A contractor error and the Navy’s failure to provide adequate oversight led to the spill of approximately 1,300 gallons of concentrated aqueous film-forming foam, or AFFF — a fire suppressant containing toxic “forever chemicals” — at the Navy’s Red Hill facility in November, according to a long-awaited report on the spill released Friday by the military.

Kinetix, a military contractor responsible for the maintenance of Red Hill’s fire suppression system, incorrectly installed an air vacuum valve in April 2022, according to the report. The contractor then failed to disable the AFFF pumps from automatically starting before testing the system on Nov. 29, leading to the uncontrolled release of the fire suppressant, which video shows quickly flowed underneath a tunnel door to the outside.

The spill released toxic chemicals into the ground and prompted a major environmental cleanup operation involving soil excavation and testing for chemicals known as PFAS in the soil and groundwater. The che­micals degrade extremely slowly in the environment and are linked to an increased risk of certain cancers and other problems.

“I’ve already said this, and it needs to be said again to the people of Hawaii, that on behalf of the Department of Defense. I’m truly sorry,” said Navy Vice Adm. John Wade, who is overseeing a task force responsible for defueling Red Hill, during a news conference to announce the results of the investigation.

The valve mistake should have been caught by quality checks performed by both Kinetix and the Navy, according to the investigation, which was ordered by Wade and carried out by Maj. Gen. Richard J. Heitkamp of the Army Corps of Engineers.

The investigation has been forwarded to the Department of the Navy to look at potentially holding Kinetix liable for the spill. Kinetix did not respond to messages seeking comment about the findings.

The AFFF system has a history of problems and played a role in the November 2021 fuel spill at Red Hill that contaminated the Navy’s drinking water system serving neighborhoods in and around Joint Base Pearl Harbor-Hickam, sickening military families.

Wade said that given this history, there should have been more government oversight in place.

“I believe that this is particularly important because the AFFF fire suppression system is what I call a troubled system,” he said. “It has had a number of issues over the last couple of years. And given that, plus the context of the 2021 spill, I believe the Navy should have had stricter safeguards and more assertive oversight in place to reduce the risk of this type of mishap.”

The military also released video of the incident Friday. While Wade said the footage didn’t reveal any more details about the cause of the spill, it did show contractors and Navy civilian personnel stepping through the AFFF concentrate without wearing protective equipment. Wade said better safety procedures have been implemented in response and that workers were advised to see their doctor.

The spill also revealed that just one of two cameras in the spill’s vicinity was functioning. Military officials subsequently conducted systemwide assessment that determined that the cameras at Red Hill were antiquated, with some beyond their service life and others inoperable.

Wade said his task force is working to purchase a new, temporary camera system that can be rapidly installed ahead of the Red Hill defueling operation.

Wade has also taken on expanded responsibilities overseeing the facility since the spill and has added more than 100 military personnel to his Red Hill task force. He said he’s put in strict controls over security at the facility and requires all contractors who enter the facility to have a military escort, among other improvements.

The state Department of Health, which has regulatory authority over Red Hill and oversaw the cleanup of the AFFF spill, called the report, which took months to release, “long overdue.”

“While the DOD identified the cause of the spill as human error, the findings emphasize that the U.S. Department of Defense must take ownership on a systemic level for operations at the Red Hill facility,” said DOH Deputy Director of Environmental Health Kathleen Ho. “It also reinforces the importance of vigorous oversight over defueling, closure, and remediation of our aquifer.”

U.S. Sen. Mazie Hirono said in a statement following the release of the report that it “is imperative” that the Navy hold those responsible for the accident accountable and that quality assurance protocols and other recommendations from the task force be implemented.

“These mishaps erode the public’s confidence in the Navy, pointing to the importance of their handling of the safe closure of Red Hill,” said Hirono.

The Red Hill facility sits just 100 feet over a critical aquifer that most of Oahu relies on for drinking water. Local agencies and environmental groups had raised concerns about the safety of the aging World War II-era fuel farm well before the 2021 incident, warning that it’s a “ticking time bomb” that threatens the island’s water supply.

“How can we trust anything that we are told about the safety of the Red Hill facility, or the myriad other places in Hawaii and across the Pacific where military sites threaten the disastrous contamination of land, water, and life?” said Wayne Tanaka, director of the Sierra Club’s Hawaii chapter.

“Within the year and a half since the November 2021 spill, we have seen continual contamination incidents and ‘accidents’ that we have to consider as chilling harbingers of even greater existential catastrophe,” said Tanaka. “With $800 billion at its disposal, why must we continue to wait for over a year while the Department of Defense takes its time ensuring the ‘safe’ defueling of the Red Hill facility?”

U.S. Rep. Jill Tokuda said in a statement that the investigation made clear that the AFFF spill should have never happened.

“When incident after incident is the result of ‘human error,’ there comes a time when we need to recognize that there are systemic problems,” she said.

Red Hill isn’t the only military site that has attracted the scrutiny of environmental groups and regulators. The crisis has heightened scrutiny of military facilities and projects around Hawaii.

Rear Adm. Jeffery Killian, commander, Naval Facilities Engineering Systems Command Pacific, said, “Undoubtedly, this will provoke complete review of our quality assurance processes on all of our facility support contracts, and I would go one step further and say our construction contracts as well.”