Notable items from the Pentagon investigations

CINDY ELLEN RUSSELL / 2015 Hundreds attend a public hearing at Moanalua Middle School on the Navy's plan to fix the Red Hill Bulk Fuel Facility storage tank that leaked an estimated 27, 000 gallons of jet fuel on Jan. 13, 2014.

JAMM AQUINO / 2023 The Joint Task Force Red Hill announced the findings of the aqueous film-forming foam concentrate spill investigation that occurred in 2022. Adm. John Wade, leader of Joint Task Force Red Hill, speaks during a press conference at Joint Base Pearl Harbor-Hickam.

U.S. NAVY Fuels director Lt. Cmdr. Shannon Bencs walks a portion of the seven miles of tunnels of the Red Hill Underground Fuel Storage Facility.

CINDY ELLEN RUSSELL / 2015 Hundreds attend a public hearing at Moanalua Middle School on the Navy's plan to fix the Red Hill Bulk Fuel Facility storage tank that leaked an estimated 27, 000 gallons of jet fuel on Jan. 13, 2014.

JAMM AQUINO / 2023 The Joint Task Force Red Hill announced the findings of the aqueous film-forming foam concentrate spill investigation that occurred in 2022. Adm. John Wade, leader of Joint Task Force Red Hill, speaks during a press conference at Joint Base Pearl Harbor-Hickam.

U.S. NAVY Fuels director Lt. Cmdr. Shannon Bencs walks a portion of the seven miles of tunnels of the Red Hill Underground Fuel Storage Facility.

FAILURE POINTS Reports from the Pentagon's Inspector General office on the Navy's fuel and water systems on Oahu were released Thursday, with detailed timelines of the failures that led to spills from Red Hill. Here are some highlights from the 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.—On several occasions in 2020, Navy officials observed an oil sheen on the water in Pearl Harbor near the Hotel Pier. Navy officials eventually tied it to a seemingly abandoned defuel pipeline that "had no external markings and that Navy officials later said was not shown on any pipeline drawings that Navy officials reviewed."—Investigators determined that Navy officials "did not have accurate infrastructure records. Additionally, we determined that (the military's fuel system ) had poor infrastructure conditions. We determined that the methods of release detection ... are ineffective, unreliable, or inoperable, and that the lack of release detection increased the risks of fuel incidents."—Navy officials told investigators that engineering drawings, schematics and records were kept in a technical library. Investigators wrote that "during our visit, we saw evidence that the library was disorganized, with documents overflowing into the hallway, a lack of labeling, and piles of engineering drawings scattered on various tables."

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Investigators asked a Navy contractor about the state of the library were told the Navy "did not have a full ‐time librarian or records keeper to organize the inventory of engineering drawings and to collect and integrate drawings from projects that changed the (fuel ) infrastructure over time."

Nobody could tell investigators whether the rec ­ords were accurate or complete.—Investigators wrote 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."—The Navy partially shut down parts of the Red Hill fire suppression system in May 2018 but didn't inform anyone working in Red Hill. According to the 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 BFSF fire protection system was partially inoperable."—In March 2022, OSHA officials issued a "Notice of Unsafe or Unhealthful Working Conditions " to Navy officials for a "serious " violation. Specifically, the notice stated, "The AFFF fire suppression system for the 12-million gallon storage tanks which contained hydrocarbon fuels, was disabled and locked out for more than a year. 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."—The Red Hill fuel facility's emergency plans did not direct Navy officials responding to any fuel incident to contact JBPHH (public works department ) officials to activate the JBPHH Community Water System Emergency Response Plan.—JBPHH commander Capt. Erik Spitzer, 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 and "did not understand the proximity of the fuel release to the Red Hill well until December 5, 2021 during a visit with the Secretary of the Navy."—During a visit to Pearl Harbor's fueling facilities in 2022, investigators witnessed maintenance team members telling the fuels director that they did not have maintenance training and that "maintenance orders were not specific enough to complete the work. "—Officials told investigators that they "have sometimes spent their own money to order parts to keep maintenance tasks moving " and that Pearl Harbor's fuel system "lacks 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."—After the November 2021 fuel spill at Red Hill, military medical providers documented 6, 138 medical encounters with residents ranging from rashes and gastrointestinal problems to neurological issues.