오월에 6, 2021, operators at the facility improperly began a fuel transfer that caused a surge of pressure within the system, the Navy’s command investigation found. The rapid buildup of pressure damaged two piping joints and led to a fuel spill. But the facility and its commanders did not realize or report the extent of the spill, believing it was only about 1,580 gallons.
실제로, 대략 20,000 gallons had spilled, the vast majority of which flowed into a fuel suppression system running through a tunnel system, the investigation found. The system’s retention lines held the fuel for six months, and its weight caused the PVC pipes to sag.
11 월 20, 2021, a small underground cart on a facility train struck a valve on the sagging PVC pipes, causing the fuel in the lines to gush out. But emergency responders were initially told the liquid was a mixture of fuel and water, not just fuel, the Navy found.
For days, local Navy officials believed there was no threat to the environment, telling their commanders there was no risk to groundwater and no danger of environmental contamination, the Navy found, insisting that fuel could not seep through the concrete tunnel or the 100 feet of rock separating the tunnel from the aquifer.
A week after the spill, the facility received its first complaint of a fuel smell in the water from a nearby resident. 다음 날, the facility received 37 more calls complaining of fuel in the water. The number of calls would quickly reach into the hundreds.
11 월 28, the Navy shut down its Red Hill well after reports of people living on base suffering nausea, vomiting, diarrhea, headaches and skin-related problems. Testing revealed petroleum hydrocarbons and vapors in the water, the Navy said at the time.
In its command investigation, the Navy found that the responses to the May spill and the November spill were inadequate and that proper training and drills after the original leak could have identified the risk to the well.
“궁극적으로, both spill responses were flawed because they concluded with a significant amount of fuel unknowingly remaining outside of reported containment boundaries,” the investigation concluded.
A complex web of responsibilities and accountability left it unclear who was in charge of what, the Navy found, making it increasingly difficult to identify the best solutions and how to implement them as the situation worsened.
“These deficiencies endured due to seams in accountability and a failure to learn from prior incidents that falls unacceptably short of Navy standards for leadership, ownership, and the safeguarding of our communities,” the Navy found.