The Crozier Affair

One hundred and twenty-five years makes all the difference. At left, French Army Captain Alfred Dreyfus is cashiered and degraded before a crowd after a botched investigation and sham trial (work in the public domain by Henri Mayer). At right, United States Navy Captain Brett Crozier is stripped of his command without even a perfunctory investigation, and the proceedings are broadcast worldwide (still from a video taken by a sailor aboard USS Theodore Roosevelt).

The (Latest) Official Story

The Navy, no doubt anticipating a large volume of Freedom of Information Act (FOIA) requests for the recently completed investigation into the coronavirus outbreak onboard USS Theodore Roosevelt, has preemptively made some materials available, along with other commonly FOIA’d investigations. The main body of the (redacted) investigation can be found here. Appendix D, consisting of finding of fact, can be found here. The investigation was presided over by the second-highest ranking officer in the Navy, Vice Chief of Naval Operations Admiral Burke, and endorsed by the Chief of Naval Operations himself, Admiral Gilday. In the endorsement, included in the front matter of the main body report, Admiral Gilday recommends upholding the relief of Captain Crozier on the grounds that he failed to:

1. Adapt in the face of adversity
   • “When faced with barriers to his primary Course of Action (COA)… [he] waited for others to act rather than… [taking] immediate and appropriate action to drive outcomes.”
2. Exercise ingenuity and creativity in crisis
   • “He did not ensure physical distancing was implemented aboard.”
3. Demonstrate resilience
   • “If there were obstacles to expeditious egress, he did not aggressively seek solutions… he was improperly focused on the ideal COA (hotels) and not the most likely COA (on base facilities).”
   • “He narrowly focused on what he considered to be obstacles outside of his control rather than ‘owning the plan’ by quickly and effectively implementing available options within his span of control.”
   • He “exercised questionable judgment when he released sailors from aft quarantine onboard the ship,” placing “comfort of the crew ahead of safety…”
4. Communicate effectively up the chain of command
   • He “failed to effectively communicate his concerns up the chain of command, at key moments, despite numerous opportunities to do so.”
   • The e-mail that precipitated his firing did not have “all of the relevant facts” and he “did not use available avenues to inform his chain of command prior to sending” the e-mail. “Specifically, he failed to pre-brief his immediate superior… and he excluded Commander, U.S. SEVENTH Fleet… on his email”
   • “[He] failed to openly communicate his concerns to senior leaders regarding the need for additional support…” such as “…during daily VTCs.”
   • “[He] did not ensure he had a full understanding of the facts before sending the email or include key members of his chain of command…”
5. Take bold and appropriate action early and often
   • He did not “forcefully and expeditiously execute the best possible and available plan, or do enough, soon enough.”
   • He “did not plan for and egress sailors off the ship… fast enough”
   • He “should have been more focused on the planning and execution of the COA to egress sailors to the facilities available on Naval Base Guam” rather than hotels, “to safeguard the well-being of his crew.”

Based on the above justifications, the decisions (or indecisions) that led to Captain Crozier’s relief being upheld, arranged chronologically, are:

1. He didn’t enforce social distancing after departing Vietnam.
2. To the extent he felt he wasn’t getting sufficient support, he didn’t make that clear enough, early enough, often enough.
3. He released a large group of sailors (who’d had close contact with COVID-19 infected or presumed infected individuals) isolated in the aft part of the ship.
4. Just prior to and after arriving in Guam, he fixated on getting his crew into hotels that allowed for individual isolation IAW CDC guidance rather than just getting the crew off the ship ASAP.
5. “The e-mail.”

While each of the above justifications is grounded in the findings of fact, recall that (1) Captain Crozier had already been relieved without an investigation, and (2) Admiral Gilday had, after a preliminary inquiry and a change in acting Secretaries of the Navy, recommended reinstating Captain Crozier to command. It was only after this initial recommendation to reinstate that a “wider investigation” was ordered at the behest of the Secretary of Defense Mark Esper and Chairman of the Joint Chiefs of Staff General Mark Milley. As a result of this back and forth, every justification put forth for by Admirals Burke and Gilday for upholding the relief, no matter how well supported by findings of fact, is inherently suspect and demands scrutiny.

Shallow Justification

1. Social Distancing. The investigation criticizes Captain Crozier’s failure to adhere to guidance on social distancing. Specifically, the investigation faults Captain Crozier for his failure to force compliance with social distancing guidelines and for decisions made with respect to “quarantined” crew members.

Social distancing on any warship with a full compliment is essentially impossible. Passageways are narrow, berthings are cramped, and tight work areas force personnel to be in close proximity to each other for extended periods of time. Food preparation and service also demands close quarters interaction. As Admiral Gilday, a career Surface Warfare Officer with extensive shipboard experience of his own, notes in his endorsement, “effective social distancing is not easily accomplished at sea” (emphasis in the original). The fact that he felt compelled to make that allowance even as he recommended firing Captain Crozier is telling, but still he goes on to criticize Crozier and his leadership team for failing to exert themselves to enforce the very same, as if it could have been accomplished. Significantly, at least one other ship’s Commanding Officer must have agreed with Captain Crozier’s assessment: indeed, whereas Captain Crozier and his leadership team gave lip service or better to social distancing guidelines, the Commanding Officer of USS Bunker Hill indicated in his statement that he made no effort at enforcing social distancing after having participated in the same port visit to Da Nang (fact 96). But nowhere is there any indication that this apparently fire-able offense resulted in Bunker Hill‘s CO’s premature relief (a quick search indicates that he completed a regularly scheduled change of command in May of 2020).

2. The Ten Thousand Mile Screwdriver. It’s not at all clear what concerns Captain Crozier “failed to effectively communicate… up the chain of command… despite numerous opportunities to do so.”

The first major point of contention between Captain Crozier and higher echelons, going off the findings of fact, appears to have been over efforts to obtain 4,000 CDC-compliant rooms to house sailors in single isolation. These were requested via Carrier Strike Group Nine’s Chief of Staff to the Seventh Fleet Chief of Staff on March 25, 2020 (fact 169). The Commanding Officer of Naval Base Guam had instead compiled a brief outlining a plan for 150 isolation and 493 non-CDC-compliant quarantine beds in gyms and open bay berthings (fact 168). Crozier’s immediate superior, Rear Admiral Baker, commanding Carrier Strike Group Nine, was then informed by Vice Admiral Merz, in command of Seventh Fleet, that obtaining 4,000 CDC-compliant rooms was not possible: not because it was physically not possible, but because the acting Secretary of the Navy at the time, Thomas Modly, had already stated publicly that no one from Theodore Roosevelt would be allowed to leave the pier (fact 171). In other words, the request for what Captain Crozier believed to be the best course of action was duly made through the chain of command (from the strike group commander to numbered fleet commander via the respective chief’s of staff), and then the reply came back that this option had already been ruled out at the highest levels of the Navy.

The next day, on March 26th, Admiral Baker informed Admiral Merz (again, duly following the chain of command) that the quarantine/isolation space allotted for Theodore Roosevelt‘s crew pierside in Guam was inadequate (fact 175), but this was on the same day that acting Secretary Modly publicly stated that no assistance would be needed from Guam (fact 176). It is hardly shocking, then, with concerns being duly raised and shot down by fiat from acting Secretary Modly (whether he was aware of them or not), that Captain Crozier did not loudly and consistently repeat his concerns that planned support in Guam was inadequate: there was no one left to appeal to, at least within the confines of the usual chain of command, up to and including the Secretary of the Navy. In this regard, it is a wonder that Crozier even bothered to craft, let alone send, “the e-mail,” particularly as it was directed solely at uniformed Navy leaders and apparently not, per the investigation, leaked by him.

Captain Crozier is later faulted for failing to communicate with higher command over a possible course of action to move the crew into US Marine barracks. Prior to Theodore Roosevelt‘s arrival in Guam, the Commanding General of III Marine Expeditionary Force (MEF) and Admiral Merz discussed the possibility of making up to 5,000 rooms available in Okinawa (fact 188). This would, ostensibly, have fulfilled both the promise that support from Guam would not be required, and allowed sailors to be moved into CDC-compliant isolation conditions within the confines of a US military facility. Where Captain Crozier is supposed to have “failed” in all of this comes on March 29th, when he e-mail Commander, Fleet Activities Okinawa (CFAO) about this proposal. CFAO, with no knowledge of the discussion between Seventh Fleet and III MEF, replied that no such rooms were available (fact 245). To be clear, this was a bona fide miscommunication as Admiral Merz had arranged with III MEF’s commanding general to have the Marines vacate their barracks if needed and move to outlying camps (fact 244). However, the significance of this miscommunication is minimal as the main thrust of it, that Okinawa was not a viable option, happened to be correct: that same day, March 29th, Admiral Aquilino, as Commander, Pacific Fleet and Merz’s superior, rejected the plan due to the risk of infection spreading while transporting crew members by air to Okinawa and complications with the government of Japan (fact 249).

A third “communication breakdown” is alleged to have occurred as a result of conflicting or confusing guidance from by Seventh Fleet and Pacific Fleet staffs, specifically related to whether or not testing was needed to leave the ship, or just to leave the naval base. Admiral Gilday attributes this breakdown to part of the reason for delays in crew egress to non-CDC approved lodging in gyms and storehouses ashore, but that characterization is somewhat dubious. For one, there were other reasons, unrelated to confusion over testing requirements, for Captain Crozier to delay putting sailors ashore, reasons which he specifically referred to in his statement as guiding his decision to delay egress (facts 263 and 268). To the extent that there was confusion over testing requirements, it points not to a failure on the part of Captain Crozier to communicate, but to failures elsewhere in the chain of command. Admiral Aquilino prioritized testing (fact 204), possibly influenced by his erroneous belief that a lab in Korea would be able to analyze tests for 1,000 sailors a day (fact 201). Admiral Merz, on the other hand, wanted sailors move off the ship as swiftly as possible (fact 204). Here, two faulty assumptions came together to complicate matters (1) the erroneous belief held by Admiral Aquilino that testing could be conducted swiftly, and thus be considered a prerequisite for egress, without substantially delaying the effort to egress, and (2) Seventh Fleet staff believed that Guam would require testing prior to moving sailors into hotels (fact 208). The latter ultimately proved to be mistaken as the Governor of Guam walked back on calling for testing prior to occupying hotels–perhaps always was willing to, if asked–after communications with Commander, Joint Region Marianas (facts 173, 232, and 320). Taken together, these two faulty assumptions, as understood by Admiral Merz, led to a breakdown in communication in which Captain Crozier and his team aboard Theodore Roosevelt were led to believe that moving sailors to hotels in Guam was not a viable option, which in turn heightened Captain Crozier’s level of concern (fact 216) as Admiral Merz continued to push getting sailors into non-CDC-compliant lodging ashore as swiftly as possible (fact 263). Moreover, Admiral Merz clearly understood that Captain Crozier was slow in moving crew ashore due to such concerns (fact 265), and hence that his delaying such movement had nothing to do with a breakdown in communication over the plan. Quite the contrary: Captain Crozier and his second in command understood all too well what the plan was, and that it was contrary to both CDC guidance and the Navy’s own NAVADMIN 083/20 dated March 23rd (facts 160 and 237).

Thus, the clearest example of a communication breakdown brought about by Crozier himself–the misunderstanding over barracks rooms on Okinawa–was also the most inconsequential. The plan, advanced primarily by Admiral Merz, proved to be a non-starter with his superior, Admiral Aquilino. It’s telling, in a way, that the investigation seems to overlook this disconnect between fleet commanders, but then goes on to criticize Captain Crozier for something as minor as not attending working group meetings arranged by the Seventh Fleet Chief of Staff during the first two days in Guam (fact 221), as if he had nothing else to worry about during that time or Admiral Merz had no other way (such as an intermediate strike group staff under Admiral Baker) of knowing what was happening on Theodore Roosevelt beyond tying down its Captain in front of a VTC. Had the chain of command been communicating effectively, Admiral Merz would have been fully aligned with Admiral Aquilino, and information would have simply flowed down through him and his staff, to Admiral Baker and his staff, and finally to Captain Crozier and his crew. That Captain Crozier received conflicting direction from the chain of command two, three, or more levels above him (he also fielded calls from acting Secretary Modly’s Chief of Staff) provides much stronger evidence of a breakdown in communication and a failure to properly utilize the chain of command at Admiral Merz’s level and above. To the extent Captain Crozier “failed to effectively communicate his concerns up the chain of command,” it appears to have been only in so far as that chain was already broken by mismanagement and miscommunication on the part of his superiors, and not least by Mister Modly as he communicated ineffectively to the public and thus constrained subordinates based on a malinformed understanding of the situation.

3. The Situation Aft. On March 29th, Captain Crozier released about one thousand members of the crew from a quarantine/segregation area in the aft part of the ship (fact 256). On the face of it, this seems like the most questionable decision made by anyone in the chain of command, effectively surrendering the whole of the ship to the virus. Captain Crozier practically stated as much, as he determined it was prudent to begin considering all sailors positive for COVID-19 (fact 257). While on the surface this seems like a huge misstep, what the investigation fails to consider–appears to take for granted–is whether the kind of contact tracing that had to be employed onboard Theodore Roosevelt (limited primarily to batch testing, with only 40 diagnostic tests conducted per day (facts 194-196)) could have ever successfully impeded the spread of COVID-19. Much like the Navy’s social distancing guidelines, which Crozier was also faulted for being unable to fully implement and maintain, it is clear that there was guidance to attempt to segregate exposed personnel to limit the spread of the virus, but little or no consideration as to whether such a regime could be realistically achieved within the confines of a US Navy warship.

Speaking to the supposed benefit of maintaining a growing aft quarantine population, Theodore Roosevelt‘s Senior Medical Officer was of the opinion that quarantining so many sailors in a limited area was ineffective (fact 259). Was he wrong? Critically, at no point does the investigation seek to properly answer that question. The closest it comes is on page 55 of the main body, noting that the Senior Medical Officer should not have been surprised that there was a higher rate of new cases in aft quarantine, and that such cases may have been from their close contact prior to being placed in aft quarantine, rather than arising from close contact that came about within aft quarantine (with all the other people who had close contact), making it a chicken-egg problem if ever there was one.

Further on, there is also this:

“The TR SMO assessed that up to half of the ship was a close contact…” (page 58)

In other words, had Captain Crozier persisted in quarantining members of the crew based on contact tracing, the number he would have had to place in aft quarantine would have been closer to two thousand than one thousand. Two thousand and growing by the hour as new cases, each with a new string of contacts, continued to arise outside of aft quarantine. Thus, even viewed in isolation, the case for maintaining the shipboard quarantine regime was questionable. However, on the other side of the equation, as Captain Crozier’s second in command emphasized in his statement, living conditions in aft quarantine were even more cramped than the rest of the ship. This not only heightened the risk of exposure to those placed there through contact-tracing alone, but resulted in “true human suffering” (fact 258), with the situation in aft quarantine assessed as unmanageable (page 58).

4. A Solution, Not a Reaction. Closely related to the problem of sailors placed in, and then released from, aft quarantine is the problem of where and how to put them ashore. As previously noted, the options considered by the various levels of the chain of command as Theodore Roosevelt arrived at the pier in Guam were:

• Individual isolation according to CDC guidelines in hotels in Guam
• Individual isolation according to CDC guidelines in Marine barracks in Okinawa
• Makeshift arrangements on Naval Base Guam (including storerooms and gyms with cots for the bulk of the crew, with limited individual rooms available for COVID-19 positive sailors and key watchstanders where available)
• Remain aboard, except as needed for medical treatment ashore

Critically, while Commander, Joint Region Marianas continued to communicate with the Governor of Guam to make local hotels available for the crew and Admiral Aquilino discounted the Okinawa option due to diplomatic considerations with Japan and the difficulty in transporting crewmembers (it would have been a nine hour plane flight, leaving the ship pierside in Guam with a skeleton crew), Admiral Merz continued to push the third option: moving the crew ashore as swiftly as possible into makeshift arrangements. Crozier is hit especially hard for not availing himself of this option, particularly after he assessed that the shipboard quarantine routine was not manageable, but here again the investigation seems to brush aside his legitimate concerns and take for granted that the makeshift living arrangements available to sailors on base would have been preferable to remaining aboard. For comparison, here are screen captures from the investigation that showcase each of the latter two options, side by side:

At first glance, the temporary arrangements in Guam look marginally better than the ship. Certainly it looks more open as the racks (beds) aren’t stacked three high on top of one another. But what these images do not capture is where the sailors are supposed to go for food, where and how numerous the toilets are, whether or not and how often they would be seen by medical personnel, and what exactly these sailors are expected to do all day. Was the expectation that they would either sleep all day or sit on the edge of their cots (as some seem to be doing) and count ceiling tiles, never once coming within six feet of one another for two weeks? The ship at least had (very small) lounge areas in the berthings, supervisors close at hand, showers, the capacity to feed everyone, and assigned medical staff.

Captain Crozier provided a statement describing a constant balancing act between keeping the crew in close quarters on the ship and sending them ashore to improper facilities that neither guaranteed sailors would be kept apart from others who might be infected nor provided basic care and feeding needs (fact 226). Admiral Merz was notified of these concerns through daily interactions between strike group and fleet staffs, but, per the strike group Chief of Staff, Admiral Merz appeared concerned only with filling beds ashore and the ongoing dialogue became contentious (fact 224). Once more, it is clear that there was communication of concerns up the chain of command, but concerns were simply brushed aside by Admiral Merz. Rather than attempt to refute Captain Crozier’s concerns that putting sailors ashore into hastily assembled temporary lodging arrangements was less preferable than keeping them on the ship pending CDC-compliant rooms for individual isolation, Admirals Burke and Gilday, in their opinions, appear to simply take it for granted that Admiral Merz was correct in his cost-benefit analysis and Captain Crozier was not. Once more, the question either nobody asked or nobody was particularly interested in answering before coming to a conclusion is: “Was he wrong?” Was Captain Crozier wrong in his assessment of conditions ashore versus conditions on the ship, and, more to the point, was he so wrong as to warrant his relief given the unique position he was in and the overall uncertainty at the time, at all levels in the chain of command?

Admiral Merz pushed for a reaction based on assumptions. Captain Crozier pushed for a solution based on guidance from the CDC. Admiral Burke, in his investigation, appears to have sided with Admiral Merz without going into much detail on why, other than to state, in his summary opinion, “The extended time Sailors remained on the ship, while no longer segregated, likely increased the number of infections.” I just don’t see where he based that opinion on any finding of fact, such as a statement from a physician or an infectious disease expert with standing to challenge the assessment made by Theodore Roosevelt‘s Senior Medical Officer.

5. The E-mail. On March 29th, Captain Crozier fielded a phone call directly from Admiral Aquilino. This is not clearly mentioned in the findings of fact, but is referenced in the main body of the investigation (page 66). Then, early the next morning, he received another call from acting Secretary Modly’s Chief of Staff, in lieu of a call from Modly himself (fact 297). During both calls, in which superiors at Pacific Fleet and on the Secretary of the Navy’s staff effectively bypassed their own subordinates to reach out to him, he indicated he was getting all the help he needed. Although the opinions endorsed by Admiral Gilday do not explicitly fault Crozier for withholding his concerns during these phone calls, the main body of the text seems to imply that he should have:

“Subsequent information provided by A-SN’s COS indicated that he did not specifically direct any additional resources as he was informed CPF and TR’s chain of command were addressing all needed support.” (page 65)

“CPF had also called the TR CO on March 29th to notify him that A-SN would be calling (which ended up being the A-SN COS). CPF asked if any additional assistance was required, and the TR CO indicated he was getting what he needed. The TR CO did not specify an immediate need for 4,000 beds fully in compliance with CDC and Navy guidelines in those conversations and did not specify that the current plans were not acceptable.” (page 66, bolded for added emphasis)

On the same morning as the Chief of Staff phone call, Captain Crozier’s immediate superior, Admiral Baker, informed his own immediate superior, Admiral Merz, that the recommended course of action was to move the bulk of the crew ashore to individual rooms (fact 284). In that respect, Admiral Baker and Captain Crozier were in alignment, Captain Crozier had consciously avoided two opportunities to bypass Admiral Merz, and the recommendation was duly made to the numbered fleet commander with full appreciation for the chain of command. It was only after this recommendation was acknowledged (and only acknowledged) that Captain Crozier sent “the e-mail.”

Contrary to initial reports–reports that culminated in Captain Crozier’s relief at the direction of then-acting Secretary of the Navy Modly–Captain Crozier did not send “the e-mail” to an excessive number of recipients, nor did he send it outside the chain of command (page 74). Ironically, the investigation now faults him for not sending it to enough people, with Admiral Merz being notably and intentionally excluded:

“The exclusion of C7F on the former TR CO’s email, as well as the lack of advanced coordination by the former TR CO with CCSG-9 and others, bypassed the operational chain of command and demonstrated poor judgment.” (page 78)

And with that, the hypocrisy in the Navy’s official position and its bias towards coming to a predetermined conclusion are made abundantly clear:

1. Though not explicit, the investigation reads as if Captain Crozier should have notified Admiral Aquilino the day before his immediate superior had the opportunity to notify Admiral Merz, who, as Commander, Seventh Fleet, occupied the spot in the operational chain of command between the strike group commander and Admiral Aquilino, in command of Pacific Fleet.
2. To the extent Captain Crozier bypassed the Chain of Command in sending “the e-mail” to Admiral Aquilino but not Admiral Merz, the chain of command had already bypassed itself, with Captain Crozier fielding calls from both Admiral Aquilino and acting Secretary Modly’s staff mere hours earlier.
3. Based on acting Secretary Modly’s statements to the media and the crew, Captain Crozier was supposed to have been relieved because the e-mail “wasn’t just sent up the chain of command, it was sent and copied to a broad array of other people… 20 or 30 other people…“
4. According to the actual investigation, he only sent the e-mail to select individuals (ten in all) and there is no indication he sent it outside the chain of command, but relief for cause was still deemed to be warranted.

Beyond that simple irony, there are four additional criticisms levied by Admiral Burke and relating to “the e-mail” that deserve scrutiny:

• The e-mail was “unnecessary, and had no positive impact on actions already being aggressively pursued by higher headquarters (CJRM, C7F, and CPF).”

This is Monday morning quarterbacking and not a valid criticism. That these men believed the e-mail had no positive impact on their decision-making or the courses of action they put most effort into is supported by statements from Admiral Merz and Admiral Aquilino (facts 321, 322). That their assessment of the situation, provided in statements six weeks after the fact, is correct, is, fittingly, contained in the “opinions” section of the investigation. Captain Crozier’s stated purpose was to cut through the bureaucracy and refocus efforts on what he considered the best course of action (fact 295). Given that Admiral Merz’s own Chief of Staff provided a statement indicating that goals became scattered after the ship arrived in Guam (fact 204), Captain Crozier’s decision to send “the e-mail” based on the information he had available at the time seems wholly justified, particularly given the time sensitive nature of the situation. Plus, taking too long to reach a decision and make a clear recommendation up the chain of command is just the sort of thing Admiral Gilday would criticize him for elsewhere.

• “Release of the former TR CO’s letter to the San Francisco Chronicle complicated the Navy’s negotiations with the Government of Guam for use of hotel rooms in Guam.”

This appears well-founded based on a letter provided by the Governor of Guam to Commander, Joint Region Marianas. The governor had intended to hold a press conference on April 1st, two days after “the e-mail” was sent and the the same day it was published by the media (fact 320). However, this has nothing to do with Captain Crozier since the investigation concluded there was no indication that he leaked “the e-mail” or intended for it to be leaked.

• That Captain Crozier did not “personally inform his Immediate Superior in Command, CCSG-9,” of his intent to send the e-mail ahead of time.

This would be a fair criticism, an example of “bad form” on Crozier’s part for failing to walk down the passageway and talk to his immediate boss before inviting a shit storm from above, if Admiral Gilday, in his endorsement, did not also criticize Crozier for his failure “to openly communicate concerns to senior leaders regarding the need for additional support.” Taken together, these criticisms–not pre-briefing his immediate superior on the one hand, but not openly communicating concerns to senior leaders (plural) on the other–creates a paradox that is exposed by entertaining the following hypothetical: What if Captain Crozier had pre-briefed Admiral Baker and Admiral Baker had responded by saying “No, don’t send the e-mail”? That would answer the first criticism, but exacerbate the second, that he failed to communicate concerns to leaders beyond Admiral Baker. Or is Admiral Gilday’s position that, had such a hypothetical situation arisen, he should have disobeyed a direct order from his immediate superior and sent the e-mail anyway?

• That he “transmitted information of a very sensitive nature about a capital warship on an unclassified network.”

This would be a fair criticism if only the investigation could point to a reason that the letter should have been classified. The potential to make the Navy look bad if it gets out is not a valid reason for a communication to be classified. This criticism is also undercut by reviewing media coverage prior to the leak. The following articles were published in the week prior to “the e-mail” and are representative of reporting at the time, much of it peppered with statements given by Navy officials, public affairs staff, and acting Secretary Modly himself:

Sailors on board carrier Theodore Roosevelt test positive for COVID-19

In the Pacific, a COVID-19 outbreak sidelines deployed aircraft carrier Theodore Roosevelt

UPDATED: USS Theodore Roosevelt Quarantines Sailors on Guam as Coronavirus Outbreak Spreads

In short, open source reporting, coupled with a basic understanding of shipboard operations, would have made it clear to any potential adversary that Theodore Roosevelt was either going to be sailing with a substantial portion of its crew unable to perform their routine duties, or remaining pierside for some weeks. Either way, it was clearly en route to Guam with a growing outbreak of COVID-19, and it was clearly not going to be fully mission capable going into at least mid-April. The most embarrassing thing about “the e-mail,” what caused the gravest harm to the US Navy’s prestige, its standing in the world, and its perception by potential adversaries, was not that it was sent or even that it was leaked, but rather the acting Secretary of the Navy’s unhinged response, and the weeks of vacillating and indecision by senior uniformed Navy leaders in the aftermath, culminating in this botched investigation.

Conspicuously Absent

Among the reasons cited by Admiral Gilday for ordering a second investigation, at least according to media reports, was to look into the “climate of leadership in the Pacific beyond the scope of the [initial] investigation.” The investigation itself, however, appears to lack proper scrutiny of many decisions made at the numbered fleet level and above, specifically, by Admiral Merz, but also including navy-wide guidance for responding to the growing pandemic throughout the month of March.

1. A Most Untimely Visit. Appendix D includes a litany of facts relating to Theodore Roosevelt‘s port visit to Da Nang (ordered by Admiral Philip Davidson, as Commander, United States Indo-Pacific Command), to include when and where the first cases were reported in Vietnam and other parts of Asia, recommended screening measures, and at what point US media outlets began reporting that people without visible symptoms could spread COVID-19. The investigation, however, falls short in its scrutiny of the decision-making process that led to this visit.

In one finding of fact (fact 52), it is noted that US media outlets first began reporting that individuals without apparent symptoms could spread COVID-19 on March 2, 2020, just two days before the port visit. That’s not particularly damning given that it can take time for initial reports to be widely disseminated and accepted, but what the investigation fails to note is when international sources, including medical journals, began reporting the possibility of asymptomatic spread. For reference, a case of asymptomatic spread in Germany was described on January 31, 2020. Later evaluation showed that this particular report was based on faulty information, but the concern it raised did not evaporate: the possibility of asymptomatic transmission was established as a known unknown, even reported on in US media sources, more than a month before the port visit. Also of note, the government of Guam had, on February 7th (after the initial report and retraction on asymptomatic spread), denied access to a cruise ship over such concerns, even though the ship had no known cases of COVID-19 (fact 137). The government of Guam, at least, appeared to weigh the danger posed by this known unknown and chose not to risk the island’s population in the meantime. In green-lighting the port visit, Admiral Davidson failed to act with similar concern, particularly as there had already been reported cases elsewhere in Vietnam.

The overall tone of the investigation and its conclusions is to give commanders (specifically, Admirals Davidson, Aquilino, and Merz) the benefit of the doubt in failing to accurately anticipate how the virus might unfold. Rather than focus on the added risk born out of uncertainty, the known unknowns, in the opening stages of the pandemic, and how due caution might have called into question some of the risks assumed on behalf of Captain Crozier and his crew by higher authority, the investigation falls short, emphasizing what was “known at the time.” This is an overly generous lens through which to view the decisions made by Admiral Davidson and his subordinate fleet commanders prior to the port visit because it fails to properly scrutinize whether or not sufficient information actually existed to base a decision off of. In conditions of uncertainty, decision-makers should have been more biased toward preserving the health and safety of the crew of a national asset–and by extension the asset itself–above the somewhat nebulous (though laudable) goal of improving relations with Vietnam through a port visit that could have been executed at a more opportune time and achieved similar results.

No, an aircraft carrier isn’t a cruise ship, and its crew may be called upon to risk their lives at any time, but then neither is a port visit on par with major combat operations. No lives should be risked to accomplish the former, and yet so many were in ordering Theodore Roosevelt to pull in anywhere but a controlled, isolated pier during the opening stages of this pandemic. Although other ships conducted port visits around this time and had better luck, they, too, should not have been risked in this fashion.

2. The (Lack of) Guidance to the Fleet. Initial guidance to the fleet on COVID-19 mitigation measures came in the form of a naval message dated March 12, 2020, followed by updates on March 19th, and again on March 21st. Each new message in the series superseded the one before it. All three messages were released in the interval between Theodore Roosevelt‘s departure from Vietnam and the first reported cases of coronavirus infecting crew members on March 24th. Focusing on the last of the three messages (the latest, most comprehensive guidance), points of interest include:

• It was, per the remarks, supposed to be the “one-stop information source.”
• The message, copied and pasted into word, 12-pt, Times New Roman font with the header information removed and just beginning with the remarks, is twelve pages long.
• The bulk of the document, seven pages in all (sections 3A thru 3J), is dedicated to minutia relating to individual travel for permanent change of station, temporary duty, and conferences, to include family members and waiver processes, and on and on and on before it finally gets to something useful to a deployed unit.
• It is the bottom of page 8 (remarks section 3K, “General Health Guidance”) before there is any information that may be even remotely useful to a deployed unit. This goes on for about a page, and is then followed by reporting requirements and various administrivia and platitudes to close out the “one-stop information source” provided by Navy leadership to commanders navy-wide.

The single page of actual *relevant guidance (not counting reporting requirements) provided as of the first recorded cases onboard Theodore Roosevelt was as follows:

• 3.K. General Health Guidance. Compliance with CDC guidance is critical to minimize the spread of COVID-19. All personnel shall:
  • 3.K.1. Wash hands often with soap and water for at least 20 seconds, especially after going to the bathroom, before eating, and after blowing your nose, coughing or sneezing. If soap and water are not readily available, use an alcohol-based hand sanitizer with at least 60 percent alcohol. Always wash hands with soap and water if hands are visibly dirty.
  • 3.K.2. Avoid close contact with people who are sick.
  • 3.K.3. Avoid touching your eyes, nose and mouth.
  • 3.K.4. Stay home when you are sick.
  • 3.K.5. Cover your cough or sneeze with a tissue, then throw the tissue in the trash.
  • 3.K.6. Clean and disinfect frequently touched objects and surfaces using a regular household cleaning spray or wipe.
  • 3.K.7. Maximize open doors within area with equivalent classification levels.
  • 3.K.8. Minimize meetings of more than five persons.
  • 3.K.9. Practice social distancing.
  • 3.K.10. Minimize attendance at large group gatherings outside of the workplace (for example shopping malls and restaurants with large attendance).
• 3.L.  Supplemental Guidance for Commanders.
  • 3.L.1. IAW reference (q), Commanders should identify and track all Service Members who travel or have a history of travel in the prior 14 days. This includes travel by military or commercial means as well as private conveyance and includes all forms of travel to include PCS, temporary duty and leave. Commanders shall ensure Service Members implement the following actions for the next 14 days:
    • 3.L.1.a. Implement self-observation, i.e., take temperature twice a day and remain alert for fever (>100.4 degrees F or 38 degrees C) and remain alert for fever, cough or difficulty breathing.
    • 3.L.1.b. To the extent possible implement social distancing, i.e., remain out of congregate settings, avoid mass gatherings and maintain 6 feet or 2 meter distance from others when possible.
    • 3.L.1.c. If individuals feel feverish or develop measured fever, cough or difficulty breathing, immediately self- isolate, limit contact with others and seek advice by telephone from the appropriate healthcare provider to determine whether medical evaluation is required.
  • 3.L.2. Commanders will adhere to DoD guidance for personnel traveling during the novel coronavirus outbreak per reference (q) to include COVID-19 screening at overseas military transportation terminals per reference (n). Commanders will review the supplemental risk-based measures and observe the operational risk level mitigation actions for COVID-19 outlined in reference (f).
  • 3.L.3. For individuals traveling OCONUS to OCONUS, Commanders will ensure travel is mission essential and follow the guidance listing in reference (s) if compelling exceptions are necessary. Military air crew are exempt from the requirements in this NAVADMIN, but will ensure they actively practice social distancing and prudent measures to mitigate potential contact and COVID-19 transmission.
  • 3.L.4. Commanders will comply with status of forces agreements when applicable.
  • 3.L.5. Consider measures to place mission essential shore staffs on alternating day or split shift rotations.
  • 3.L.6. Use maximum latitude to authorize telework, liberal leave, permissive TDY as necessary to minimize spread within your teams.
  • 3.L.7. Implement social distancing techniques for any meetings you conduct.
  • 3.L.8. Ensure the health of your force by conducting regular screenings and restrict movement of those potentially infected with COVID-19.

*Items included in the “relevant” sections deemed (at the risk of editorializing) “not relevant” because they do not apply, are extraneous, or cannot be performed by a deployed warship have a line through.

The Navy’s guidance to deployed commanders, as encapsulated in the above message, is akin to a First World War General telling his soldiers to simply “duck” as they cross no-man’s land. The Navy’s response and then investigation to justify the response to the outbreak aboard Theodore Roosevelt, would be like the very same General being shocked to learn that some of his soldiers were hit by machine gun fire anyway, the objective was not taken, and then zeroing in on and punishing those who were observed failing to keep low at all times, as if that was the one thing that led to failure to take an entrenched enemy position in a frontal assault without adequate guidance or support.

Beyond being overall inadequate and largely unachievable for a deployed warship, what is particularly troubling about the guidance is section 3.L.3, because it makes clear that there was virtually no additional guidance given to air crews operating overseas, as in the case of Carrier On-board Delivery (COD) flights between Theodore Roosevelt and points ashore. For much of the time between when the ship left Vietnam and the first cases of COVID-19 were recorded onboard, COD flights were operating out of the Philippines. Twenty-nine passengers, plus aircrew members, transited between the ship and the Philippines during this time (fact 91). These flights were terminated on March 23rd due to the increasing spread of COVID-19 in the Philippines. This decision was made internal to the ship, possibly by Captain Crozier on his own, but going no higher than Admiral Baker, and absent guidance from the Navy to do so (fact 128). The main body of the investigation states:

“Later, four of those personnel [who arrived by COD from the Philippines] tested positive for the virus, however the investigation team as well as the NMCPHC concluded that none of these Sailors were the likely source of the outbreak on TR (details in Appendix F).” (page 38)

Unfortunately, Appendix F – Analysis of Binnacle List is not included in the released materials, and Appendix D – Findings of Fact contains no reference to this analysis. Curiously, the thirty-nine sailors who were quarantined after close contact in Vietnam tested negative (fact 109), but beyond that and another vague statement about “the probable source of COVID-19 on TR” (which doesn’t actually say what the probable source was, only that it’s in Appendix F), no further detail is provided on the source of the outbreak and the investigation does not appear to subject the adequacy of Navy-wide guidance to scrutiny. Instead, it zeroes in on how Captain Crozier “failed” to fully implement the Navy-wide guidance, adequate or not. He is most heavily criticized for his failure to rigorously enforce social distancing, as he, his second in command, and the ship’s Senior Medical Officer all stated they felt such guidance was of little use to a deployed carrier (fact 94). The question remains, effectively unanswered in the investigation: “Was he wrong?“

3. Statements from Physicians. Admiral Burke stated in his opinion that Captain Crozier erred in acting on recommendations from his Senior Medical Officer to consider the whole crew exposed and lift quarantine for those previously identified as having close contact. Specifically:

“The TR SMO’s recommendation and the resulting release by the former TR CO of crewmembers in quarantine from the aft portion of the ship on March 29, 2020 likely resulted in infection to a larger portion of the crew.”

“…efforts to move the crew off the ship were uncoordinated, unsupervised and slow. The extended time Sailors remained on the ship, while no longer segregated, likely increased the number of infections.”

But, again, these are opinions, and Admiral Burke is a career submariner with bachelor’s and master’s degrees in electrical engineering. He is not, himself, a physician or infectious disease expert. There is reference to a statement from the Seventh Fleet staff surgeon related to the risk assessment in conducting port visits and other interactions during the opening stages of the pandemic (fact 47), and there is reference to a statement from Pacific Fleet’s staff surgeon noting that the TR SMO did not attend daily medical synchronization meetings organized by Seventh Fleet staff (fact 225). What is conspicuously absent, however, from the findings of fact is any statement from a relevant professional, some kind of doctor (medical or otherwise), relating to the advisability and effectiveness of shipboard quarantine and temporary lodgings versus CDC-compliant individual isolation rooms, other than a statement from Theodore Roosevelt’s Senior Medical Officer, and statements from other members of the ship’s medical department with similar concerns, whose recommendations Admiral Burke apparently feels qualified to rebut.

The status of the following recommendation, made as a result of the preliminary inquiry and still being tracked in this latest investigation, is especially telling:

“c. Examine the impact of the ship’s decision to release personnel from isolation on March 29th and use this to inform the infection spread model recommended in recommendation b. In progress.”

In other words, the part of the investigation that might actually show, based on expert evaluation, that Captain Crozier erred in relying on advice from his Senior Medical Officer, has not yet been completed. For the fourth and final time, the question is, “Was he wrong?” and once more, the man charged with carrying out the investigation doesn’t seem to have come up with an answer based in fact before passing judgement. He apparently presumes that Captain Crozier was “likely” wrong, and recommends his relief for cause as well as possible administrative action against the medical officer who advised him. Perhaps the answer is contained in Appendix F. If so, a reference to it might have conferred at least some level of legitimacy on the investigation and its findings, but as it stands, I can only note the absence of a finding of fact to support Admiral Burke’s opinion.

4. Dueling Chains of Command. Much of the uncertainty over the plan to get or keep Theodore Roosevelt‘s crew healthy–uncertainty which Captain Crozier is faulted for not resolving through effective communication–appears to have centered around a disconnect at Seventh Fleet, under the command of Admiral Merz. The findings of fact covering the period just prior to Theodore Roosevelt‘s arrival in Guam, 25-27 March, in particular show a series of miscommunications and reversals with an origin among Seventh Fleet or his staff. While Admiral Baker and Captain Crozier pushed a relatively straight-forward course of action that required political will and coordination between military leaders and the Governor of Guam more than anything, Admiral Merz pushed options that were not in alignment with the Navy’s own guidance for isolation and quarantine and, from his command ship, compounded the difficulties faced by leaders aboard Theodore Roosevelt. That, at least, was the sense of Crozier’s second in command (fact 160). But the investigation has only good things to say about Admiral Merz, his fellow flag officers, and their staffs, going so far as to state up front in the preliminary statement:

“It is clear that TR received exceptional support and resources from all levels of the chain of command.” (page 7)

With a lead-in like that, it’s a wonder that no one in the chain of command above Crozier was recommended for a medal for their “exceptional support.”

Where acting Secretary Modly, the fleet commanders, and their staffs make mistakes or bypass the chain of command to interact with Captain Crozier directly, they are lauded for their “exceptional support.” For these leaders, each residing over the horizon from Captain Crozier, Admiral Baker, and one another, there is nothing like the scrutiny that Captain Crozier receives for his e-mail in terms of the factual basis for their opinions, how clearly they present information, or the extent to which their communications respected (or bypassed) the chain of command. To the extent missteps and misunderstandings between staffs at echelons above the strike group level are touched on (Admiral Merz’s Okinawa fantasy comes to mind, as does the disconnect over testing), the focus seems to be more on how Captain Crozier failed to properly navigate the crossfire between these dueling staffs than on how the command climate at Pacific Fleet and Seventh Fleet might have influenced decision making or complicated efforts to get Theodore Roosevelt the “exceptional support” it truly needed.

5. The First Investigation. Admiral Gilday never explains what, specifically, differed in this second investigation that led him to change his mind about reinstating Captain Crozier to command. Although the first investigation was included as an appendix to this second investigation, listed as “Appendix E – Preliminary Inquiry,” it was not released, even in a redacted form, as part of the FOIA materials.

Conclusion: A Historical Parallel

The rush to judgement at the highest levels of the Navy and the ongoing apparent lack of interest in getting to ground truth–who was really responsible and who should be held accountable for any failures that may have contributed to the severity of the outbreak aboard Theodore Roosevelt–initially drew comparisons, in my mind, to the treatment of Alfred Dreyfus, who had to endure two trials (both arriving at guilty verdicts) before finally receiving a pardon and, later, an exoneration. But at this point, a more fitting parallel to the hyper-focused criticisms levied at Captain Crozier, singled out for blame to the exclusion of higher level leaders who might have established conditions that made true success virtually impossible, seems to be the sad case of Admiral John Byng.

During the Seven Years war, Admiral Byng was given the near-impossible task of relieving a besieged garrison with insufficient time to prepare and inadequate resources at his disposal. When he (not surprisingly) failed to achieve that objective, he was court-martialed and then executed by firing squad on the quarter-deck of his own flagship. While even his critics at the time generally agreed that he was put in a bad spot by the Admiralty, the overriding consensus was that he had, per the charge, “failed to do his utmost” to do his duty. Whether or not any amount of effort was likely to have won the day given the forces he had at his disposal was not at issue, just the principle of following orders “to the utmost,” as if that mattered more than lives or whether such orders were well-considered and achievable. As Voltaire put it in a contemporary bit of satire, “it is good to kill an admiral from time to time to encourage the others.” But we are more civilized: we content ourselves merely with the careers of our scapegoats, and mostly only go after Captains. But then Admiral Baker, as strike group commander, has also seen his career stalled as a result of the latest investigation, so…

Normally I aim these tweets at my own account, just to see if anyone ever clicks (they don’t). But just this once, I thought I’d @USNavyCNO.

J’Accuse…! #USSTheodoreRoosevelt #CrozierAffair

Tweet

Go on, click it. I dare you. Maybe share this link on facebook while you’re at it?