After a string of sailors assigned to the USS George Washington took their own lives in 2021 and 2022, the Navy opened an investigation to see if there were any commonalities that would suggest action should be taken.
The report from that investigation, which was released Monday, largely absolved the Navy of creating an environment that led to the suicides. But it offered a much more comprehensive and authoritative look at the lives of the victims, painting a picture of sailors facing the consequences of a ship whose leaders were oblivious to the problems before them and a Navy whose efforts to offer mental health care were insufficient and rife with mistrust.
Those conditions left the sailors to struggle all alone.
The report pointed to a range of issues facing the sailors but didn't find a common thread. In one portion, investigators suggested that leadership failed by not punishing a sailor enough while, in another, an admiral put blame on senior leaders' failure to understand the sailors they lead.
In its description of the lives of three sailors who died by suicide, the report lays out the types of pressures that can happen aboard any ship in the Navy, but were concentrated on a troubled carrier stuck in the yard.
Master-At-Arms Seaman Recruit Xavier Mitchell-Sandor was one of hundreds of junior sailors who had to live aboard the ship until the spate of suicides finally compelled leaders to move the crew off at the end of April. His body was found by fellow sailors on April 15, the most recent death in the wave that led the ship's captain to tell the crew the ship had 10 suicides in less than a year.
Military.com has confirmed at least six suicides by sailors assigned to the ship in under a year -- the Navy has disputed the cause of death for one of those sailors -- and nine in total since November 2019.
Mitchell-Sandor is the only suicide in which the ship's environment was "a contributing factor," the Navy found.
Investigators, citing sailor interviews, described life aboard the ship as uncomfortable, with constant outages of electricity, heat, air conditioning, water and other services that lasted anywhere from "three days to two weeks."
On top of that, sailors living aboard had few spaces to unwind.
"There is little for Sailors to do onboard other than work," the report noted.
The reason the crew was ordered back on the ship was because the carrier was running almost a year behind on its four-year refuel and overhaul. Originally scheduled to be done by 2021, the ship's prior commander -- Capt. Kenneth Strong -- moved the crew back on April 16, 2021.
The report noted that Strong felt pressure to make room for the next carrier coming in for work at the shipyard but also as an effort to "boost morale by achieving a milestone and take back ownership" of the ship, telling investigators that he thought the crew "needed a victory."
He turned over command of the ship just over two months later.
Mitchell-Sandor, along with many other sailors assigned to the ship, resorted to sleeping in his car. Other junior sailors fixed the problem with money. One master chief interviewed by investigators said that he had "25 Sailors living out in town on their own dime out of 149 total." "Almost all are E-3 and below," he added -- sailors who typically make less than $2,000 a paycheck.
Mitchell-Sandor went even further and would constantly drive for hours from Virginia to spend weekends with his parents in Connecticut or a girlfriend in South Carolina.
Yet, despite the conditions on the ship and Mitchell-Sandor's constant efforts to spend time anywhere but aboard, the report said "his leadership at the E-9 level and above were largely unaware of his concerns with berthing" and that they didn't know he was traveling to Connecticut every other weekend. "Most were unaware he was traveling to Connecticut at all," the report adds.
Mitchell-Sandor had multiple run-ins with his bosses over infractions that essentially amounted to ditching work as soon as possible -- sometimes without waiting for his replacement. In one instance, he blew off a meeting with the ship's top enlisted sailor, the command master chief, in order to drive home.
While investigators did discover that many of these incidents did not result in punishment for the sailor, their conclusion was that this was not a kindness but a missed opportunity to "counsel MASR Mitchell-Sandor on how to effectively use his off-duty time."
Counseling in this context refers to a Navy practice of formally speaking with a sailor about their behavior and often following it up with documentation. Though it is possible for a sailor to be issued positive counseling, it has a negative connotation in the vast majority of instances..
"If departmental leadership had made the required documentations in MASR Mitchell-Sandor's record, then the red flags would have been more evident," investigators concluded. Had they done so, the report says they could have helped the sailor adapt better by giving him "extra military instruction (EMI), counseling, providing necessary resources, etc."
The first two options on that list are largely considered punishments.
Investigators also noted that another benefit of documenting the struggling sailor's rule-breaking would have been to provide ammunition to kick him out of the service.
"These relevant data points would have established a pattern that would have helped the command determine whether MASR Mitchell-Sandor was compatible for continued Naval service," investigators wrote.
However, it's unclear what value this suggested course of action would have had. At one point, investigators note that Mitchell-Sandor did not seek guidance outside of his department's leadership about his concerns or resources available to him. In another section, the report notes that his senior leaders knew about his practice of sleeping in his car; they counseled him for it, "but there is no evidence of any follow-through to understand the root cause for his decision making," the report states.
This lack of engagement from sailors in charge of the ship appears to have extended beyond Mitchell-Sandor. Investigators were told by many sailors that "there is a lack of ownership and investment in [the ship], and the present mission." Furthermore, "junior Sailors discussed not feeling comfortable making complaints to leadership about issues they encounter while living and working aboard the [ship]."
Interior Communications Electrician 3rd Class Natasha Huffman, another sailor whose life and death are covered in the report, reveals serious issues with how sailors who seek help are treated by the service.
Huffman's entire career in the Navy was an exercise in seeking help for mental health issues. Investigators found that she had "34 confirmed prior mental health encounters" with nine in boot camp alone. There was also a suicide attempt in 2020.
Despite this track record, Huffman struggled to get help. She resorted to paying for care out of pocket.
The report detailed a saga of one doctor diagnosing her with bipolar disorder and setting her on a track for separation. Then, a new physician changed her diagnosis and threw the discharge into doubt. Then doctors again flip-flopped back to a bipolar diagnosis and discharge.
Amid this back-and-forth, which the report admits "caused anxiety about her future, and frustrated her ability to make adequate plans," Huffman started seeing a civilian therapist. Her boyfriend, also a sailor on the George Washington, said this caused tension with her bosses.
She "was once told by her supervisor that she was taking too much time off to get care, and her supervisor prevented IC3 Huffman from going to an appointment," the boyfriend told investigators. Eventually, "her out-in-town provider dropped her as a patient due to the missed appointment, and she was forced to see another care provider that was more expensive," the report explained.
Investigators concluded that, given her extensive mental health history and trends, Huffman should have been put on limited duty after her suicide attempt in 2020. "This would have removed her from operational duty and allowed her dedicated time to focus on receiving medical care." Instead, she moved between different Navy doctors, which "created confusion for IC3 Huffman and disrupted her continuity of care."
Huffman's story of inconsistent, if not outright unhelpful, mental health treatment is not unique. Military.com reported on one sailor -- Jatzael Perez -- who said that he sought help for his mental health, only to be drug-tested and have a positive result be used to punish him. He disputed the result. In speaking with the George Washington's crew days after Mitchell-Sandor's suicide, the Navy's previous top enlisted sailor, Master Chief Petty Officer of the Navy Russell Smith, revealed that when he tried to get counseling following a divorce, he faced a wait of at least six weeks.
Additionally, the report reveals that there was little trust among the crew for the help the Navy was offering.
Sailors told investigators that "leadership doesn't want to talk about, or otherwise feels uncomfortable talking about, mental health issues," and some were hesitant to "seek mental health treatment through Navy channels due to concerns it would affect future career opportunities."
In the security department where Mitchell-Sandor worked, sailors said that seeking help would lead to them being '''red tagged' and thus be unable to carry a firearm and stand their watch."
Others simply told investigators that they didn't have confidence in the mental health care they were offered at the nearby naval hospital. According to Huffman's boyfriend, she stopped seeing one of the ship's psychologists because she didn't trust him.
While the report offers no insights into where this lack of trust comes from, Military.com's reporting on Perez's story revealed that Navy doctors can, and in difficult to define circumstances, inform commanding officers of certain medical details, including drug tests, even if those tests are conducted for legitimate medical reasons necessary for adequate care.
Yet despite these trust issues, the George Washington still had a staggering amount of demand for the ship's four counselors -- a psychologist, a behavioral health technician and two substance abuse counselors. Between January 2021 and January 2022, "there were an estimated 2,615 patient encounters" between the four providers, which they described as "overwhelming."
Another mental health professional available to the crew was a "Deployed Resiliency Counselor (DRC)." The report said that they were a three-mile walk away from the ship and almost never aboard. Since January 2021, that person has only seen 46 patients. "Multiple Sailors interviewed did not know who the DRC was, what the DRC offered, or where the DRC was located," the report added.
"Living All Alone"
Amid the report's recommendations were suggestions that the ship should have had more professionals available for sailors, but for reasons unexplained in the report, they were absent.
Investigators recommended that the ship be given priority to "fill the gapped Deployed Resiliency Counselor (DRC) billet," with "gapped" a common term for an unfilled job. It also recommended that the carrier's bosses "fill a billet for a Human Factors Engineer" -- a job that, among other things, is responsible for "improving force operational safety."
The letters from Navy leaders who received the report indicate that the additional DRC has already been put in place while the engineer should have been hired "in late summer of 2022." None of the follow-on letters from the other admirals receiving the report say whether this hire took place.
Despite all of the issues, missteps and deep institutional problems laid out in this report, the conclusions that investigators and Navy leaders laid out in the report are measured and reserved.
The investigators agreed that "for IC3 Huffman and MASR Mitchell-Sandor, it is clear that Navy life added stress to their lives" but were quick to note that "it is impossible to know definitively if any action by the Navy prior to these events would have changed the outcomes."
Rear Adm. John Meier, the commander of Naval Air Force Atlantic and the man who first received the investigation's results, suggested both in his statement as well as in additions to the report, that some of the conditions reported by sailors ran deeper than just the George Washington or these suicides.
"It is safe to say that generations of Navy leaders had become accustomed to the reduced quality of life in the shipyard, and accepted the status quo as par for the course for shipyard life," Meier wrote in his statement.
In making changes to the report, Meier expressed sympathy for Mitchell-Sandor's plight.
"As senior Sailors, it is easy to forget our Navy life in the beginning," the one-star admiral noted as he tweaked the language to place less emphasis on the sailor's decision to not move off the ship.
"As officers with no enlisted experience, it is easy to lose sight of how powerless one might feel as the most junior member of a crew ... It appears [Mitchell-Sandor] felt truly alone, and at least onboard the ship, was living all alone."
The report said that "Mitchell-Sandor hadn't been in the Navy long enough to realize, nor was he likely ever told, that life in the Navy would continue to get better than the experience he was going through on the GW."
-- Konstantin Toropin can be reached at email@example.com. Follow him on Twitter @ktoropin.