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In a little-publicized report released last week, the U.S. Chemical Safety Board (CSB) determined that an egregious lack of oversight at chemical storage company Freedom Industries, which used tanks damaged by corrosion to hold toxic materials, caused the disastrous chemical spill in West Virginia in January that contaminated the state’s largest public water supply.

Two holes in the bottom of a 48,000-gallon tank allowed hazardous materials to contaminate a portion of West Virginia’s Elk River, which supplies fresh drinking water to nine of the state’s counties. But it was Freedom’s widespread, deeply ingrained lack of oversight and necessary regulations — despite knowing the hazard the materials might present to the public — that was responsible for the spill, CSB said.

“[It] has become clear that Freedom Industries did not have a rigorous inspection program for these chemical storage tanks sited close by the Elk River and just upstream from the facility supplying water to hundreds of thousands of people,” said CSB investigator Lucy Tyler.

The board said it could not find any record of a formal, rigorous inspection of the company’s storage vessels prior to the January 9 leak. The damage to the tank that eventually spilled the toxic chemical MCHM into the river was likely a result of water leaking through the roof and onto the tank floor. Up to 300,000 residents lost access to fresh drinking water in the immediate aftermath of the spill, with at least 170 experiencing side effects of chemical exposure and 14 needing hospitalization for nausea, vomiting, and rashes. These symptoms, CSB said, are consistent with effects from MCHM exposure.

CSB chairperson Rafael Moure-Eraso said, “An underlying root cause of many of our investigations… is the lack of thorough inspections and hazard reviews, and the need for stricter regulations in areas where we find self-policing is not preventing accidents.”

West Virginia Governor Earl Ray Tobin and Sen. Joe Manchin (D-West Virginia) announced last week that the Centers for Disease Control and Prevention (CDC), the National Institutes of Health’s (NIH) National Toxicology Program, and NIH’s National Institute for Environmental Health Sciences would continue studying the health effects of the spill, although CDC director Dr. Tom Frieden had spent months denying that chemical exposure posed any long-term consequences or risks to public safety.

CSB also noted that the West Virginia America Water Company water treatment center, one mile downstream from Freedom’s facilities, waited more than five hours to warn the public of the spill and send a “Do Not Use” order. The CDC was also criticized for its rush to categorize the water as “safe” before testing results had completely shown it to be potable for all residents, including pregnant women, who were advised to stop drinking it days after it was declared clean enough for consumption.