administration have suggested numerous times the Flint water crisis could happen in any city with aging infrastructure.

While aging infrastructure is certainly a problem, this was a preventable crisis -- one that could have been avoided if the DEQ required proper treatment of Flint River water at a cost of about $80 per day.

Culture is the ‘culprit’

Snyder, 57, an accountant by training who had never held public office, promised to bring bottom-line, corporate culture to government.

The people of Michigan bought into his message -- twice -- electing him governor in 2010 and again in 2014.

Taking office on the heels of the Great Recession, the venture capitalist and former president of Gateway computers touted himself as "one tough nerd," a problem solver who would rise above partisan politics. He preached about measurable outcomes, dashboards and the philosophy of Relentless Positive Action.

Snyder is known around the capital as an introvert more comfortable analyzing a spreadsheet than chatting up colleagues.

Dennis Schornack, a former Snyder aide who also served under Gov. John Engler, told the Detroit Free Press in February that Snyder is "basically a good guy," but tends to be tone-deaf to problems that defy a cost-benefit analysis.

"It's sort of a single dimension for decision-making -- thinking that, if it can't be solved on a spreadsheet, it can't be solved," said Schornack, who was Snyder's senior transportation advisor for three years. "The people of Flint got stuck on the losing end of decisions driven by spreadsheets instead of water quality and public health."

Senate Minority Leader Jim Ananich speaks to the press on Feb. 2, 2016, about how the Gov. Rick Snyder administration needs to move more swiftly to address the Flint water crisis. (Emily Lawler | MLive.com)

Senate Minority Leader Jim Ananich, a Democrat who lives in Flint, said Snyder doesn’t see himself as a part of state government; he views state government as something he is fixing.

"If it's not something he wants to hear, he says, 'It's not on my agenda,'" Ananich said.

He isn't alone in perceiving Snyder as too insular. The governor-appointed Flint Water Advisory Task Force report, released last month, offered a similar criticism.

Snyder "seems to have managed the communication between cabinet officials and him in a way that he gets very limited information," said Ken Sikkema, task force co-chairman and a Republican who was Michigan Senate majority leader from 2002 to 2006.

For instance, instead of regular meetings with his full cabinet, Snyder organized his cabinet into subgroups called "rivers of opportunity" and meets with only a few department heads at a time.

That may be a more efficient way of driving a proactive agenda but, "in a crisis, it doesn't work as well, and you're not going to get the same quality of information," said John Truscott, president of Truscott Rossman public-relations firm and a top aide for Engler.

It wasn't just the governor's management style, some of his policies helped fuel the crisis. The Flint task force's report specifically cited Snyder's use of emergency managers and a problematic culture within the DEQ.

The problem with emergency managers, the task force said, is they have near-dictatorial powers but can be so focused on finances that other issues get ignored.

And, because emergency managers are not elected officials, they can feel free to ignore citizens' concerns.

"The EM situation is clearly a problem," Rothstein said. "It failed in Flint with acute consequences."

As for the DEQ, Snyder's administration shifted the mission from enforcement to compliance and continued a decade-long trend of budget cuts in the DEQ's Office of Drinking Water and Municipal Assistance.

Michigan Governor Rick Snyder addresses media on the Flint Water Advisory Task Force final report findings on Wednesday, March 23, 2016 at Mott Community College. The team, appointed by Gov. Snyder, reviewed actions regarding water use and testing, and offered recommendations to protect the health and safety of all Michigan residents in the future. Conor Ralph | MLive.com

"I think the bureaucracy got into a bunker mentality -- check your boxes off and don't stick your neck out," Chris Kolb, a member of the Flint task force, said about the DEQ. "I think that mentality developed over time. The budget crunch has really spread them thin. You get comfortable doing the minimum."

Ananich and former Flint Mayor Dayne Walling are among those who say Snyder's governing philosophy set the stage for the water crisis.

"The culture that he created is the main culprit of what happened here," Ananich said.

Walling, who believes he lost re-election in November partly because of his own handling of the crisis, said Snyder "just seems to have zero interest in working with local officials."

"I think the governor has spent so much time preaching relentless positive action, he has no ability to deal with real life," Walling said. "We end up in a bubble of positive information."

Rich Baird, Snyder's closest aide, defended the governor.

"He is not insular and his mentality is not 'spreadsheet,' rather it is fact based and accountable," Baird said in an email responding to MLive questions. "... The final question from him is always 'What is the right thing to do?'"

Ananich and consultant TJ Bucholz, who worked for Engler and former Democratic Gov. Jennifer Granholm, are among those who believe the water crisis would not have happened in those administrations.

It's improbable that Granholm, a politician known for her empathy, would have ignored the public outcry in Flint, Ananich and Bucholz said.

As for Engler, he "was too good of a policymaker and politician" to have such a crisis on his watch, Ananich said, echoing the thoughts of Bucholz and Truscott. "He would have expected to know (the details)."

All about the money

“This was never about money,” Snyder -- aka @onetoughnerd -- tweeted on March 6 as Democratic presidential hopefuls Hillary Clinton and Bernie Sanders verbally bashed the governor during a debate in Flint.

This was never about money. This was a failure of government at all levels that could be described as a massive error of bureaucracy. — Governor Rick Snyder (@onetoughnerd) March 7, 2016

Emails, interviews and the governor's own Flint Water Advisory Task Force tell a much different story.

Finances were behind three key decisions that led to the Flint water crisis:

The decision to join the newly formed Karegnondi Water Authority for the city's water supply, ending 47 years of buying water from the Detroit Water and Sewerage Department.

Using the Flint River as an interim water source until the KWA pipeline was built.

The continued use of the river for 17 months despite a mounting litany of problems and concerns.

"Clearly, money was a factor," Sikkema said.

Joining the KWA in April 2013 was supposed to save Flint $100 to $300 million over 30 years. Then-state Treasurer Andy Dillon, a Snyder appointee, signed off on the deal, saying Flint officials were eager to leave the Detroit system.

"If we rejected this, there would be a political backlash" from Flint leaders, Dillon said about his understanding of the deal at the time. "There was no financial risk to the city of Flint."

The Detroit Water and Sewerage Department wasn't pleased to lose its largest water customer and gave notice to terminate Flint's contract in April 2014. If Flint wanted to stay on Detroit water from 2014 until the KWA started operations in 2016, they would have to pay much higher rates.

Former Flint emergency manager Ed Kurtz, right. Lauren Justice | MLive.com

This did not sit well with Ed Kurtz, then Flint's emergency manager, who determined the Flint River was the least expensive option in the interim.

The catch was Flint had to quickly upgrade its water plant, and the city public works staff had to shift from simply distributing pre-treated Detroit water to treating and distributing Flint River water. The plant already was slated to start treating KWA water in 2016 but, now, the rush was on to get it online by April 2014.

As it turned out, Flint was ill-prepared to treat the river water and the DEQ wasn't providing the proper oversight.

"They rushed to do it," Kolb said. "They moved too quickly. They just put the pedal to the floor and tried to do it with an inexperienced staff."

As problems with the water surfaced, emergency managers said reconnecting to Detroit water was simply not an option, noting it would cost the city $1 million more per month.

The biggest blunder -- failing to use corrosion control, causing lead from the pipes to leach into the water -- also was made in an environment of cost savings.

The Flint Water Department and the DEQ were understaffed and underfunded as they scrambled to get the treatment plant into operation. In the process, DEQ officials misinterpreted federal lead regulations and deemed corrosion control unnecessary until after a year of testing.

That misjudgment wasn't directly about money, according to Sikkema, "but it was happening in an environment where everything was about pinching pennies."

Flint resident Andrea Watson, back right, drops to the floor in tears as Flint police stand guard at the city council chamber doors, not allowing city residents to listen to Gov. Rick Snyder speak in January 2016, six days after he declared a state of emergency in the city over lead in the water supply. Jake May | MLive.com

Since acknowledging the lead contamination in October, the Legislature has approved more than $67 million in funding to address the Flint water crisis, including the costs of lead testing and treatment, filters for water taps, bottled water, credits to water bills and the state's share of paying to reconnect Flint to Detroit's water system. Snyder has requested another $165 million to provide support for Flint residents affected by the water crisis.

The state also is paying $1.2 million for Snyder's outside legal bills, including contracts with a criminal defense attorney and an attorney specializing in civil lawsuits.

In addition, the Michigan Attorney General's office is spending $1.5 million to conduct its investigation into the crisis.

So far, that investigation has led to criminal charges against two DEQ employees and a Flint water department supervisor -- and, at this point, the state is paying for the defense attorneys for the DEQ workers.

The state also faces the expense of defending civil lawsuits filed against the state on behalf of Flint residents.

What the governor knew

Gov. Rick Snyder speaks about the Flint water crisis during a press conference on Wednesday, Jan. 27, 2016 at City Hall in downtown Flint. Jake May | MLive.com

Snyder has maintained that the Flint water crisis was the fault of “career bureaucrats” in the DEQ and that his mistake was not asking enough questions.

Snyder has said he wasn't told that Flint had a confirmed lead issue until Oct. 1, 2015, and that he didn't know until January 2016 about an outbreak of Legionnaire's disease possibly linked to the switch in Flint's drinking-water source. The outbreak sickened 91 people, including 12 who died, between June 2014 and November 2015.

But the evidence shows Snyder knew since fall 2014 that something was seriously amiss with Flint water.

He knew since July 2015 that outside experts were raising concerns about lead contamination. And, while he says he didn't know about Legionnaire's earlier, the outbreak was known to the heads of the DEQ and Department of Health and Human Services, as well as at least three top aides in the governor's office.

In addition, because Flint was under emergency management, Snyder was receiving regular, detailed reports on the city's affairs.

In spring 2013, Snyder hosted a meeting with Flint and Detroit officials in which he pushed a new water deal between the two cities. Detroit also was under a state-appointed emergency manager and soon would enter bankruptcy.

The effort failed, and Flint opted for the KWA.

In spring 2014, Snyder was briefed that Flint was switching to the Flint River as an interim drinking water source until the KWA pipeline was ready.

Conversations in the governor's office about Flint water heated up in fall 2014 when Snyder was briefed about two boil water advisories in Flint due to fecal coliform bacteria, as well as complaints about the water's color, odor and taste.

Then, in October 2014, a new bomb dropped. General Motors announced Flint River water was too corrosive for its manufacturing needs.

Many Flint residents saw this as a turning point and demanded to be reconnected to Detroit water.

Even Snyder's top legal aides suggested Flint be switched back.

"I see this as an urgent matter to fix," Valerie Brader, Snyder's deputy legal counsel, said in an email to Michael Gadola, Snyder's legal counsel; Dennis Muchmore, Snyder's chief of staff; and two other aides in Snyder's office.

Gadola, a Flint native, was more personal in his email response.

"The notion that I would be getting my drinking water from the Flint River is downright scary," Gadola wrote. "... My Mom is a City resident. Nice to know she's drinking water with elevated chlorine levels and fecal coliform. I agree with Valerie. They should try to get back on the Detroit system as a stopgap ASAP before this thing gets too far out of control."

Sikkema said the governor was aware of the problem and Brader's suggestion to switch back to Detroit water.

At a minimum, the governor should have conducted a full review of water quality at that point, according to the task force.

But that didn't happen.

Former Flint emergency manager Darnell Earley. Zack Wittman | MLive.com

Instead, Brader's email led to a phone conversation between her, Rich Baird, Snyder's closest aide, and Darnell Earley, Flint's emergency manager at the time.

"Darnell says it's too costly (to go back to Detroit water) and that's the end of discussion," Sikkema said.

It was a conversation that played out again and again among the governor's top aides during the winter and spring of 2015 as the level of water complaints rose.

It was brown. It smelled and tasted odd. It was causing rashes.

Still, the DEQ said it was safe to drink.

Even when the water exceeded federal standards for total trihalomethanes or TTHM, a carcinogen, the DEQ told the public -- and the governor -- it was safe to drink.

Meanwhile, Flint was on "the precipice of civil unrest," state Rep. Sheldon Neeley said in an open letter to Snyder.The unrest didn't go unnoticed by Snyder's top aides.

"This is a public relations crisis -- because of real or perceived problem is irrelevant -- waiting to explode nationally," Adler, then Snyder's special projects manager, wrote in a January 2015 email to two of his colleagues in the governor's office.

"Since we're in charge, we can hardly ignore the people of Flint," Muchmore, Snyder's chief of staff, wrote in a February 2015 email to the Department of Treasury.

Because of the TTHM issue, there was a new sense of urgency among the governor's top aides about Flint's water issues during the winter and into spring 2015. Emails were exchanged. Meetings were held. The governor received written, detailed briefings in February and April about the situation in Flint.

"Unfortunately, if we had known there was a lead issue, we would have been able to respond to it," said Dick Posthumus, senior adviser to Snyder who hosted a meeting about Flint water involving several agencies in January 2015.

Flint did take steps to improve its water in winter 2015, the biggest of which was the addition of a $1.5 million filter at the water plant, a move recommended by Veolia, an international consulting firm on environment issues hired by the city to look at the TTHM problem.

Amid the concerns over Flint's water quality, there were suspicions among the governor's aides the water complaints were fueled by politics, including anger over the state takeover of Flint and by political opponents of the Flint mayor, who was seeking re-election.

The Snyder administration also repeatedly reminded itself the Flint River was only a temporary water source.

"Once the city connects to the new KWA system in 2016, this issue will fade in the rearview," DEQ spokesman Brad Wurfel wrote in the February 2015 briefing memo.

Even more important, Treasury officials repeatedly reminded everyone of the high cost of buying water from Detroit, as the DEQ continued its assurances the water met federal and state safety standards.

When the Flint City Council voted in March 2015 to return to the Detroit Water and Sewerage Department for drinking water, the idea was vetoed by emergency manager Jerry Ambrose, who called it “incomprehensible,” considering the cost.

"Water from Detroit is no safer than water from Flint," Ambrose said.

The water-quality problems outside of lead "were local issues" and "not health-related directly," Snyder told an MLive reporter during a short interview he granted April 28 about his trade mission to Europe.

Snyder also said the state directed $2 million in federal grant money to Flint in February 2015 for infrastructure improvements, although that was for long-term projects, and solicited businesses to donate water filters for Flint residents, which were distributed in August 2015.

Ananich called Snyder's comments "delusional," saying concerns about the boil-water advisories, TTHM, GM's decision to switch water supplies and complaints about the water's color, smell and taste "were all health related."

Ananich also dismissed the contention those were "local issues," noting the city was governed by a state-appointed emergency manager.

"If they had investigated earlier and taken the concerns more seriously, this could have been solved earlier," Ananich said.

Legionnaire’s disease

The two issues that have caused the most concern -- lead and the possibility the water was responsible for Legionnaire’s cases -- were being discussed at various levels of government long before Snyder went public about them.

Both were being talked about in connection with Flint water at least by winter and spring 2015.

The Legionnaire's issue arose in fall 2014 when the Genesee County Health Department noticed a rash of cases that coincided with the switch to Flint River water.

Dan Wyant resigned as director of the Michigan Department of Environmental Quality in late December 2015 after Gov. Snyder's task force cited failures in the DEQ's handling of the Flint water crisis. Jake May | MLive.com

It’s still unclear whether the Flint River water was responsible for the 91 confirmed Legionnaires’ cases. Dr. Matthew Davis, a member of the Flint water task force, said it is likely that will never be known.

The outbreak and its possible link to the Flint River became public on Jan. 13, 2016, a few days after Snyder said he was first informed about the issue.

However, officials in the DEQ and Michigan Department of Health and Human Services were alerted in fall 2014 about the outbreak and the potential link to the change in Flint water. DEQ Director Dan Wyant and Health and Human Services Director Nick Lyon knew by January 2015, according to the Flint water task force.

On Jan. 28, 2015, DEQ spokesman Wurfel had an email exchange with Snyder's then-assistant press secretary, Dave Murray, about Flint water.

Wurfel said he didn't want Wyant "to say publicly that the water in Flint is safe until we get the results of some county health epidemiological traceback work on 42 cases of Legionnaire's disease in Genesee County since last May."

Three days later, Murray sent a detailed memo about the Flint water situation to Snyder in advance of a grant announcement to improve Flint's water system. The memo did not mention Legionnaire's.

Murray could not be reached for comment.

Other emails show Snyder's then-press secretary Sara Wurfel and Harvey Hollins, the director of urban initiatives, also knew about the outbreak by spring 2015.

Jarrod Agen, then Snyder's communications director, also was copied on an email about Legionnaires, but said he never opened it.

Hollins gave Snyder a detailed briefing report on Flint water issues in April 2015, but he didn't mention Legionnaire's.

"I assumed others would inform the Governor but looking back now it is clear that was not the case," Hollins said in an email response to questions from MLive.

Sara Wurfel has been vague on how the information was shared among the governor's staff.

"As the press secretary, I worked hard to identify and elevate important issues -- including and especially water quality in Flint as issues and (questions) arose -- to the executive office," she said in an email to The Flint Journal. "I routinely flagged topics of concern for review and discussion. That was a role and responsibility I took immensely seriously. Recently released records underscore that fact. There were discussions about the critical issues raised in these emails."

Gov. Rick Snyder answers questions from U.S. representatives during a hearing about the Flint water crisis in front of the U.S. House Committee on Government Oversight and Reform at the Rayburn House Office Building on Thursday, March 17, 2016 in Washington D.C. Jake May | MLive.com

While being grilled before a Congressional committee in Washington, D.C., in March, Snyder said he didn't "recall" being told anything about Legionnaire's before January 2016.

In the brief April 28 interview with MLive, Snyder said: "I wish people would have informed me and I've said in my current State of the State that issues like that should rise to my level."

Lead in the water

The lead issue surfaced in February 2015 when the DEQ and federal Environmental Protection Agency became aware of a Flint resident whose water tested extremely high for lead.

State DEQ officials saw it as an anomaly, while EPA official Miguel Del Toral repeatedly warned that Flint might have systemic lead contamination.

But these conversations were happening in the bowels of the EPA and DEQ.In the thousands of emails released by the governor and other documents released under the Freedom of Information Act, there is no evidence Snyder or anyone in the governor's office was aware of lead issues before summer.

However, Hollins, in his email response to MLive, said he first became aware of "lead concerns by a few residents in Flint sometime in late May 2015 and I referred them to the DEQ."

In early July, the news media began reporting on an internal EPA memo written by Del Toral, detailing concerns about potential lead contamination in Flint.

But, instead of considering why an EPA lead expert thought Flint's water was unsafe, the Snyder administration focused on the messenger -- the initial report on the memo came from the American Civil Liberties Union, and it was written off as a partisan attack.

"Anyone who is concerned about lead in the drinking water in Flint can relax," DEQ spokesman Wurfel told Michigan Radio on July 13.

Privately, Wurfel told colleagues in an email, "The ACLU's fear campaign on this issue is an embarrassment."

Then, in late July, a delegation of Flint residents met with Muchmore and Hollins, and said people who were getting their water tested were finding lead.

That prompted Muchmore to email the DEQ, Treasury and the health department.

"I'm frustrated by the water issue in Flint. I really don't think people are getting the benefit of the doubt," Muchmore wrote in a July 22 email.

"Now they are concerned and rightfully so about the lead level studies they are receiving from the DEQ samples. ... These folks are scared and worried about the health impacts and they are basically getting blown off by us."

The DEQ reiterated assurances that Flint water met federal and state standards. Health department officials told Muchmore they looked at lead levels in Flint children and didn't see a spike they connected to a change in Flint water.

Muchmore backed off, and the city of Flint would continue to use river water until October, when Snyder first acknowledged the problem.

Muchmore declined to be interviewed for this story.

To the rescue

Flint’s saviors didn’t come in the form of government officials paid to serve the public, but in two individuals outside of government.

Virginia Tech professor Marc Edwards

In August, Marc Edwards, a Virginia Tech scientist, started testing Flint water and was vocal in his contention that the city had a very serious lead contamination problem.

Dr. Mona Hanna-Attisha

In September, Dr. Mona Hanna-Attisha, a Flint pediatrician, held a news conference saying she found increased lead levels in Flint children since the water switch.

Over the next few days, the city of Flint and the Genesee County Health Department issued public-health advisories about lead contamination in the water.

The response from the public relations arm of Snyder's administration was to discredit those who questioned whether Flint water was safe.

The DEQ's Wurfel referred to Del Toral as a "rogue employee" and said Edwards was "fanning political flames irresponsibly."

A health department spokeswoman called into question Hanna-Attisha's analysis, saying state health officials failed to find a similar trend with more comprehensive data.

But Hanna-Attisha's presentation gave state officials serious pause and finally caused them to rethink their position that the water was safe, Sikkema and Rothstein said.

"They were still in denial for about a week, but more and more people were accepting what Dr. Mona was saying," Sikkema said. "It got to the point where (state officials) couldn't objectively deny it anymore."

On Sept. 28, four days after Hanna-Attisha's presentation, Snyder was told by his administrators that outsiders might be right about lead contamination.

"Gov. Snyder on the moment when the DEQ told him the outside experts were probably right: 'That's the kind of thing you never want to hear. And talk about being upset, I was upset,' "Adler, the governor's spokesman, wrote in response to MLive questions.

Why did it take Snyder so long to acknowledge the growing chorus of people worried about lead contamination?

"The governor was relying on only one expert -- the DEQ," Sikkema said. "He wasn't relying on Marc Edwards or Miguel Del Toral or Dr. Mona or the people of Flint coming to his office or the Genesee County Health Department. His information was limited to one entity -- and that entity happened to be wrong."

It remains baffling that no full review of the situation was ever ordered, one that sought input beyond DEQ, the state health department and Treasury, Sikkema said.

It's especially perplexing, since the governor's chief of staff repeatedly raised concerns -- a man with the ear of the governor and, one would assume, in a position of considerable authority.

"What was the decision-making milieu?" Sikkema said. "It's a good question. It's a fair question."

Lt. Gov. Brian Calley said the "normal interaction" is for the chief of staff to ask questions and gather information before taking it to the governor.

"The fact that he didn't turn around and go the other direction tells me that he did go to that department, he did get answers that, at least at that point, seemed credible," Calley said.

He said that, even in late September, the DEQ was providing "very direct and absolute-sounding answers" on why outsiders were wrong about systemic lead poisoning.

"Because their answer was so absolute that there is no problem, I believe the chief of staff simply believed his department," Calley said.

Parceling out blame

Since October, one of Snyder’s stock lines about the Flint water crisis has been that it was a failure at the local, state and federal level.

The report by the Flint Water Advisory Task Force lays waste to that contention.

The state is "fundamentally accountable for what happened in Flint," the report says.

"Primary responsibility for the water contamination in Flint lies with MDEQ," the report says. "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."

In fact, local government was a non-factor in the Flint water crisis, according to Sikkema.

"Who was running the city?" he asked "An emergency manager appointed by the state. ... There really wasn't a local government."

Likewise, the blaming of Flint's failure to maintain its aging infrastructure is a red herring: While the aging infrastructure is certainly a concern, lead contamination in the water was not an issue for Flint until it switched to using river water without corrosion control.

As for the EPA, Sikkema noted the agency didn't issue an order until January 2016 -- almost a year after it first became aware of a potential problem.

"They could have taken enforcement action earlier, and they should have," Sikkema said. "There is no excuse for that."

"But if I were the DEQ, I wouldn't be criticizing the EPA too much," he added. "We're saying the EPA delayed making the DEQ do their job. The delay of the EPA hardly absolves the DEQ from creating the situation in the first place."

Sikkema said he thinks that, overall, the Snyder administration got caught up in groupthink.

"Once the decision was made by the emergency manager to use the Flint River, I think there a circling of the wagons and a feeling of 'We're going to defend this,'" Sikkema said.

Baird offered a different perspective.

"I'm not a scientist or an engineer. I was told there were an inordinate number of water main breaks which resulted in discolored water and over (or under) chlorination which contributed to the smell," Baird wrote in an email response to MLive questions. "Every time I asked, the response was that the water meets the range established for drinking standards and the problems were being addressed."

Long-lasting harm

Gov. Rick Snyder drinks filtered Flint tap water with Flint resident Cheryl Hill while listening to her concerns with the city's ongoing water crisis at her home on Monday, April 18, 2016 on Flint's east side. Jake May | MLive.com

In the months since Snyder released his first action plan for Flint, numerous lawsuits have been filed; four people have lost their jobs, including DEQ director Wyant and the regional director of the EPA; and more criminal charges may result from investigations by the FBI, Michigan attorney general and the Genesee County prosecutor.

Snyder is facing calls for his resignations and is the subject of a recall campaign.

"Not a day or night goes by that this tragedy doesn't weigh on my mind," Snyder said in the written responses to MLive's questions. "What are the questions I should have asked? What are the answers I should have demanded? How I could have prevented this?"

Beyond Snyder's legacy, the Flint water crisis has generated debate about the more philosophical questions pertaining to governance.

Rothstein said the task force members talked among themselves about how the crisis is a prime example of the unintended consequences of government budget cuts, especially the "systemic funding cuts in public health" to the point where "government agencies don't have the tools or the resources to do their jobs."

Bucholz said the crisis proves "government cannot be run like a business. This is an absolute failure of that concept."

This was a case where decisions were made based on money versus sound public policy, and "public water is the last thing you do on the cheap," Bucholz said.

It also reflects the unintended consequences of the "systemic dismantling of government by conservatives" via budget cuts and the disdain for government regulation, he said.

U.S. Rep. Dan Kildee, D-Flint, sounded a similar theme.

"That is all anyone needs to know about the state of Michigan and Gov. Snyder's approach to this," he said. "It was as if he was running a company he took over. He is running Michigan like he acquired it on Wall Street.

"He said he was going to govern by dashboard, (but) there's no little dial there for health of the kids in Flint. It's just a failed philosophy of government."

Truscott, the former Engler aide who now heads a consulting firm, said he was "a big fan of the governor until this incident. There was obviously a breakdown on so many levels."

"I really sympathize" with Snyder, he added. "I think he's done so much good for the state.

"But this is one area where he didn't ask the right questions," Truscott said.

"I think he's taken responsibility and working to fix it but, unfortunately, some of the harm is permanent or very long-lasting."

Photo illustration at top by Milton Klingensmith, MLive.com. At far left is Gov. Rick Snyder. Top row, from left, is Jerry Ambrose, Dan Wyant, Wayne Workman and Rich Baird. Bottom row, from left, is Harvey Hollins, Dennis Muchmore, Darnell Earley, Nick Lyon and Ed Kurtz.

Julie Mack, Ron Fonger and John Counts are reporters for MLive's Impact Team. They can be reached at jmack1@mlive.com, rfonger1@mlive.com and JohnCounts@mlive.com.

MLive reporter Emily Lawler contributed to this report.

Page design and production by Scott Levin