The Navy's investigation into a cluster of four suicides in the span of a month at one East Coast maintenance center found the command was not well suited to managing the sailors, who were all evaluated for medical issues.
The latest investigation, which was released alongside a report on USS George Washington carrier suicides, noted that all of the deaths at the maintenance center were among first tour sailors who were at various stages of the disability evaluation process and "suffering from a confluence of external stressors."
All four also had unrestricted access to personally owned guns -- an issue that goes largely unaddressed in the report.
The report investigated four sailors who killed themselves between Oct. 29 and Nov. 26, 2022. Three reported some form of anxiety or stress related to their Navy service, but some also had serious medical issues. One sailor was being evaluated for seizures; another obesity; and one had "debilitating back pain."
The command the four sailors were assigned to is the Navy's Mid-Atlantic Regional Maintenance Center, or MARMC, a massive unit that manages the maintenance needs of the many ships in the Norfolk, Virginia, area. The command has around 3,000 people, and half are active-duty sailors.
About one-third of those sailors at any time are assigned to the unit because they are undergoing some sort of medical issue or event.
For example, on Jan. 23, the report says 200 sailors were being evaluated for a disability, 213 had recently given birth, and a handful were either waiting for new orders or to be separated from the Navy.
The command struggled to offer even basic suicide prevention. The MARMC's policies didn't have any guidance on dealing with sailors who demonstrated suicidal behaviors or what should be done in the aftermath of a suicide.
Investigators found that the unit hadn't conducted an annual suicide prevention drill in three years.
The report did note, though, that "the Navy, writ large, has failed to fully implement the Suicide Prevention program" as defined by its own rules.
Some commands, including a similar maintenance center in Mayport, Florida, did use the cluster as a chance to come up with new and different ways to talk about and try to prevent suicide.
Ultimately, investigators made recommendations for 25 reforms that the Navy leaders who received the report accepted in their letters endorsing the findings. Missing among the actions was any mention of addressing the method that these four sailors used to end their lives: guns.
Investigators found all of the sailors had ready access to firearms, and some resisted suggestions of keeping them under lock.
The Navy report found that "access to personally owned firearms, and unwillingness to
surrender access to lethal means, to include the use of gun locks, was a causal factor in the deaths of all four Sailors."
An independent panel commissioned by the Pentagon recently recommended that military exchanges stop selling guns to service members under 25 years old and put in place waiting periods for gun and ammunition purchases as a way to bring down the military's high suicide rates.
The panel's findings showed guns were involved in 66% of active-duty suicides, as well as 78% of National Guard suicides and 72% of reserve suicides.
Military.com's own investigation into the issue revealed that, while guns are not allowed in the barracks, leaders have few ways to police that policy since they aren't being told by the stores when one of their service members buys a gun.
Adm. Daryl Caudle said in a call with reporters last week that the Navy is looking into when sailors are issued a gun by their ship as part of watch-standing duties. The call was part of the release of the report and another that looked into the suicides aboard the aircraft carrier USS George Washington.
"Far too many, on a percentage basis, of the tragic deaths due to suicide are due to a firearm and far too many of that population is with a service-provided weapon," Caudle added.
The report into the suicides at MARMC noted that the command handed out about 100 locks after the second suicide, and more than 300 since it received them in November 2022.
The report recommends that, if the Navy plans to continue assigning potentially disabled sailors to these centers, more manpower with the appropriate background and skill sets would be needed.
Investigators ultimately concluded that the four suicides "were neither related, nor connected," but the report found communication between the doctors who were regularly seeing the sailors and leadership at the command was fractured.
That led to blind spots in keeping tabs on the sailors at the MARMC and became a contributing factor in their deaths, the Navy found.
Investigators said that, due to the industrial environment and fast-paced work tempo, maintenance centers like the one in Norfolk are "not well-suited" to provide effective management, administration and oversight of the sailors.
One issue was an overwhelmed system of oversight that began with the command's deployability coordinator -- a sailor charged with the accurate "accounting, tracking, medical treatment, and expeditious movement" of sailors on medical restrictions from duty through the screening process.
The sailor "was overwhelmed … given the significant number of [limited duty] Sailors under his cognizance [and] the amount of work involved," the report said.
Investigators also determined that the training available for that position was inadequate: Ideally, the sailor in the position should have a medical background and receive "focused training beyond a PowerPoint presentation."
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 firstname.lastname@example.org. Follow him on Twitter @ktoropin.