On Thursday the Pentagon’s Inspector General office released long-awaited reports on the Navy’s fuel and water systems on Oahu.

Hawaii’s congressional delegation called for the Pentagon to launch a probe after jet fuel from the Navy’s Red Hill fuel facility contaminated the Red Hill well inside the facility, and in turn the Navy’s Oahu water system, which serves 93,000 people, in November 2021.

The reports contain detailed timelines of the failures that led to the incident. Many of the details had already become public as a result of previous investigations — some of which are cited in the new reports. But the Pentagon probe includes new details on just how unprepared and disorganized the Navy was when the crisis began.

Notably, investigators reported that “some Navy officials told us that they did not know about the existence of the Red Hill well and the water development tunnel or did not understand the proximity of the fuel release to the Red Hill well” and that many were not trained on or even had no knowledge of their service’s own emergency response plans.

Capt. Erik Spitzer, the now retired commander for Joint Base Pearl Harbor Hickam who told residents on Nov. 29, 2021, that “there are no immediate indications that the water is not safe,” did not know the Red Hill well was in the Red Hill Fuel Facility.

In the aftermath more than 6,000 men, women and children sought medical help, reporting a litany of ailments from rashes to vomiting and neurological issues. Many say they suffer long-term medical problems to this day.

The immediate response and the subsequent effort to close Red Hill have cost taxpayers more than $2 billion.

Investigators wrote that “because the Navy officials lacked sufficient understanding of the risks, they incorrectly believed that the fuel released during the November 2021 fuel incident did not have a pathway to contaminate the Red Hill well.” But they also concluded that there were enough documents available to Navy leaders at the time that “clearly identified the risks to the Red Hill well in the event of a fuel incident.”

The inspector general made 38 recommendations, including appointing a single official to manage fueling operations at JBPHH, a review of leak detection systems and updating response plans. The office is also calling for a review to determine whether anything illegal occurred in the installation of Red Hill’s $50 million fire suppression system, during which contractors used PVC piping instead of the steel required by the contract.

In a joint statement the members of Hawaii’s congressional delegation said, “These independent reports make clear that for decades the Navy and the Department of Defense have failed to manage fuel and water operations at Red Hill and across Joint Base Peal Harbor­-Hickam to a standard that protects the health and safety of the people of Hawai‘i. It’s outrageous and unacceptable.”

“The Navy must take full responsibility for its failures and immediately implement the recommendations from the Inspector General in order to address the ongoing impacts to public health and the environment,” the lawmakers continued. “The delegation requested this investigation, and we will continue to exercise our oversight duties and ensure that the Navy and the Department of Defense fully comply with the recommendations outlined in these reports.”

The Red Hill facility, built underground during World War II to protect it from enemy attacks, sits just 100 feet above a critical aquifer most of Honolulu relies on for fresh water. Documented fuel spills go back as far as 1948, but a 2014 incident involving Red Hill’s Tank 5 made it a lightning rod for controversy.

In May 2021 fuel spilled from a pipeline in Red Hill. The Navy said at the time it cleaned it up, but a few thousands gallons were still unaccounted for. Later reports revealed it leaked into the facility’s fire suppression system. In November 2021 a worker at the facility accidentally ruptured the PVC piping, spilling fuel that made its way into the Navy’s Red Hill water well and throughout the Navy water system.

The military has since defueled Red Hill and is working to permanently shut it down — but Red Hill isn’t the only place there are problems. According to the new Pentagon reports, there are approximately 23 miles of above- and underground fuel pipelines extending across Joint Base Pearl Harbor-­Hickam and connecting the fuel systems, including Red Hill, with widespread issues.

Lt. Cmdr. Shannon Bencs, a former Red Hill fuel director and Navy whistleblower who was removed from her duties in 2022 after raising concerns about fuel leaks, told the Honolulu Star-­Advertiser that while reading the report she had “mixed emotions” because, although the Department of Defense acknowledged the issues and incidents she’d raised alarms about while there, no one was held formally accountable.

“What it comes down to is that they didn’t just violate DoD orders, they violated Navy orders, they violated the state and federal laws,” Bencs said. “Someone needs to go to jail, in my opinion.”

Spotty records

On April 26, 2007, Navy officials reported a fuel level decline at an above-ground fuel tank at JBPHH. On April 28, 2007, Navy officials inspected the base’s upper tank farm and found a 1-1/2-by-3-inch hole in a tank. Navy officials estimated approximately 359,000 gallons of marine diesel fuel leaked into the ground through the hole.

The Navy began remediation efforts in May 2007. According to the Navy, its officials conducted significant work to remediate the leak, and from June 2007 to December 2011, 25,647 gallons of fuel was recovered. Laboratory testing of the recovered fuel indicated the presence both of fresh and “weathered fuel,” fuel that has degraded enough to indicate in tests that it is older than 5 years, suggesting that some may have come from an earlier leak.

On March 17, 2020, Navy personnel observed an oil sheen on the water in Pearl Harbor near Hotel Pier and spotted similar sheens throughout the year. The Navy looked into it and found a seemingly abandoned pipeline that had no external markings and did not show up on maps officials reviewed.

Investigators wrote, “Navy officials told us that they determined that it was the source of the oil sheen and sealed the defuel pipeline. However, Navy officials told us that on August 11, 2020, they saw another oil sheen on the water in Pearl Harbor near Hotel Pier.” By December 2020 the state Department of Health ordered the Navy to fix it and report updates immediately.

When Pentagon investigators visited JBPHH in 2022, they asked to see engineering drawings and schematics for the interconnected fuel system and were told records were kept in a technical library.

When the investigators went to see them, they said the library “was disorganized, with documents overflowing into the hallway, a lack of labeling, and piles of engineering drawings scattered on various tables.” A Navy contractor said there was no one on staff to “collect and integrate drawings from projects that changed the (fuel) infrastructure over time.”

Investigators also said nobody could tell them whether the records were accurate or complete, and were generally told that nobody saw it as their responsibility. They wrote, “We determined that Navy officials did not have accurate and up to date as-built drawings of … tanks, pipelines, and supporting infrastructure.”

At another point investigators visited Fleet Logistic Center Pearl Harbor Headquarters and reported that they saw maintenance team members who said they did not have proper maintenance training and that “maintenance orders were not specific enough to complete the work.”

Officials also told the investigators that while they had a large parts warehouse and someone to make purchases, they didn’t have staff to receive, inventory and keep records for future parts orders. They said the actual ordering process was long and unreliable as they searched for information on the original manufacturer, looked for vendors and wrestled with long wait times.

Investigators even said some officials reported that they had “sometimes spent their own money to order parts to keep maintenance tasks moving,” and that because the FLC lacked a formal tool control program, “accountability for the tools needed to perform operator maintenance is left to individual maintainers who hold onto their own tools to perform their maintenance tasks.”

‘Bad assumption’

At the Red Hill facility, investigators blasted poor maintenance, planning and preparedness.

In particular, they criticized key officials for not following their own guidelines, writing that “although the incident response plans were inadequate, we determined that, if Navy officials had followed any one of the incident response plans, the effects of the May 2021 and November 2021 fuel incidents might have been mitigated or prevented.”

They noted that there was little discussion of the risk to the well inside the fuel facility, despite the potential being previously well documented. Investigators noted that a 2015 simulation of a major fuel failure “showed the worst-case discharge scenario would threaten the Red Hill well even with the oil-tight door closed.”

The investigators noted that nevertheless, protocols on potential Red Hill fuel incidents did “not direct Navy officials responding to any fuel incident to contact JBPHH (Public Works Division) officials to activate the JBPHH Community Water System Emergency Response Plan.”

One Navy official told investigators that “all the spill plans, the response plans, (were) based on the premise of a tank failure. All the incidents post 2015 have been infrastructure failures. The bad assumption we made was that the tunnel system would be containment. There was never a leak from a tank (since the January 2014 fuel incident). There was no emphasis put on other potential impacts to the drinking water well, because we believed it would be contained in the tunnel.”

But the Pentagon investigators concluded that due to Red Hill’s location, it should have been clear that “there was an inherent risk to the aquifer and the JBPHH Community Water System. Additionally, based on historical incidents, we concluded that the lower access tunnel … floors, soil, and rock below are permeable to liquids, such as fuel.”

The investigators found that in August 1945 a significant water draw lowered the water level in the water development tunnel. The Red Hill well pumps, which were designed to be fully submerged, began experiencing problem. Army and Navy personnel drilled and use dynamite to modify the well.

Investigators wrote that “the drilling and dynamiting increased the risk to the Red Hill well, because it damaged the structural integrity of the water development tunnel … therefore, releases of liquids … such as fuel, could flow to the water development tunnel in the event of an incident, as evidenced in 1948.”

The investigators also found that the Navy partially shut down parts of the Red Hill fire suppression system in May 2018 due to ongoing concerns about it, but didn’t inform anyone working in Red Hill.

According to Occupational Safety and Health Administration, the Navy “did not inform personnel working in the Red Hill (facility), including Navy employees and contractors, that the Red Hill (facility) fire protection system was partially inoperable.” In March 2022, OSHA officials issued a notice to the Navy warning that “welding and hot work on the tanks, and the tank gallery area of the tunnel was ongoing. Alternative firefighting measures were not put in place, exposing employees to fire hazards.”

In 2021, during the May and November incidents, investigators “determined there was no consensus among Navy officials regarding who was in charge during either fuel incident.” The investigation also painted a scathing picture of communication with the community once the fuel entered the water.

The JBPHH emergency plan for water was to assume that the entire system was a threat unless demonstrated otherwise, but investigators alleged that Navy officials kept information from both each other and the public, and didn’t proactively look for answers until it was too late.

Investigators wrote that “Navy officials reported that ‘the drinking water remains safe’ based only on the lack of immediate indicators of drinking water contamination.”

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Staff writer Victoria Budiono contributed to this report.