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A string of extraordinary failures in maintenance, training and leadership at the Navy’s Red Hill fuel facility resulted in fuel spewing from a broken pipeline for 30 hours, leaking petroleum into the military’s drinking water and sickening entire families last year, military officials said Thursday. 

The results of two U.S. Pacific Fleet investigations into the disaster, , laid bare the human errors and systemic negligence that allowed two catastrophic leaks to occur within months of each other. 

The reports reveal that a leak on May 6 was much worse than initially reported – some 20,000 gallons escaped instead of the initially reported 1,000 – and that the failure to properly investigate that leak was a major factor in another one happening on Nov. 20. That second spill was the one that injected as many as 3,322 gallons of fuel into the drinking water, according to one of the reports. 

The findings back up community members’ longstanding concerns that Red Hill is fundamentally unsafe, a contention that the Navy denied for years – until now. 

“They were right,” Adm. Sam Paparo, commander of the U.S. Pacific Fleet, told Civil Beat after a press conference to discuss the findings. “The Navy was wrong to say that it was safe. That is clearly evident in the outcome.” 

, by Rear Adm. Christopher Cavanaugh, says human error was the primary cause of both leaks, but that’s “not the full story,” the report says. 

At Red Hill, there was a culture of disregarding procedures, poor training and supervision, ineffective command, a lack of ownership over operational safety, a lack of timely, accurate and thorough reporting, and a flawed investigation into the May spill. 

“The lack of critical thinking, intellectual rigor and self-assessment by key leaders at decisive moments exemplified a culture of complacency and demonstrated a lack of professionalism that is demanded by the high consequence nature of fuel operations,” the Cavanaugh report states. 

Two leaders, in particular, stand out for actions that were “disturbing,” the reports states.

In February 2021, just a few months before the May leak, the commanding officer of Fleet Logistics Center Pearl Harbor –  Capt. Trent Kalp – modified the duties of the fuels officer to effectively remove military oversight of the day-to-day operations of Red Hill, according to Cavanaugh’s report. 

That action “significantly” increased the risks associated with fuel handling operations, the report states. As a result, the report says no military members were overseeing fuel operations in a 12-hour period on May 6. 

Kalp left his position just two months after the May leak with a . A Navy official commended him on his “unequaled professionalism” and “outstanding record of achievement.” 

The Cavanaugh report also points blame at the commander of the Naval Facilities Engineering Systems commander, who was Capt. James “Gordie” Meyer.

Meyer – along with Capt. Albert Lee Hornyak, the former commanding officer of NAVSUP Fleet Logistics Center Pearl Harbor – “failed to exercise the sense of urgency, critical thinking, forceful backup and timely and effective communication demanded by the seriousness of the situation.” 

Meyer was  this month. But he’ll still be involved with Red Hill. According to a Navy press release, he will serve as the “lead for supporting the NAVFAC organization responsible for defueling the Red Hill Bulk Fuel Storage Facility.” 

Since the crisis, several other leaders have left their positions. including Rear Adm. Tim Kott, the former commander of Navy Region Hawaii. 

Navy Capt. Erik Spitzer – the Pearl Harbor commander who initially said the area’s drinking water was fine when in fact the community had been drinking fuel – departed in June, but not before receiving the for his service.

Hornyak was fired following yet another leak at Red Hill in April of this year. The Navy said his termination was based narrowly on that recent leak of an estimated 30 gallons and not related to the fuel releases that tainted the water. However, the investigative report by Cavanaugh paints an unflattering picture of him. It says he failed to take charge as the on-scene commander during the November leak. 

“He demonstrated poor judgment by deciding that the spill was stable and manageable despite uncertainty about key elements of the unfolding incident,” the report said. 

Paparo and Adm. John Aquilino, commander of the U.S. Indo-Pacific Command acknowledged on Thursday that some military officials have been removed from their positions because of the debacle. But the commanders refused to identify them nor specify how many people have been reassigned. 

A separate process is underway regarding disciplinary actions, and its results may be made public later, Paparo said. 

“The Navy has a profound moral obligation and ethical duty to fix our mistakes and rebuild trust with the community here in Hawaii,” Paparo said.

In the meantime, the Navy has to the Hawaii Department of Health. Defueling is estimated to begin by the end of 2024, according to ​​Meredith Berger, the assistant secretary of the Navy for energy, installations and the environment. 

The Pentagon announced in early March that it will permanently shut down the World War II-era facility, reversing years of efforts to keep it open. But officials have warned that the facility needs major repairs for the fuel to be drained safely.

The Navy made senior officials available and provided journalists with a copy of the main investigation into what happened at Red Hill along with a supplemental report early Thursday but only under the condition that the information be embargoed until 1 a.m. Friday.

The state health department later released the investigation report along with the defueling plan, saying it was doing so “in the interest of transparency” and breaking the embargo.

In a statement, Deputy Director of Environmental Health Kathleen Ho said Red Hill needs to be shut down as quickly as possible.

“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,” she said. 

In the meantime, impacted families say they’re still sick and need assistance. 

Kristine Baehr, an attorney who represents over 100 clients in the Pearl Harbor area, said in a statement that there are still many unanswered questions. That includes the test results for water samples she says her clients never received. 

“The Navy insists the health effects are fleeting. But our clients continue to experience very real and long-lasting heath challenges,” she said. “We will pursue truth and recovery.” 

‘Cascading Failures’

The Red Hill facility is an 80-year-old fuel storage complex located up the mountain from Pearl Harbor and just 100 feet above Oahu’s primary drinking water aquifer. The facility is made up of 20 massive fuel tanks that together currently store about 100 million gallons of fuel. 

According to the Cavanaugh report, the water contamination was the result of “cascading failures” that were preventable. 

The basic facts have been shared previously, but the investigative reports reveal new details that have not been shared before. 

On May 6, 2021, operators at Red Hill improperly executed a fuel transfer, resulting in a pressure surge and the rupture of two piping joints, the reports state. At the time, the operations orders were “poorly written and unclear,” the Cavanaugh report states. 

The event resulted in a 500-pound section of pipe popping off, allowing thousands of gallons of fuel to spray into the tunnel. 

Much of the fuel was captured by a fire suppression system retention line, which is designed to catch water and firefighting foam after a fire. In this case though, it captured about 16,999 gallons of fuel, which flowed makai of the Red Hill tanks but then stagnated in the pipe, according to the report. 

The initial report from the deputy fuels director – who is a civilian, John Floyd – stated that the spill was contained and that no fuel was released into the environment, according to the report. That assessment was later echoed by the Fleet Logistics Center Pearl Harbor commander, Kalp, even though it was based on visual observations alone, the report states. 

FLC Pearl Harbor failed to make immediate reports about the spill to NAVSUP and the regional operations center, despite requirements to do so, the report states. The day after the spill, a Department of Health coordinator asked why she had not been informed of the spill. According to the report, a Navy representative told her reporting wasn’t required because there was no release to the environment. 

In the end, Red Hill personnel failed to properly investigate the May 6 surge and didn’t realize there were thousands of gallons of fuel unaccounted for, hidden in the fire suppression system, according to the report. 

On May 7, personnel determined that Tank 12 had lost 19,983 gallons of fuel in 17 minutes on May 6. Despite this, Kalp emailed NAVSUP reporting that only 557 gallons had been released. 

“This was the last total reported to him by (Deputy Fuels Director Floyd),” the report states. 

On May 7 or 8, FLC Pearl Harbor contacted a fire suppression system contractor, Kinetix, to inspect the system, and the company falsely concluded the fire suppression pumps had not been activated, the report says. 

Later that month, the discrepancy in the fuel amounts was reported to Floyd and Kalp, according to the report. However, the report states that “(Kalp) did not recall this report.” 

Multiple supervisors, including Kalp, “failed to ask hard questions” or demand an explanation for the disappearance of so much fuel. An earlier root cause analysis of the May 6 release, shared with the public in October, blamed the incident on human error and made no mention of the 19,000 gallons of fuel. 

The lack of inquiry would lead to a catastrophe months later.  

‘Not Trained Or Equipped’

On Nov. 20, a Red Hill rover inadvertently hit the valve of the fire suppression pipeline with the cart of a tunnel train, cracking the valve and spilling fuel that had been sitting there for months. 

Because it was a PVC pipe, the weight of the fuel in the pipeline over time may have caused it to sag, putting it at risk of a collision, according to the report. 

“I do not assess this event was due to misconduct,” the report states.

The Navy initially said that 14,000 gallons of fuel and water was released, but in fact, the Cavanaugh report says the pipeline was holding 16,999 gallons of jet fuel, which was released on “full blast.” 

An engineer who responded was also covered in fuel when he slipped and fell in it, and he sustained minor chemical burns, according to the report. 

“During the emergency response, the Red Hill rover attempted to stop the spill and was doused with fuel,” the report states, adding that he visited the emergency room that night for burning and itching skin. 

“FLC Pearl Harbor personnel were not trained or equipped to stop the source of the fuel spill,” the report states. “Without the ability to stop the spill, responders defaulted to managing it. They did not know how much fuel would spill or for how long, and even as (the) spill was ongoing, personnel were focused on recovery and cleanup rather than control.” 

Appropriate personal protective gear was not available at the scene, the report said. 

Red Hill personnel were initially confused because there shouldn’t have been fuel in the fire suppression system at all, according to the report. They initially reported the substance as water, despite a fuel smell.

The leak’s location near an exhaust fan sent fuel vapors into the outside environment, the report said. On Floyd’s ride into work, he said he could smell fuel from the H-3 interstate, according to the report. 

While an emergency response plan was in place for catastrophic fuel leaks, it was not formally activated. 

“No single person took charge at the scene,” the report states. 

The plan also did not include a procedure for addressing the Red Hill well, according to the report. Responders did not adequately understand the risk to the well, the report says. They were aware of its proximity to the fuel release and, early on, checked the well for fuel, but they found none. 

“Based on those initial actions, they incorrectly assessed here was no risk to the drinking water well,” the report said. “This knowledge gap is surprising and concerning given persistent scrutiny on the environmental risks associated with a major fuel spill at Red Hill.” 

The well was not secured until Nov. 28, over a week after the fuel release when families started to report a chemical smell in their water and accompanying health problems.  

By then, fuel had already seeped into the well through multiple pathways, the report found. One was through a drain line that led from the floor of the tunnel on Nov. 20 to the drinking water well. But the tunnel itself is also made of porous concrete, the report notes. 

The report cites numerous systemic problems, including that there was:  

• Understaffing “at every level.”
• A lack of qualified staff, training and drills.
• A bias among the leadership to assume best case scenarios. 
• A lack of clear leadership, with “blurred lines of responsibility, authority and accountability.” 
• No formal or effective process for self-assessment. 

“Although the Navy is proficient at conducting technically complex, high-consequence operations at sea, many of those processes were not applied at Red Hill,” the report states.