Navy probe: ‘Cascading,’ preventable failures caused water crisis that sickened thousands

In response to the report, Hawaii's Health Department said its first priority is to ensure the Navy's defueling activities are performed safely.
Published: Jun. 30, 2022 at 3:04 PM HST|Updated: Jul. 1, 2022 at 10:42 AM HST
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HONOLULU (HawaiiNewsNow) - Two fuel spills at the Red Hill underground storage facility that triggered a water crisis and sickened thousands of Hawaii families were the result of a series of preventable and “cascading failures,” according to an exhaustive report conducted by the Navy and released by the state Health Department on Thursday afternoon.

The report outlines an embarrassing series of failures that led to contamination of the Navy’s water system with as much as 5,000 gallons of diesel jet fuel ― along with an ongoing threat to the public water system that continues until today.

As part of the months-long probe, Navy investigators said they found a culture of procedural noncompliance at Red Hill, poor training and supervision, no “ownership” around operational safety, and a flawed investigative process.

“The water contamination resulted from a series of cascading failures and those failures were preventable,” investigators concluded, in the report. “They were both individual error and systemic problems.”

Adm. Samuel Paparo, commander of U.S. Pacific Fleet, said at a news conference Thursday morning that he’s hopeful the investigation bolsters public trust in the Navy. “I believe that the basis for trusting us as we move forward is the fact that we elevated this investigation,” he said. “I think the trust could be derived from the technical details and the exhaustiveness.”

The probe also includes a series of recommendations for moving forward.

[Read the Navy’s full investigation in the Red Hill water crisis.]

Separately, the Health Department released the Navy’s plan for emptying the Red Hill tanks, which officials said will wrap up no earlier than the end of 2024. The report concluded major infrastructure repairs to the facility are needed before fuel can be moved.

“Red Hill needs to be shut down as quickly as possible and we fully expect that the Navy will marshal all possible available resources to defuel and decommission the facility,” Deputy Director of Environmental Health Kathleen Ho said, in a news release.

“However, with the extensive repairs needed and the Navy’s history of spills from unsafe pipelines, our first priority continues to be ensuring that all defueling activities are performed safely for the sake of the people and environment of Hawaii.”

The Navy probe of the water crisis examined two spills at the Red Hill facility in 2021: One on May 6 and the second on Nov. 20.

Investigators said the May 6 spill was caused by a failure to follow the required procedure for fuel transfer.

The Navy said the spill was initially believed to involve only a small release, but actually included more than 20,000 gallons ― most of which drained into a retention line where it sat for over six months.

In a particularly eyebrow-raising portion of the report, investigators found that the commander of Navy Region Hawaii first learned about the May 6 spill after receiving an email seeking more information from Hawaii News Now.

The situation ballooned into a crisis on Nov. 20, when a trolley struck the pipe where the fuel from the May 6 had settled.

“The team that’s there is inadequately trained to respond and doesn’t have the type of equipment to pick up fuel,” Papparo said.

While much of the fuel was recovered, more than 5,000 gallons was “unaccounted for” ― and believed to have seeped through concrete flooring at the facility into the Navy water system that serves 90,000 people on Oahu, mostly military families.

Shortly after the Nov. 20 incident, people reported getting sick after drinking or using the water.

And for months, those served by Navy water were unable to use their taps.

“Key leaders at the scene of the 20 November 2021 fuel spill ... failed to exercise the sense of urgency, critical thinking, forceful backup, and timely and effective communication demanded by the seriousness of the situation,” the report said.

The report outlines an embarrassing series of failures that led to contamination of the Navy’s water system.

The Navy said those who didn’t do their jobs correctly will face disciplinary action, but details were not released.

Authorities also said the investigation determined deficiencies at Red Hill were not unique. That revelation has prompted a broadened probe of 57 fuel installation worldwide.

The Navy initially embargoed the findings of the investigation until 1 a.m. Friday, but HNN released them after being provided with a copy of the report independently.

The state Health Department subsequently made both reports available online.

The Navy investigation comes as environmentalists and critics are increasingly skeptical of the Navy’s ability to safely and efficiently empty the World War II-era tanks, which contain about 180 million gallons of diesel jet fuel.

The facility sits just 100 feet above an aquifer that serves as the principal source of drinking water for Oahu.

“Multiple errors led to what ended up to be a catastrophic incident at Red Hill,” said Congressman Kai Kahele, D-Hawaii.

Added David Henkin, Earthjustice senior attorney, added that failures like those documented in the report don’t happen “unless it’s really an indifference to what the impacts are and what the consequences are.”


This story will be updated.

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