Carole Smith's reign at the top of Portland Public Schools went down the drain in 38 pages.

That's the length of an outside investigation's damning report on PPS's systemic failures to adequately test for lead in schools' drinking water, fix plumbing fixtures when positive test results popped up, and warn students and teachers about possible sources of poisoning.

On July 18, the school district released the results of that investigation, conducted by the law firm Stoll Berne.

The report pointed to wholesale failures by the school district to protect children's health.

"Although a 'Lead in Water Program' existed," the report says, "no one was aware of what the program was and no one supervised the program. Within the PPS administration hierarchy, there has been no reporting mechanism or oversight up the chain of command, and no top down direction provided."

Within minutes, Smith announced she would resign as Portland Public Schools' superintendent immediately, rather than retire in 2017.

Just four weeks ago, Smith went public with her plan to retire next year after WW exposed how the district failed to disclose elevated lead levels at dozens of schools, dating back to 2010 ("Failing the Test," WW, June 1, 2016).

But the investigation's report made it impossible for Smith to stay another year.

The Portland School Board, which just a month ago supported Smith's decision to stay for another year, at best looks weak and at worst is now in complete chaos.

"I fault years and years and years of school boards that failed to provide any kind of oversight," says Rita Moore, a North Portland schools activist. "The fact is that PPS is a system with no systems in place. This is not new. It's not even new news. This is just outside confirmation."

Board members are left explaining away their decision to support Smith's plan to stay another year—only to have her walk away as soon as the dismal report came out.

"She clearly sensed she was out of synch with the board," says School Board Chairman Tom Koehler.

He adds that the report offered a critical look at the "lack of management" at the highest levels of the school district. "That's what we want to change going forward."

Koehler does not yet have plans for who will take over from Smith, but says the board will have someone in place before the school year begins Aug. 29.

There's also a political context to Smith's departure. The School Board plans to go to voters in November for approval of a record-setting $750 million construction bond.

The political consulting firm Strategies 360, hired to run the campaign by the private committee supporting the bond, has already conducted polling. (The firm has declined to release its survey results and says it has offered the district no advice on leadership decisions.)

PPS also hired a crisis public relations consultant, Anna Richter Taylor of ART Public Affairs. Emails obtained by WW via a public records request show Richter Taylor was pressuring a reluctant Smith to announce her retirement in June.

The school district will have to prove to voters in the next three months that it can clean up a huge mess, and the report made it obvious Smith was damaging to that case. "I think the report did her in," says Southeast Portland parent Lisa Zuniga. "It just pointed out too many flaws."

What's not in the report is in many ways as important as what is.

Unlike in Flint, Mich., where public officials knowingly covered up a water crisis shown to have harmed residents' health, no child in Portland has tested positive for elevated lead as a result of PPS's water.

The report's authors, in fact, go out of their way to shield district employees from Flint-like accusations. "We found no indication," the Stoll Berne lawyers write, "that anyone intended harm or to neglect his or her job duties."

And the report finds no smoking gun showing that Smith was aware of any test results indicating elevated lead levels before the scandal broke in late May, or that she lied about what she knew.

So why is Smith out after nearly nine years at the helm of the state's largest school district?

The short answer from the scathing 38 pages: PPS cultivated a culture of ignorance, incompetence and deception.

And Smith? She presided over a district that was unprepared to deal with health problems, that looked the other way when hazards appeared, and that covered up the truth when asked. It's how little Smith knew, or wanted to know, that ended her tenure.

Here's what the report shows—and how it leads back to Smith and board members who didn't hold her accountable.

1. The PPS employee in charge of safeguarding students from lead hazards had no qualifications to hold that position.

In April 2014, the district made Andy Fridley its senior manager of environmental health and safety. PPS placed Fridley in charge of keeping the drinking water safe, but the district gave him "no guidance or training," the report reads.

That was a major oversight, because Fridley "has no formal training in the field of lead in water," the report states. "Mr. Fridley learned 'on the job' by conducting internet research and looking at what PPS had done in the past."

His superiors—Tony Magliano and David Hobbs—also had "no training or specific background regarding lead in drinking water."

That helps explain why the district didn't follow U.S. Environmental Protection Agency guidelines in multiple ways, such as conducting ongoing tests of sink faucets and drinking fountains in school buildings. "Without periodic testing, it is not possible to detect when fixtures…may again exceed acceptable levels of lead in the water," the report notes.

And when the district found elevated lead levels in the water this spring at Creston and Rose City Park school buildings, no one shut off the water to the affected sinks and fountains before they were fixed—another violation of EPA guidelines.

2. When the person in charge of health learned about problems, he did nothing.

WW made a public records request for information on lead testing in schools in early 2015.

Fridley, the senior manager of environmental health and safety, pulled together the information from a PPS database.

In the process, he made a startling discovery: "The database showed no remediation action for some of the fixtures that had tested for excessive levels of lead in water," the report says.

But Fridley did nothing.

"Simply put, in February 2015, Mr. Fridley observed that the database appeared to show that some fixtures tested above acceptable levels for lead in water that did not appear to have been remediated, but Mr. Fridley did not address this with any of his superiors," the report says.

3. When the district was asked to explain the problems, it tried to hide them.

Fridley shared the database with Jon Isaacs, PPS's chief spokesman and public information officer, in February 2015.

Smith hand-picked Isaacs for her cabinet in 2013 after he successfully ran the district's 2012 campaign to pass a construction bond. He was given a raise and promoted to chief of communications and public affairs in 2014; his background was as a political consultant—not a public information officer.

Fridley, the report says, "informed Mr. Isaacs that the database report was missing some data."

But Isaacs provided WW with only an excerpt of the database—a portion that failed to show PPS had apparently made no fixes on some of the sinks and fountains after the testing in 2011 and 2012.

As the report notes: "In one significant instance, the former Chief of Communications & Public Affairs knowingly provided incomplete excerpts of the water testing database to Willamette Week."

Isaacs disputed the finding Monday, saying he followed district protocol for records requests, and other top officials knew what he was doing.

4. Smith gave a raise and a glowing review to the person responsible for overseeing the health and safety of school buildings.

Fridley's boss was Magliano, who ascended the ranks of the facilities department to chief operating officer in charge of district facilities in 2014. From 2010 to 2012, he was facilities director.

That timeline is important because in 2011, the district hired a part-time employee to test drinking fountains for lead.

Her findings clearly showed that PPS had a lead problem. Yet no one, including Magliano, "was more than vaguely aware of the work."

Despite this, Smith gave Magliano top marks in January for his job performance. She gave him the highest possible rating, in fact—"A Role Model"— in managing the business operations of the district, the report says.

But in June, Smith blamed the problems on Magliano, abruptly putting him and Fridley on leave amid the investigation.

Her positive review of Magliano shows, at best, she had little idea whether he was on top of his job.

5. Top leaders displayed an "absence of diligent inquiry" regarding lead in PPS's water both before and after the scandal broke.

The old saying goes: It's not the crime, it's the cover-up.

But investigators pinpoint willful ignorance as the bigger problem at PPS. And that's where the buck stops with Smith.

Even after the superintendent was alerted to lead testing in one of two schools this spring, she failed to inquire about the results. She and her chief of staff, Amanda Whalen, who brought attorneys with them to their interviews, told investigators that "they believed that if there was a problem with the tests, they would be notified."

Investigators characterize this, mildly, as "an absence of diligent inquiry by PPS individuals in upper levels of administration hierarchy." That's a nice way of saying that top officials, including Smith, were taking a see-no-evil, hear-no-evil approach while navigating the district's biggest health scandal in decades.

"There has been no 'top down' management and no supervision in this area," the report says. "The district is largely unable to account for its activities and, in some cases, has reported inaccurate information."

That's the main reason Smith is gone: The school district must quickly demonstrate it can make reforms, and the superintendent, who oversaw a culture of looking the other way, was in no position to do it.

Smith declined an interview request. But in her letter announcing her resignation, she suggested the School Board was to blame for the district's dysfunction.

"In order to accomplish the significant work that lies ahead," Smith wrote, "I believe it is critical for the board to figure out how to work together with each other as a governing board and in partnership with the superintendent."

Observers say the School Board must now demand better.

"What the report highlights," says Portland Association of Teachers president Suzanne Cohen, "is a management culture that kind of leaves everybody and nobody accountable."