'A 9/11-like Event': Navy Report on Carrier Suicides Cites Missed Warning Signs, Leadership Failures

A Navy investigation of an unprecedented streak of suicides aboard the USS George Washington aircraft carrier has revealed failures at all levels of leadership, and the service is now promising to provide sailors better ameneties and pay in the future.

The massive investigation released Thursday, which aimed to look at the challenges for all aircraft carriers undergoing long and complex refueling like the George Washington, found that the ship had woefully understaffed departments and lacked senior leadership. Navy surveys found widespread thoughts of suicide among the crew.

At the same time, the ship was failing to provide many of the programs that were supposed to help the crew deal with stress. During a briefing to reporters, Adm. Daryl Caudle, the man who oversees much of the Navy's East Coast fleet, said he saw the cluster of deaths as "a 9/11-like event."

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"It was pointedly obvious that the Navy had failed the George Washington through a host of things that we put that ship into," Caudle said.

Among the 86 findings of fact and 87 recommendations was one especially striking detail: The warning signs for the pending crisis were captured in the ship's own survey data but never acted on by the carrier's leadership.

Investigators found that the ship had the highest number of suicide-related behaviors from 2017 to 2019 when compared to all aircraft carriers on the East Coast.

In a 2019 command climate survey, the George Washington's results were below aircraft carrier and Navy-wide averages in all assessment categories. A 2020 survey showed the same results.

Plus, from 2019 to 2020, those same surveys showed that sailors' "awareness of suicidal ideations" on the ship ballooned from 31% to 56%. The report notes that the ship "did not address this finding."

The carrier also struggled to get the crew to participate in the surveys. It had as few as 11% of the crew giving leaders their feedback.

During the investigation, Capt. Brent Gaut, the ship's current commanding officer, told investigators that "there was nothing out of the ordinary that was voiced in that survey that could have given the awareness of a massive problem or anything particularly related to suicidal ideations."

Gaut took command of the ship in June 2021 and has presided over five of the seven suicides that Navy data says occurred aboard the ship between 2020 and 2023.

It took sailors reaching out to Military.com after the final incident in April 2022 to make the spate of suicides public. The sailors who were interviewed pointed to issues like commuting time, challenges with living aboard, and absent leadership as problems far before any Navy report.

The Navy investigators also found that the Command Resilience Team, or CRT -- a group of sailors who, among other things, were charged with running those climate surveys and putting plans in place to address the concerns they raised -- was not doing its job.

"USS George Washington CRT functioned poorly and did not execute its duties and responsibilities effectively" and the ship's leaders "did not provide effective oversight" of this team, investigators found.

Team members were not formally named by Gaut, and the senior command climate specialist didn't even know that was a requirement. This specialist also didn't know that there was a requirement to keep notes of the CRT meetings. Investigators found that the meetings varied in frequency and were poorly attended.

The report goes on to say that the ship's executive officer, Capt. William Mathis, is supposed to be head of the CRT, but he "was not aware of this requirement and had not attended any CRT meetings during his first 4 months aboard."

In all, investigators made eight findings of deficiency or noncompliance by the ship's crew related to either the CRT or the overall command climate efforts.

Furthermore, the report said both the current and former commanding officers of the carrier said they were not provided formal lessons learned -- reports that documented issues prior carriers had going through during the same type of maintenance and refueling.

Housing

Another major revelation of the report is that the Navy has never properly articulated what makes a ship habitable by crew and who is ultimately responsible for making that call.

This detail is critical because sailors cited harsh living conditions aboard the ship -- it was functionally a construction zone at the time -- as one of the key issues that was making life miserable.

While investigators concluded that moving the crew aboard in June 2021 was "premature," they also say that their interviews revealed "divergent opinions regarding who had the authority to declare habitability and the criteria to reach this determination."

There were four, if not more, groups involved in this decision, including inspectors from the commander of the Navy's Air Forces Atlantic; the supervisor of Shipbuilding, Conversion and Repair; the project office that controlled the money for the overhaul; and the leadership aboard the George Washington.

Also driving this decision was money. The report noted that the entire overhaul was underfunded by $322 million -- money meant to pay for both the work on the ship and housing for the crew. As a result, quality-of-life programs became bill payers for contract maintenance shortfalls, the report says.

In fact, George Washington's previous commander, Capt. Kenneth Strong, tried to delay the move aboard in early 2021 but was told by the Navy office paying for the overhaul that the money to house sailors off-ship was gone. Investigators said that the program manager in that office was given direct orders not to take on any additional financial obligations.

A former program manager told investigators that, once the ship is deemed habitable, "there is no requirement to fund sailor off-ship billeting with ship maintenance funds" and "that the term 'quality of life' is not part of any habitability standard."

Meanwhile, accommodations at the shipyards were far from ideal. The report found the Newport News Shipyard's residential building did not meet Defense Department or Navy standards for accommodation, though the Navy's contract with the shipyard does not prescribe minimum standards of lodging.

As a result, sailors who were able to get into these barracks had on average 85 square feet in shared rooms -- in a building that the Navy believed likely had lead paint, asbestos and other toxic substances. The use of the 149-room building cost the Navy about $4.36 million per year.

Meanwhile, according to a prior investigation into the suicides aboard the carrier, sailors were resorting to sleeping in their cars or paying for rent out of paychecks that are typically less than $2,000 a month.

Rear Adm. John Meier, to whom the George Washington's commanders report, said in his letter on the report that "it came as a surprise to me that Navy unaccompanied housing falls below minimum adequacy standards set by the Department of Defense."

Todd Corillo, a spokesman for Huntington Ingalls Industries, the company that runs the shipyard, told Military.com in a statement that it is reviewing the findings of the report and they "remain committed to working closely with the Navy and all stakeholders on exploring options that continuously improve quality of service."

The Path Forward

The letters of the three admirals who reviewed and accepted the report, including Caudle, all promised that big, institutional changes are coming.

Vice Adm. Kenneth Whitesell, who oversees all of naval aviation, wrote in his letter that the entire carrier refueling process needs a fundamental shift to improve sailor quality of life and work, as well as the quality and timely maintenance of the carrier.

In the letter written by Caudle, he recommended that the Navy assign first-term sailors to ships undergoing the same kind of overhaul for no more than two years, and give them a chance to spend time with operational units.

He also recommended that sailors be paid a food allowance regardless of whether the ship's galley is running, and a housing allowance even for sailors who would not normally receive it.

Caudle also recommended that no sailor should live on a housing barge, with the exception of a small rotating portion of the crew that stands watch on the ship overnight.

Corillo also noted that some improvements have already been put into place, such as better parking, Wi-Fi, food service and security.

However, when pressed for a timeline in which sailors can expect all the changes -- especially some of the more ambitious ones like the extra pay -- to materialize, Caudle would not give a firm answer.

"It's hard to give you a definitive timeline on when this will all be wrapped up," he said. "It is going to take resourcing and working with partners in Congress to get some funds in place to do the things we're talking about."

The Navy also hopes to allow leaders from its East Coast commands to oversee and control carriers that come to the Newport News Shipyard from the Pacific.

Meier noted in his letter that he does not have the authority to hold commanders of ships like that accountable. "Responsibility without authority is less than ideal," he wrote.

Meanwhile, Caudle said there would not be firings or any other administrative measures taken against any of the people listed in the report.

"While it may seem that there's not a person ... being held accountable, I'm telling you, this is the most exquisite accountability we have had post a major mishap," the admiral said.

"You basically got a letter of instruction written by the chief of naval operations and the secretary of the Navy to Navy leadership, holding us accountable to fix the quality of service in the Navy," he added.

The Navy's data found that 57% of all aircraft carrier suicides from 2017 to the present happened while the ship was in the shipyard. The George Washington had been slated to complete her overhaul in March 2023, but at the moment she is still at the shipyard.

Veterans and service members experiencing a mental health emergency can call the Veteran Crisis Line, 988 and press 1. Help also is available by text, 838255, and via chat at VeteransCrisisLine.net.

-- Konstantin Toropin can be reached at konstantin.toropin@military.com. Follow him on Twitter @ktoropin.

Related: What the Deaths of Sailors Who Took Their Own Lives Aboard the George Washington Reveal About the Navy