An alarming list of operational and leadership failures, communication breakdowns and cavalier attitudes toward oversight at the Navy’s Red Hill fuel storage facility contributed to two leaks in 2021 that ultimately contaminated the Navy’s drinking water system with jet fuel, according to a long-awaited investigation released Thursday by the Navy.

The investigation concluded that about 5,542 gallons of fuel ultimately escaped into the environment during a Nov. 20 pipeline rupture at the facility, a portion of which made its way to the Navy’s Red Hill well and the tap water of residents living in neighborhoods in and around Joint Base Pearl Harbor-Hickam.

The fuel release was not contained for 30 hours. About a week later, hundreds of residents began reporting fuel odors coming from their water and symptoms including vomiting, rashes and chemical burns.

“The investigation presents a brutally honest and highly critical self-assessment of the Navy’s mistakes and errors,” Adm. Samuel J. Paparo, commander of U.S. Pacific Fleet, said at a news conference to discuss the findings. “The Navy takes responsibility for its actions. The way forward is for the Navy to transparently acknowledge its mistakes while acting with a sense of urgency to safely and efficiently defuel.”

Following the Red Hill fuel leaks, and amid a groundswell of political and public pressure, the Pentagon announced earlier this year that it would shut down the facility and drain the massive underground fuel tanks.

The investigation lays out in painstaking detail events beginning with the May 6, 2021, fuel spill and leading up to the Nov. 20 spill and its aftermath, revealing multiple missed opportunities for preventing spilled jet fuel from making its way into the Navy’s Red Hill drinking water well.

On May 6, workers were transferring fuel from one tank to another when there was a loud explosion and fuel began pouring out of a pipe, filling a room, overtopping a bulkhead door and flowing into a tunnel. A Navy investigation released in October concluded that about 1,600 gallons of fuel had been released, all but 38 gallons of which was recovered.

But that conclusion, by Navy contractor Austin Brockenborough, was terribly wrong.

During the transfer, fuel in Tank 12 dropped by about 20,000 gallons in about 50 seconds, but workers and the contractor concluded that it likely remained in a pipeline. Over the course of the investigation, multiple Navy leaders expressed concerns that the 20,000-gallon drop in volume hadn’t been adequately accounted for, and raised concerns the contractor’s report was not thorough or well done.

But they released the report anyway, without further review, according to the findings released Thursday.

The fuel, as previously reported, was actually sucked up into a fire suppression pipeline that ruptured Nov. 20 when it was hit by a trolley cart for passengers and equipment. That fuel then seeped into the Red Hill shaft and the Navy’s drinking water system.

The investigation found that top Navy officials didn’t act quickly enough to communicate with one another about the seriousness of the situation or alert residents in late November that their water might be contaminated with fuel.

For example, by midnight Nov. 20, the commanding officer of Fleet Logistics Center Pearl Harbor and the commander and regional engineer for Naval Facilities Engineering Systems Command knew the spill was primarily fuel and likely from the May 6, 2021, spill, according to the report, but didn’t tell regulators or the public.

The commander of Fleet Logistics Center Pearl Harbor, who at the time was Capt. Albert Hornyak, also failed to report that the initial responder to the spill had gone to the hospital that evening due to chemical burns and that a second person had been injured.

The first complaint of a chemical odor came from a Moanalua resident on Nov. 27, but there was no indication that any action was taken beyond logging it. Then on the morning of Nov. 28, calls began streaming in to Joint Base Pearl Harbor-Hickam’s public works department complaining of fuel or chemical odors. The Navy had logged 37 calls by the end of the day.

By that evening top Navy officials, including Capt. James Meyer, commanding officer, Navy Facilities Engineering Systems Command Hawaii, thought the fuel smell in the drinking water could be coming from the Red Hill well because the calls were coming in from neighborhoods closest to the water source.

In response, the Red Hill well was shut down that evening, but the public was not informed.

Meyer was able to personally detect a petroleum odor in the water at NAVFAC’s headquarters that night.

By the next day, reports from military families about fuel odors in their water and getting sick flooded social media. Navy officials began flushing water from hydrants and scrambling to respond to the emergency. State Rep. Aaron Ling Johanson called in to report a constituent was able to set her tap water on fire.

Despite the alarm, Capt. Erik Spitzer, commander of Joint Base Pearl Harbor- Hickam, released a statement to residents of military housing reiterating there were no immediate indications the water was unsafe.

“My staff and I are drinking the water on base this morning, and many of my team live in housing and drink and use the water as well,” wrote Spitzer.

It wasn’t until later that evening that military families were warned not to drink the water — and that warning came not from the Navy, but from the state Department of Health, which was also being flooded with calls.

Despite the numerous missteps, the investigation concluded that Navy leaders were operating in good faith.

There “was never an intent to mislead, lie or obfuscate in any case,” according to the report. “All communications were developed with the intent of being truthful based on the facts known at the time, all of which were unfolding in a dynamic and fast developing environment.”

The investigation also found there was no camera footage of either the May 6 or Nov. 20 spill because out of the 57 closed-circuit security cameras in the facility, only 13 worked, and none of those covered areas inside Red Hill where the two spills occurred.

About five months prior to the May spill, the Navy realized the camera system was not fully operable, and routed a request through the Defense Logistics Agency to fund a replacement system. The request was approved prior to the May 6, 2021, spill, but a miscommunication resulted in the Navy’s Fleet Logistics Center being “erroneously informed” that the system would not be funded, according to the investigation.

It wasn’t until January that the Defense Logistics Agency resolved the “communication breakdown” and committed to funding a new system. Navy officials said Thursday that all of the cameras are now working.

The investigation also concluded that the responses to the May and November spills were virtually the same because there was “no learning or assessment” following the May spill.

“Most troubling, there were no integrated spill response training or drill events conducted with installation and other support personnel between the May and November spills,” according to the report. “Without such actions, there was no opportunity to understand the deficiencies, friction points, and challenges experienced by the combined team during the May spill.”

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