A Navy investigation released Thursday revealed that shoddy management and human error caused fuel to leak into Pearl Harbor's tap water last year, poisoning thousands of people and forcing military families to evacuate their homes for hotels.
The investigation is the first detailed account of how jet fuel from the Red Hill Bulk Fuel Storage Facility, a massive World War II-era military-run tank farm in the hills above Pearl Harbor, leaked into a well that supplied water to housing and offices in and around the sprawling base. Some 6,000 people suffered nausea, headaches, rashes and other symptoms.
The investigation report listed a cascading series of mistakes from May 6, 2021, when operator error caused a pipe to rupture and 21,000 gallons of fuel to spill when fuel was being transferred between tanks. Most of this fuel spilled into a fire suppression line and sat there for six months, causing the line to sag. A cart rammed into this sagging line on Nov. 20, releasing 20,000 gallons of fuel.
The area where the cart hit the line isn't supposed to have fuel, and so the officials who responded to the spill didn't have the right equipment to capture the liquid.
“The team incorrectly assumes that all of the fuel has been sopped up," Adm. Sam Paparo, the commander of the U.S. Pacific Fleet, told reporters at a news conference. About 5,000 gallons wasn't recovered.
"Meanwhile, over the course of eight days, that fuel enters into this French drain that is under the concrete and seeps slowly and quietly into the Red Hill well. And that fuel into the Red Hill well is then pumped into the Navy system,” Paparo said.
Red Hill officials thought that only 1,618 gallons had leaked in the May spill and that they recovered all but 38 gallons. They noticed that one of the tanks was short 20,000 gallons but believed it had flowed through the pipes and didn't realize it had flown into the fire suppression line. They didn't report the discrepancy to senior leadership.
The report said officials defaulted to assuming the best about what was happening when the spills occurred, instead of assuming the worst, and this contributed to their overlooking the severity of situation.
Paparo said the Navy was trying to move away from that. He called it an ongoing process “to get real with ourselves” and “being honest about our deficiencies.”
He recommended that the Navy review operations at 48 defense fuel storage facilities worldwide.
“We cannot assume Red Hill represents an outlier, and similar problems may exist at other locations,” Paparo wrote in the report.
The report said the investigation revealed that poor training and supervision, ineffective leadership and an absence of ownership regarding operational safety also contributed to the incident.
“The lack of critical thinking, intellectual rigor, and self-assessment by key leaders at decisive moments exemplified a culture of complacency and demonstrated a lack of professionalism that is demanded by the high consequence nature of fuel operations,” the report said.
In particular, the investigation highlighted a February 2021 decision by the commanding officer of Fleet Logistics Center Pearl Harbor to remove uniformed military oversight from day-to-day operations at Red Hill. The report said this significantly increased the risks of fuel handling operations.
It also noted key leaders at the scene of the November 2021 spill failed to exercise a sense of urgency, critical thinking, forceful backup and timely and effective communication demanded “by the seriousness of the situation.”
Navy leaders briefed reporters on the investigation on Thursday but had placed an embargo on it until early Friday morning. The Defense Department also filed a copy of its defueling plan with state Department of Health to meet a Thursday deadline. State health officials released both the investigation and the defueling plan to the public on Thursday.