A sailor's mental health problems were underdiagnosed and not properly communicated to his command in the months leading up to last year's fatal shooting at a Hawaii shipyard, a newly released investigation into the attack found.
Navy officials say they still haven't pinpointed exactly what drove Machinist's Mate Auxiliary Fireman Gabriel Antonio Romero, a 22-year-old assigned to the fast-attack submarine Columbia, to shoot three civilians at the Pearl Harbor Naval Shipyard Dec. 4, 2019.
Romero killed two Defense Department employees that day -- Vincent J. Kapoi, a metals inspector apprentice, and Roldan A. Agustin, a shop planner -- and injured another using his M4 service rifle. As law enforcement personnel responded within seconds, Romero shot and killed himself using a Navy-issued M9 pistol.
A 190-page investigation into the murder-suicide found no explanation for why Romero targeted the three people who were shot that day. The report stated, though, that the sailor "had long-developing problems that in aggregate should have raised concerns about his mental condition, and his maturity, stability, and dependability."
"He constituted an insider threat," investigators found. "... If these risk factors would have been shared among medical providers and the USS COLUMBIA chain of command before December 4, 2019, the Navy may have interrupted the chain of events that led to this tragedy."
The shooting was one of two fatal attacks at Navy facilities that week. Two days later, a Saudi officer opened fire in a classroom building at Naval Air Station Pensacola in Florida, killing three and injuring several others. The two incidents prompted the Navy's No. 2 officer to direct separate investigations into the attacks; those reports provided detailed recommendations for the service and other lead agencies.
Now, officials say the service has stood up a special working group, organized by the Navy's Security Coordination Board, to help prevent similar attacks from happening again. The group, the service said in a Tuesday news release about the investigation, will implement findings and recommendations after the attacks that will "make the Navy safer and more secure."
"The safety and livelihood of our Sailors is dependent on this effort," former Vice Chief of Naval Operations Adm. Robert Burke wrote in a May endorsement letter.
An Ordinary Day
Romero reported for roving patrol duty just after 2 p.m. on Dec. 4. He'd qualified for the watch duty, which required him to rove the area around the submarine, within months of reporting to the Columbia.
The sub to which he was assigned was in Dry Dock 2, inside the controlled industrial area at Pearl Harbor Naval Shipyard on Joint Base Pearl Harbor-Hickam. The sailor Romero replaced that day told investigators the watch turnover was ordinary.
"Romero took possession of the M4 rifle with 90 rounds of ammunition and M9 pistol with 45 rounds of ammunition and made required entries in the duty logbook," the investigation states.
The investigation also details how, on the day of the shooting, Romero missed duty muster because he was attending a semi-annual training requirement. Romero was supposed to check in with the duty section leader before reporting to his watch station, but he didn't do so.
While he was found not to have drugs or alcohol in his system, the missed security and safety brief, the report states, "demonstrates a lack of procedural compliance and was a missed opportunity for duty section leadership to assess Romero's suitability for watch before he was issued a firearm."
Before Romero began his first roving patrol, he told the petty officer of the deck -- the other armed topside watch stander for the Columbia, "I'll be back." What happened next occurred within seconds, the report states.
Romero began walking around Dry Dock 2 from port to starboard around the same time three civilian employees who had been working on the sub earlier that day left their workstations in a trailer. Romero turned, approaching the three from behind.
"The Petty Officer of the Deck observed Romero chamber a round, raise his M4 rifle, and begin firing at the civilians," the report states.
The three fell to the ground about 15 feet from Romero's position. As first responders rushed to the scene, Romero turned the pistol on himself. He died at the scene.
Kapoi and Agustin were pronounced dead at local hospitals, while the third victim was treated and later released.
Investigators were not able to establish a motive for Romero targeting the three victims, but did point to stressors leading up to the shooting that "likely led him to choose violence."
"If shipmates would have reported potential risk indicators to supervisors, the chain of command may have aggregated them with other known risk factors to recognize that circumstances warranted his rescreening for armed watchstanding," the report states.
The Navy determined Romero acted alone and that no one could have reasonably predicted that he would carry out the murder and suicide.
But investigators were tasked with identifying any actions the Navy could have taken to recognize early warning signs and to reduce risks associated with personal stress and mental health to prevent similar incidents from happening again, officials said in a statement Tuesday.
"This tragic event was heartbreaking to our community and our valued shipyard workforce, and we must work hard to restore confidence in the Navy's ability to protect our most valuable assets -- our people," Adm. John Aquilino, U.S. Pacific Fleet's commander, said in the statement.
After qualifying to be a watchstander soon after being assigned to the Columbia, Romero's performance in other areas began to slip, the investigation found.
"Romero quickly fell behind in his other qualifications, and the chain of command took administrative action to address exceeding the qualification deadline of 12 months, poor performance, and continued tardiness," the investigation states. "He received written counseling or extra military instruction on ten separate occasions in the months before the shooting, beginning in June 2019, and he had to attend after-work study periods for his qualification delinquency."
Less than three months before the shooting, Romero was counseled for sitting down while on watch, which led to a remedial review of watchstanding principles. Then, when on temporary duty to another sub to earn qualifications for a submarine warfare pin, Romero didn't interact with other sailors and displayed a low level of knowledge, giving the impression he didn't want to be there.
He was sent back to the Columbia before his temporary duty was complete to build up more knowledge for his qualifications, the report states.
When counseled for poor performance, Romero often cried, according to the investigation. A little more than a week before the shooting, Romero was informed he didn't pass the Naval Advancement Exam and wouldn't be promoted to E-4.
The day before the shooting, Romero faced an executive officer inquiry following a November disciplinary review board for repeated tardiness and qualification delinquency. The executive officer asked Romero whether his mother would be happy if she knew he was squandering the opportunity the Navy gave him, according to the report.
Romero, the investigation states, again became emotional and began to cry, expressing his desire to stay in the Navy.
The XO issued a Page 13, a form of formal written counseling, stating that if Romero was late to work again, he'd face nonjudicial punishment from the commanding officer. Romero didn't sign it, claiming, according to the report, that the XO told him he didn't need to do so until the end of the week.
The XO was planning to clarify the matter by personally delivering the Page 13 the next day, Dec. 4.
"The Page 13 was not signed or delivered before the shooting incident," the investigation states.
As Romero faced professional challenges while assigned to the Columbia, he began seeking mental health treatment. It started in March 2019, when Romero went to the Tripler Army Medical Center in Honolulu to report that he had had a hard time focusing at a traffic court hearing earlier that day.
"Romero denied any suicidal or homicidal ideations," the report states. "TAMC staff called a Tripler Police Department Officer to conduct a contraband search as a precautionary measure and contacted the command to provide support. Romero's division chief went to the emergency room, where TAMC staff told him that Romero was not a risk to harm others or himself."
The center noted in Romero's electronic medical record that the sailor had a possible diagnosis of Attention Deficit Disorder, the report adds.
He was then referred to the Naval Submarine Support Command's embedded mental health program clinic in Pearl Harbor for further evaluation and treatment. But that clinic can't receive outpatient referrals through the electronic medical record system, according to the investigation.
The TAMC staff, according to the report, "did not inform the division chief, the eMHP staff, or USS COLUMBIA's medical department representative (MDR) by telephone, email, or other means."
Romero didn't go to the embedded mental health program clinic until September, after telling his division chief he'd been having difficulty sleeping and was worried about his health, the report adds.
During a 90-minute clinical interview, the force psychologist described Romero as "odd, awkward, guarded, and confused," according to the report. In his intake questionnaire, Romero said he was having problems "with mood stress," the investigation states, adding that he wanted to call his father more, think about the future and take time to relax.
When describing how frequently he felt certain problem areas, Romero reportedly answered that he frequently felt no interest in things, almost always had difficulty concentrating, frequently felt there was something wrong with his mind, sometimes felt hopeless about the future, and sometimes had disturbing thoughts that he couldn't get rid of.
He went to the clinic eight times over three months and, according to the report, was not diagnosed with a mental disorder. That left him qualified for continued submarine duty without any limitations, the investigation states.
"Romero never expressed suicidal ideations or threats of violence toward others during his eMHP Clinic visits," the report adds.
A forensic psychologist who was assigned to the investigation took issue with Romero's mental health assessment.
Though the psychologist did not treat Romero and acknowledged the staff who did "could not have reasonably predicted his violent behavior," he found the force psychologist "under-diagnosed and inadequately managed Romero's mental condition."
"An accurate diagnosis likely would have disqualified Romero from submarine duty," the psychologist wrote. "... The prioritized likelihood of diagnosis (beginning with most likely) were the following: Autistic Spectrum Disorder; Attention Deficit and Hyperactivity Disorder; Social Anxiety Disorder; Personality Disorder (Avoidant and Borderline features); Anxiety Disorder; Depressive Disorder; and Adjustment Disorder."
In his endorsement letter of the investigation, Aquilino stated that, while the Submarine Force embedded mental health program is valuable, he's concerned the clinic "failed to strike the balance between supporting the submarine community readiness and providing necessary mental health resources to submarine Sailors, to include diagnosing Sailors when necessary so they can receive further treatment."
Navy officials, in the Tuesday statement on the probe's findings, also said the investigation uncovered communication barriers between health care professionals and leaders, which place "undue emphasis on patient confidentiality, particularly where Sailors may have access to weapons.
Aquilino made several recommendations on that front in his endorsement letter, including reviewing whether underdiagnosis is a pattern within the embedded mental health program, and reviewing processes for sharing records between military treatment facilities, like the one Romero visited in Honolulu, and command-level clinics.
"The service member's right to confidentiality must be balanced against evaluating what information is necessary to relay to the chain of command," the admiral wrote. "This not only ensures our Sailors are receiving the best care, but also garners crucial support from the chain of command necessary for a successful resiliency approach.
"The overly-conservative stance on patient confidentiality served neither the patient nor the command well in this situation," Aquilino added.