81-Page Report on Response to Outbreak Aboard Carrier Spreads Blame Beyond Its Captain

Capt. Brett Crozier, then commanding officer of the USS Theodore Roosevelt, instructs Information Systems Technician 3rd Class Eden Betzler in February on how to steer the ship. A month later, Crozier and his crew would be embroiled in trying to contain an outbreak of COVID-19 aboard the carrier that received worldwide attention. U.S. Navy/Mass Communication Specialist 2nd Class Pyoung K. Yi

ARLINGTON, Va. — Capt. Brett Crozier, the former skipper of the first U.S. Navy warship to suffer a novel coronavirus outbreak at sea, wasn’t restored to command last week as many had expected following a weeks-long investigation, but the detailed report on the affair spreads fault to other officers as well in the response to the outbreak that infected hundreds, hospitalized several and killed one Sailor.

Chief of Naval Operations Adm. Mike Gilday and new Navy Secretary Kenneth J. Braithwaite announced the decision on June 19 at a Pentagon press briefing on the results of the USS Theodore Roosevelt Command Investigation, which was begun April 2, the day Crozier was fired. The probe was conducted by Vice Chief of Naval Operations Adm. Robert Burke.

That day, Gilday said he would not reassign Crozier as the commanding officer of the nuclear aircraft carrier, “nor will he be eligible for future command. Capt. Crozier will be reassigned.”

Gilday also said the promotion of Crozier’s immediate superior, Rear Adm. Stuart Baker, commander of the Theodore Roosevelt Carrier Strike Group, to a second star was being put on hold “pending further review.”

The investigation’s 81-page report also faults the actions of the carrier’s air wing commander and the TR’s medical officer during the outbreak. Gilday said those officers would be subject to administrative action by Adm. John Aquilino, the Pacific Fleet’s commander. Gilday also criticized a breakdown in communications with the U.S. 7th Fleet staff, leading to mistrust among the Theodore Roosevelt’s leadership.

The Theodore Roosevelt, seen from USS Nimitz in the Philippine Sea on June 23 during dual carrier operations in the Indo-Pacific. The Theodore Roosevelt resumed its mission June 4 after months spent moored in Guam recovering from the COVID-19 outbreak. U.S. Navy/Mass Communication Specialist Seaman Bryant Lang

The investigation also ruled out resupply flights to the carrier from the Philippines as the source of the COVID-19 outbreak aboard, leading officials to conclude the ship’s port visit to Da Nang, Vietnam, likely was the cause of infection among crew members.

However, both Gilday and the report took pains to explain why no one — including commanders of the Pacific Fleet and U.S. Indo-Pacific Command — was disciplined for ordering a port call to a country where dozens of COVID-19 cases had been reported.

The cases were all in the Hanoi area, 450 miles north of Da Nang, and both the U.S. Centers for Disease Control and Prevention and the World Health Organization advised Navy planners that Vietnam was — and remains — transparent and reliable in its outbreak reporting.

Also, several precautionary measures were taken, including briefing the TR’s crew to the risks, checking their symptoms before they left the ship and upon their return, Gilday said. Only locations approved by the State Department could be visited and crew members were not allowed to buy food in port. “Based upon the pre-event risk analysis, the decision to execute the Da Nang port visit was appropriate,” the report concluded, adding: “The visit was executed with sensible precautions, based on the world’s understanding of COVID-19 at the time.”

Braithwaite, who took office just a month ago, said he fully supported the report’s findings and recommendations. He also said he had received “no communication whatsoever with anybody at the White House” and had discussed the controversial decision not to reinstate Crozier only up the chain of command to Defense Secretary Mark Esper.

The 81-page report may not be the end of the saga, however.

The chairman of the House Armed Services Committee, Rep. Adam Smith (D-Wash.), said his committee will launch an investigation into the Theodore Roosevelt’s COVID-19 outbreak “in order to better understand the full range of mistakes that were made throughout the entire chain of command.”

Gilday’s Change of Heart on Crozier

Gilday conceded that he previously believed Crozier should be reinstated after conducting an initial investigation following the captain’s removal, but that a wider investigation had a much deeper scope.

“It is my belief that both Admiral Baker and Capt. Crozier fell well short of what we expect of those in command,” he said at the June 19 briefing.

“Had I known then what I know today, I would not have made that recommendation to reinstate Capt. Crozier. Moreover, if Capt. Crozier were still in command today, I would be relieving him,” Gilday added.

Gilday’s mind was changed, he said, by the investigation’s conclusion that the carrier’s captain and the strike force commander “did not do enough, soon enough” to prevent the spread of COVID-19 aboard the Theodore Roosevelt.

Missteps included not enforcing physical distancing in many public areas of the carrier once crew began testing positive and releasing quarantined crew from the carrier’s aft section to ease crowding conditions.

The 81-page report may not be the end of the story. The House Armed Services Committee will launch its own probe into the outbreak.

Once portside in Guam, Crozier did not “forcefully and expeditiously execute the best possible and available plan” for evacuating the ship’s crew.
Instead, Gilday maintained, Crozier focused on obtaining single-room occupancy hotel rooms with separate bathrooms, in compliance with CDC recommendations, rather than moving crew to hundreds of beds spaced 6 feet apart in Naval Base Guam facilities as well as unoccupied hotel rooms and barracks on base and ships in port with extra berth space.

Crozier was relieved of command April 2 by then acting Navy Secretary Thomas B. Modly after a March 30 letter that Crozier wrote to top Navy officers and fellow naval aviators, pleading for faster intervention from his superiors to assist his crew, was leaked to a San Francisco newspaper.

In the letter, which was sent, unencrypted, via e-mail, Crozier expressed alarm over the slow pace of disembarking his crew at Naval Base Guam while the virus spread rapidly on the ship. Publication of the letter in the San Francisco Chronicle sparked an outcry and worldwide media attention over the captain’s actions and the fate of the carrier’s crew.

The decision not to reassign Crozier to command either afloat or ashore was not based on the letter nor its contents, Gilday said. Rather, the investigation found it was unnecessary because higher commands were already responding to Crozier’s requests to find sufficient places to lodge crew members on Guam.

A deal brokered by Guam’s Gov. Lou Guerrero to place thousands of Sailors in hotels there was closed six hours before Crozier sent his letter. Not only did the letter not speed up the crew disembarkation, the tone caused problems for Guerrero, whose constituents feared depositing thousands of Sailors and Marines, many of whom might have been infected, on Guam.

Life and duty is returning to normal aboard the Theodore Roosevelt, except for extra precautions against COVID-19. Sailors in protective masks, including Retail Services Specialist Seaman Olivia Hungness, take part in security reaction force training in the hangar bay of the carrier on June 24. U.S. Navy/Mass Communication Specialist 3rd Class Julian Davis

Gilday said Crozier did not have his facts straight when he sent his letter up the chain of command and confused the situation by skipping over the 7th Fleet.

Pressed by reporters asking if Crozier was being held to a higher standard than the commanders who authorized the TR’s stop in Vietnam, Gilday said he didn’t think so.

“If I take a look at what Crozier was dealing with and yes, we had a lot of questions at that time about the transmission of asymptomatic cases,” Gilday said, adding “[but] we surely knew that we were in a better place getting those people off the ship. So even given what we didn’t understand about COVID, we understood that.”

Eventually, 1,100 of the Theodore Roosevelt’s nearly 5,000 crew members — including Crozier himself — tested positive for COVID-19. Only a fraction required hospitalization, but one Sailor, Aviation Ordnanceman CPO Charles Thacker Jr., did succumb to the virus.

TR Affair Forces Examination of Pacific Fleet Chain of Command

Crozier was hailed as a hero by his crew — who were seen on video cheering for him as he departed the ship in Guam — while others criticized the captain for circumventing the chain of command.

Modly said at the time that Crozier was not fired in retaliation for his letter but because the secretary had lost confidence in the captain’s leadership. Crozier, Modly said, had allowed the complexity of the COVID-19 challenge “to overwhelm his ability to act professionally, when acting professionally was what was needed.”

However, Modly complicated matters by flying to Guam to defend his actions in an April 6 profanity-laced address to the TR’s crew. Modly called Crozier “too naive or too stupid to be the commanding officer of a ship like this,” according transcripts of the Navy secretary’s remarks made by several crew members. Less than 24 hours after the speech, Modly issued an apology to Crozier, the Theodore Roosevelt’s crew and the Navy, and offered his resignation to Defense Secretary Mark Esper, who accepted it.

Gilday directed Burke to investigate the circumstances and climate of the entire Pacific Fleet affecting the chain of command. Previously, Gilday spoke of “a potential comms breakdown, wherever it occurred,” adding: “We’re not looking to shoot the messenger here, we want to get this right.”

Lt. j.g. Pamichella Torres (left) draws blood from Hospital Corpsman 3rd Class Shea Ashmore-Scianna on June 19 aboard the Theodore Roosevelt to test for COVID-19 antibodies. U.S. Navy/Mass Communication Specialist 2nd Class Robyn B. Melvin

The completed initial report was delivered April 24 to Modly’s replacement, acting Navy Secretary James McPherson, who directed Gilday to conduct the second probe, saying he had “unanswered questions that the preliminary inquiry has identified and that can only be answered by a deeper review.”

COVID-19 was detected on board the aircraft carrier in late March, 15 days after the TR made the Da Nang port visit. Stopping at Guam for a scheduled visit on March 27, Crozier began disembarking crew as the number of Sailors testing positive for the virus continued to rise. Finding suitable accommodations for thousands of personnel on the island was a slow process.

In his letter, Crozier said the carrier had inadequate space to isolate or quarantine Sailors. “We are not at war. Sailors do not need to die,” he wrote. “If we do not act now, we are failing to properly take care of our most trusted asset — our Sailors.”

Testing the entire crew for COVID-19 was completed in mid-May. They began returning to the carrier in waves after 14 days of isolation and after twice testing negative for the virus. Despite those efforts, at least 14 returning Sailors tested positive again for COVID-19. Following a bow-to-stern deep-cleaning process by about 700 crew members and recertifying aviation activities for its Carrier Air Wing 11, the carrier left Guam and resumed it mission on June 4.