Series of Mistakes Led to Fuel Poisoning of Pearl Harbor Water, Says Navy Report

PEARL HARBOR, Hawaii — A Navy investigation released Thursday found that mismanagement and human error caused fuel to leak into Pearl Harbor’s tap water last year, poisoning thousands and forcing military families to evacuate their homes to hotels.

The survey is the first detailed account of how kerosene from the Red Hill Bulk Fuel Storage Facility, a massive World War II military tank farm located in the hills above Pearl Harbor , seeped into a well that supplied water to housing and offices. in and around the sprawling base. Some 6,000 people suffered from nausea, headaches, rashes and other symptoms.

After months of resistance, the military accepted an order from the state of Hawaii in April to drain the tanks and close the Red Hill facility. A separate report the Department of Defense provided to the state Department of Health on Thursday said December 2024 was the earliest possible time to safely refuel tanks.

The investigation report listed a series of cascading errors beginning on May 6, 2021, when operator error caused a hose to burst and spill 21,000 gallons of fuel during the transfer of fuel between tanks. Most of this fuel spilled into a fire extinguisher line and remained there for six months, causing the line to collapse. A trolley slammed into this sagging line on November 20, releasing 20,000 gallons of fuel.

The area where the cart hit the line is not believed to have fuel, and so officials responding to the spill did not have the correct equipment to capture the liquid.

“The team incorrectly assumes that all the fuel has been absorbed,” Admiral Sam Paparo, commander of the US Pacific Fleet, told reporters at a press conference. Approximately 5,000 gallons were not recovered.

“Meanwhile, for eight days, that fuel goes into that French drain that’s under the concrete and slowly and silently seeps into the Red Hill well. And that fuel in the Red Hill well is then pumped into the Navy system,” Paparo said.

Red Hill officials believe only 1,618 gallons leaked in the May spill and they recovered all but 38 gallons. They noticed that one of the tanks was 20,000 gallons short, but they believed it had gone through the pipes and didn’t realize it had flown into the fire extinguisher line. They did not report the discrepancy to senior management.

After the November spill, when people started getting sick, the military moved about 4,000 families, mostly military, to hotels for months while they waited for their water to be safe again.

The spill contaminated the Navy’s water system. The fuel did not enter the Honolulu municipal water supply. But concerns that oil could migrate through the aquifer and enter the city’s wells prompted the Honolulu Water Supply Board in December to shut down a key well serving some 400,000 people. The agency asked residents to conserve water because of this and the unusually dry weather.

The report says officials failed to assume the best of what was happening when the spills happened, instead of assuming the worst, which helped them forget about the seriousness of the situation.

Paparo said the navy was trying to get away from that. He called it an ongoing process of “getting real with ourselves” and “being honest about our shortcomings.”

He 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 issues may exist in other locations,” Paparo wrote in the report.

The vice chief of naval operations tasked the chief of U.S. Fleet Forces Command, a four-star admiral, with determining disciplinary action for those in uniform. Recommendations for civilian employees will be sent to their supervisors, Paparo said.

The report says the investigation found that poor training and supervision, ineffective leadership and a lack of operational safety ownership also contributed to the incident.

“The lack of critical thinking, intellectual rigor and self-assessment by key leaders at decisive moments exemplifies a culture of complacency and demonstrates a lack of professionalism 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 of day-to-day operations at Red Hill. The report states that this significantly increases the risks associated with fuel handling operations.

He also noted that key leaders at the scene of the November 2021 spill failed to demonstrate a sense of urgency, critical thinking, strong support and quick and effective communication. required “by the gravity of the situation”.

US Representative Kaiali’i Kahele said the Navy had repeatedly declared Red Hill a vital part of US national defense, but had been left for decades without proper oversight. He said it shows a lack of leadership, investment and gross negligence.

“The Navy report indicates that the fuel leaks at Red Hill in May and November 2021 were preventable. This is shocking and deeply concerning,” Kahele, a Democrat from Hawaii, said in a statement.

David Henkin, an attorney for Earthjustice, who has filed lawsuits against the facility, said the Navy hasn’t learned from its mistakes.

“Rather than act quickly to remove the more than 100 million gallons of toxic fuel that remain perched on Oahu’s sole source aquifer, the Navy is proposing to take another two and a half years – until the end of 2024 – to empty the reservoirs of Red Hill,” he said. “It is totally unacceptable.”

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