Navy report: Multiple errors poisoned Pearl Harbor water

The investigation is the first detailed account of how jet fuel from the Red Hill Bulk Fuel Storage Facility, a massive World War II-era military-run tank farm in the hills above Pearl Harbor, leaked into a well that supplied water to housing and offices in and around Pearl Harbor.

The report listed a cascading series of mistakes from May 6, 2021, when operator error caused a pipe to rupture and 21,000 gallons of fuel to spill when fuel was being transferred between tanks. The fuel spilled into a fire suppression line, sat there for six months and then spilled again when a cart rammed into it on Nov. 20.

Military medical teams examined some 6,000 people for nausea, headaches, rashes and other symptoms. The military moved about 4,000 mostly military families into hotels for months while they waited for their water to be safe again.

The report said officials defaulted to assuming the best about what was happening when the spills occurred, instead of assuming the worst, and this contributed to their overlooking the severity of situation.

Adm. Sam Paparo, the commander of the U.S. Pacific Fleet, told reporters at a news conference that the Navy was trying to move away from that. He called it an ongoing process “to get real with ourselves” and “being honest about our deficiencies.”

The report said the investigation revealed that poor training and supervision, ineffective leadership and an absence of ownership regarding operational safety also contributed to the incident.

“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 report said.