A Navy investigation released Thursday, June 30, 2022, revealed that mismanagement 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. A Navy investigation released Thursday revealed that mismanagement 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 research is the first detailed account of how jet fuel leaked from the Red Hill Bulk Fuel Storage Facility, a massive World War II-era military tank farm in the hills above Pearl Harbor, into a well that provided water in homes and offices. in and around the extended base. About 6,000 people suffered nausea, headaches, rashes and other symptoms. After months of resistance, the military agreed in April to an order from the state of Hawaii to drain the tanks and close the Red Hill facility. A separate report given by the Defense Department to the state Health Department on Thursday said December 2024 was the earliest it could safely evacuate the tanks. The investigation report listed a series of errors from May 6, 2021, when operator error caused a pipe to rupture and spill 21,000 gallons of fuel while transferring fuel between tanks. Most of this fuel spilled into a fire line and remained there for six months, causing the line to loosen. A cart entered this slack on November 20, releasing 20,000 gallons of fuel. The area where the cart hit the line is not supposed to have fuel, so officials who responded to the spill did not have the proper equipment to contain the liquid. “The team mistakenly assumes that all the fuel has accumulated,” Adm. Sam Paparo, commander of the US Pacific Fleet, told a news conference. About 5,000 gallons were not recovered. “Meanwhile, over the course of eight days, this fuel enters this French drain that’s under the concrete and slowly and quietly seeps into the Red Hill well,” Paparo said. Red Hill officials thought only 1,618 gallons had leaked in the May spill and that they recovered all but 38 gallons. They noticed one of the tanks was short 20,000 gallons, but believed it had flowed through the pipes and did not realize it had flown into the fire suppression line. They did not report the discrepancy to senior leadership. After the November spill, when people started getting sick, the military moved about 4,000 mostly military families into hotels for months while they waited for their water to be safe again. The report said officials failed to assume the best about what was happening when the leaks occurred, instead of assuming the worst, and that contributed to overlooking the gravity of the situation. Paparo said the Navy was trying to move away from that. He called it an ongoing process of “getting real with ourselves” and “being honest about our shortcomings.” It recommended that the Navy review operations at 48 defense fuel storage facilities around the world. “We cannot assume that Red Hill represents an outlier and similar problems may exist in 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 crucial moments exemplified a culture of complacency and demonstrated a lack of professionalism required by the high consistency of fuel operations,” the report said. Specifically, the investigation highlighted a February 2021 decision by the commander 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. He also noted that key leaders at the scene of the November 2021 spill failed to exercise the sense of urgency, critical thinking, strong support and timely and effective communication required “by the gravity of the situation.” Navy leaders briefed reporters on the investigation Thursday, but had embargoed it until early Friday morning. The Defense Department also filed a copy of the fuel decommissioning plan with the state Department of Health to meet Thursday’s deadline. State health officials released both the research and the fuel release plan to the public Thursday.
